As HIV has changed from a rapidly progressive fatal illness to a chronic manageable disease often lasting decades, new, potentially deadly, entities such as cancer, hepatitis C and heart disease have moved to the forefront, replacing traditional opportunistic infections as causes of HIV-related morbidity and mortality.

Changes in immune surveillance as well as coinfection with cancer-inducing viruses -- such as human papillomavirus, Epstein Barr Virus and Kaposi's sarcoma herpes virus-8 (HHV-8) -- have meant a change in the number and types of cancers occurring in HIV-infected patients and their impact on survival rates.

Although HIV-infected patients are at a higher risk of developing both AIDS-defining cancers (ADC) and non-AIDS defining cancers (NADC), highly active antiretroviral therapy (HAART) has meant an overall decrease in ADC and an increase in NADC. This study reviews the types of cancers occurring in men versus women in the pre-HAART versus the post-HAART era.

Nuyankalva et al reviewed the cancer registry from Howard University, a minority teaching hospital, for all cases of cancer occurring in HIV-infected patients from January of 1990 through December of 2003.

A total of 203 HIV-infected patients -- 162 men (78.9% of total) and 41 women (21.1%) -- were found to have at least one type of cancer. The median age of the male patients was 34 years and 41 years for female patients, with no significant difference pre-HAART versus post-HAART.

CD4+ cell counts were 70 and 143 cells/mm³, respectively in men and women, at the time of the cancer diagnosis with lower CD4s pre-HAART (33 and 204 cells/mm³, respectively) than post-HAART (113 vs. 221 cells/mm³, respectively). At the time of cancer diagnosis, women tended to be older and have a higher CD4+ cell count than men.

Post-HAART, the incidence of ADC declined in men while remaining the same in women. The incidence of NADC clearly increased in both groups post-HAART (Table 1). ADC mortality decreased and NADC mortality increased in both sexes after the advent of HAART, although the difference in men was more dramatic.

The most common malignancies in men were Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL) and lung cancer (Table 2). In women, cervical cancer, NHL and lung cancer were most common (Table 3).

Although mortality from ADCs has decreased, both incidence and mortality of NADCs has risen post-HAART in this cohort.

This study corroborates data on cancer trends from both the large HIV Outpatient Study (HOPS) and Women's Interagency HIV Study (WIHS) cohorts while emphasizing gender differences.

Similar to this study, Patel et al reporting at the 12th Conference on Retroviruses and Opportunistic Infections on approximately 12,000 HIV-infected patients from the HOPS and two Chicago clinic cohorts found KS and cervical cancer declining in the post-HAART era, but not NHL.¹ Their study found an increased relative risk of lung cancer, Hodgkin's lymphoma, anorectal cancer and melanoma in the HOPS cohort relative to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data in the post-HAART era.²

Hessol and colleagues, reporting on the 1,850 women in the WIHS cohort, similarly found a significantly increased incidence rate in women for all cancers, KS, NHL and lung cancer compared to SEER data in the post-HAART era.³

Further risk-adjusted multivariate analysis with this data compared to national standards such as the SEER database from the National Cancer Institute would be useful.

The authors' conclusion that "all clinicians should be more vigilant in counseling and screening [HIV-infected] patients at an earlier age for prevention and early detection of cancer" needs to be supported by larger studies in varied populations to determine which sub-groups of HIV-infected patients are developing particular cancers and at what age or point in their disease these occur. This clarification will be useful for the development of specific guidelines. Timely implementation of cancer screening/prevention guidelines similar to the opportunistic infection prophylaxis guidelines that improved HIV survival in the first half of the 1990s is crucial to meeting the needs of practitioners and patients in this ever-changing epidemic.

Footnotes

1. Patel P, Novak RM, Tong T, et al. Incidence of non-AIDS-defining malignancies in the HIV Outpatient Study (HOPS). In: Program and abstracts of the 11th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004; San Francisco, Calif. Abstract 81.

2. SEER database of the National Cancer Institute.

3. Hessol NA, Seaberg EC, Preston-Martin S, et al. Cancer risk among participants in the Women's Interagency HIV Study. JAIDS. August 1, 2004;36(4):978-985.