PerspectiveIn the Journals

HIV patients less likely to receive treatment for many cancers

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May 23, 2016

An analysis of more than 2 million U.S. cancer patients suggested that those with HIV are less likely to receive cancer treatment, regardless of insurance status or comorbidities.

This disparity was present among patients with every examined cancer type but anal cancer, according to Gita Suneja, MD, MSHP, assistant professor in the department of radiation oncology at the University of Utah, Huntsman Cancer Center, and colleagues, and it supports efforts to improve treatment for this population.

Gita Suneja

Gita Suneja

Black race, no private insurance predict treatment

“HIV-infected patients with cancer have lower overall survival compared with HIV-uninfected individuals,” they wrote. “Although this may in part be related to deaths from AIDS-related complications, a recent population-based study found higher cancer-specific mortality among HIV-infected vs. HIV-uninfected patients with cancer. Lack of appropriate cancer treatment may contribute to worse cancer-specific mortality.”

To test this hypothesis, Suneja and colleagues examined patient data reported to the National Cancer Data Base from 2003 to 2011. The researchers included all adult patients aged younger than 65 years diagnosed with the 10 most frequent cancers, and collected demographic, treatment, comorbidity and insurance status data. The investigators then conducted an analysis to identify predictors for lack of cancer treatment capable of controlling for comorbidity and insurance status, variables that they wrote have remained unexplored throughout past studies on HIV and cancer.

HIV-infected individuals frequently have other illnesses, and patients with significant comorbid disease may not be candidates for standard cancer therapy,” Suneja and colleagues wrote. “Similarly, insurance status also plays an important role in access to and delivery of cancer treatment. HIV-infected patients in the United States are more likely to be uninsured or underinsured compared with the HIV-uninfected population, which could be a major contributing factor [in poor patient outcomes].”

HIV table

The study’s final cohort included 10,265 HIV patients and 2,219,232 patients without HIV, the researchers wrote. Those in the HIV group were younger (median age, 47 years vs. 55 years), and were more often non-Hispanic black (41.1% vs. 13.2%) and Hispanic (14% vs. 5.7%). Patients without HIV more often had private insurance and lower modified Charlson-Deyo comorbidity score.

Multivariate analysis found HIV patients with every examined cancer type but anal cancer were significantly less likely to receive cancer treatment than those without HIV. This disparity was most apparent among cervix (adjusted OR = 2.81; 95% CI, 1.77-4.45), upper GI (adjusted OR = 2.62; 95% CI, 2.04-3.37) and lung (adjusted OR = 2.46; 95% CI, 2.19-2.76) cancer patients. While predictors of unreceived cancer treatment varied by tumor type, black race and no private insurance were both associated with missed cancer treatment.

“These findings suggest that cancer care providers and policymakers need to devote special attention to the HIV-infected patient population to understand and address the factors driving differential cancer treatment,” the researchers wrote.

Cancer incidence increasing among aging population

Suneja and colleagues stressed the importance of these findings in light of data suggesting increased aging and cancer rates among HIV patients, such as those reported by Michael J. Silverberg, PhD, MPH, research scientist in the division of research at Kaiser Permanente Northern California, and colleagues last October.

Michael Silverberg

Michael J. Silverberg

To determine whether the increase of cancer in this population was due to increased lifespan or other influences, Silverberg and colleagues compared time trends in the incidence of cancer by age 75 years among 86,620 individuals with HIV and 196,987 individuals without HIV from the North American AIDS Cohort Collaboration on Research and Design of International Epidemiologic Databases to Evaluate AIDS who were followed between 1996 and 2009.

Compared with individuals without HIV, the cumulative incidence by age 75 years of Kaposi’s sarcoma (4.4% vs. 0.01%), non-Hodgkin’s lymphoma (4.5% vs. 0.7%) and lung cancer (3.4% vs. 2.8%) appeared greater in individuals with HIV from 2005-2009. Researchers also observed a greater cumulative incidence of anal cancer (1.5% vs. 0.05%), liver cancer (1.1% vs. 0.4%) and Hodgkin’s lymphoma (0.9% vs. 0.09%) among those with HIV, but no increases in colorectal cancer, melanoma or oral cavity/pharyngeal cancer.

Trends in cumulative incidence and hazard rate decreased for Kaposi sarcoma and non-Hodgkin lymphoma. The researchers were able to attribute the increased cumulative incidence for anal, colorectal and liver cancers to decreasing mortality rates; however, the declines in Hodgkin lymphoma, lung cancer and melanoma were not associated with lifespan.

“The high cumulative incidences by age 75 years for Kaposi’s sarcoma, non-Hodgkin’s lymphoma and lung cancer indicate that public heath efforts need to be intensified to promote early, sustained antiretroviral therapy, smoking cessation and lung cancer screening,” Silverberg and colleagues wrote. “As the population with HIV ages, future estimates of cumulative incidence could be stratified by levels of cancer risk factors such as CD4+ count, smoking, alcohol consumption, and HBV or HCV infection, to more accurately inform patients and providers about risk and to help further target prevention efforts.” – by Dave Muoio

Disclosures: Suneja and colleagues report no relevant financial disclosures. Silverberg reports research grants from Merck and Pfizer. Please see the full study for a list of all other authors’ relevant financial disclosures.

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PERSPECTIVE
Paul A. Volberding

Paul A. Volberding

We have long known of the association of HIV infection and cancer risk. With more effective HIV therapy some, but not all, cancers are seen less often. Still, all patients with HIV and cancer deserve the best possible cancer management.

This study adds troubling new information to our concern that persons with HIV often receive less appropriate care than those without this infection. Whether this is a reflection of economic issues or other factors is not yet completely clear, but this area should be urgently investigated. Our advances in treating HIV will have less impact if other care is not being provided.


Paul A. Volberding, MD
Infectious Disease News Chief Medical Editor
Director, AIDS Research Institute
University of California, San Francisco

Disclosure: Volberding reports no relevant financial disclosures.