#214

Prognosis in HIV Associated Malignancies

  • Steven Oppenheim MD

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Fast Fact #213 discussed the prognostic principles in adults with HIV or AIDS for many life threatening complications of HIV infection. This Fast Fact presents survival data for malignancies commonly arising in the setting of HIV/AIDs.

Background   Currently 25-35% of all deaths in HIV infection are related to malignancies (1,2). The incidence and death rate from HIV-associated malignancies, also referred to as AIDS-defining malignancies (ADM), have decreased with the use of combination antiretroviral therapy (cART). The 10 year survival rates from ADM are about 60% (3,4). These malignancies include Kaposi’s sarcoma, invasive cervical carcinoma and the non-Hodgkin’s lymphomas (NHL) (1,5).

Risk factors for Mortality in ADM:  older age, metastatic at presentation, lack of cancer treatment, unsuppressed HIV-RNA despite cART, low CD4 count at diagnosis, and active substance abuse (6).

Prognosis in ADM

  • AIDS-related Kaposi’s sarcoma (KS) has become much less common with the use of cART. KS is a grossly violaceous spindle cell tumor, more common in men who have sex with men and is associated with human herpesvirus-8 infection. cART is the mainstay of therapy which may be combined with chemotherapy and can result in complete resolution. In one study the 5-year survival for mucocutaneous KS was 92% and 82.6% for visceral KS (7).
  • Invasive cervical cancer has not declined in frequency in the cART era. It is well known to be associated with human papillomavirus infection and has a median survival of 5.1 years and a 10 year survival of 78.5% (6).
  • ADM NHLs in descending order of frequency, include diffuse large B-cell lymphoma (DLBCL), Burkitt lymphoma, primary CNS lymphoma (PCNSL) and the rare immunoblastic lymphoma and effusion body cavity lymphoma. As a group, studies suggest the median survival is 2.1 years, 5-year survival is 65.1% and 10-year survival is 42-48.2% (4,7,9). Overall, survival with NHL in HIV infected persons remains poorer than the HIV uninfected population (10,11).
  • ADM NHL subcategories: DLBCL’s, have a 2 and 5-year survival of 55.6% and 44.1% respectively (2, 12). Burkitt lymphoma has a 53.1-71% 2-year survival (2, 11). PCNSL continues to have a very poor prognosis ranging from 0.7 to 4 months; longer survival appears to be associated with cART, increased performance status, and use of chemotherapy (13). Immunoblastic lymphoma has a 5-year survival of 24 to 47%; median survival is estimated to be 11 months (8,14).
     

Prognosis in Non-AIDS-Defining Malignancies (NADM)   NADMs present at a more advanced stage than in HIV- persons (1). They comprise about half of all HIV-associated malignancies and are now the leading cause of death in people with HIV in the developed world (1). Studies suggest that the mortality rate per hospitalization is about 1.6% in patients with ADM and 13% in persons with NADM (3).  Ten year survival rates for NADM are about 45% (4).  In order of approximate decreasing frequency the most common NADMs are hepatocellular cancer, anal cancer, Hodgkin’s disease and lung cancer. The survival rate for NADM’s adjusted for age and stage is roughly the same as the general population (7).

  • Hepatocellular cancer: median survival is 441 days with 2 and 5-year survival reported as 12 and 17.5% (4,6,7).
  • Hodgkin’s Disease: median survival is 795 days; 3-year survival is 85% and 10-year survival is 49.5% (4,7,9).
  • Lung cancer: median survival is 113 days with a 2 and 5-year survival of 24% and 16% (4,6,7).
  • Anal cancer: 2 year survival is 75-87%, 5 year survival is 62.9%.(6,7).

References

  1. Rubinstein PG, Aboulafia DM, Zloza A. Malignancies in HIV/AIDS: From Epidemiology to Therapeutic Challenges. AIDS 2014; 28(4): 453-465.
  2. Gopal S, Patel MR, et al. Temporal Trends in Presentation and Survival for HIV-Associated Lymphoma in the Antiretroviral Therapy Era. Journal of the National Cancer Institute 2013; 105(16): 1221-1229.
  3. Cowell A, Shenoi SV, et al. Trends in Hospital Deaths Among Human Immunodeficiency Virus-Infected Patients During the Antiretroviral Therapy Era, 1995 to 2011. Journal of Hospital Medicine 2015; 10(9): 608-614.
  4. Gotti D, Raffetti E, et al. Survival in HIV-Infected Patients after a Cancer Diagnosis in the cART Era: Results of an Italian Multicenter Study. PLOS ONE 2014; 9(4): e94768.
  5. Selik RM, Mokotoff ED, et al. Revised Surveillance Case Definition for HIV Infection – United States 2014. Morbidity and Mortality Weekly Report 2014; 63(RR03): 1-10.
  6. Achenbach CJ, Cole SR, et al. Mortality after cancer diagnosis in HIV-infected individuals treated with antiretroviral therapy. AIDS 2011; 25: 691-700.
  7. Hleyhel M, Belot A, et al. International Journal of Cancer 2015; 137: 2443-2453.
  8. Djawe K, Buchacz K, et al. Mortality Risk After AIDS-Defining Opportunistic Illness Among HIV-Infected Persons – San Francisco, 1981-2012. Journal of Infectious Diseases. 2015; 212:1366-1375.
  9. Spagnuolo V, Galli L, et al. Ten-year survival among HIV-1-infected subjects with AIDS or non-AIDS-defining malignancies. International Journal of Cancer 2012; 130: 2990-2996.
  10. Chao C, Xu L, et al. Survival of non-Hodgkin lymphoma patients with and without HIV infection in the era of combined antiretroviral therapy. AIDS 2010; 24: 1765-1770.
  11. Gopal S, Martin KE, et al. Clinical Presentation, Treatment, and Outcomes Among 65 Patients with HIV-Associated Lymphoma Treated at the University of North Carolina, 2000-2010. AIDS Research and Human Retroviruses. 2012; 28(8): 798-805.
  12. Dunleavy K, Wilson WH. Implications of the Shifting Pathobiology of AIDS-Related Lymphoma. Journal of the National Cancer Institute. 2013; 105(16): 1170-1171.
  13. Bayraktar S, Bayraktar UD, et al. Primary CNS lymphoma in HIV positive and negative patients: comparison of clinical characteristics, outcome and prognostic factors. Journal of Neuro Oncology 2011; 101: 257-265.
  14. Castillo JJ, Furman M, et al. Human Immunodeficiency Virus-Associated Plasmablastic Lymphoma. Cancer. 2012; 118: 5270-5277.

Author Affiliation:  The University of Arizona College of Medicine and Banner Medical Group Division of Palliative Medicine

Version History:  Originally published March 2009.  Significant revision occurred in February 2016 by Steven Oppenheim MD to reflect updates in the literature.

Conflicts of Interest: none