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Commentary
Recent Trends and Future Directions in Human
Immunodeficiency Virus-Associated Cancer
Meredith S. Shiels, PhD, MHS; James J. Goedert, MD; and Eric A. Engels, MD, MPH
Malignancies, including the 3 that are part of the definition of acquired immunodeficiency syndrome (AIDS)
(Kaposi sarcoma [KS], non-Hodgkin lymphoma [NHL], and cervical cancer) as well as certain non-AIDS–defining cancers, cause significant morbidity and an estimated one-third of the deaths reported among patients infected with the
human immunodeficiency virus (HIV).1 Seaberg et al2 examined cancer incidence among HIV-infected and HIV-uninfected men who have sex with men (MSM) in the US Multicenter AIDS Cohort Study (MACS). The cancer risk in HIVinfected men was compared internally with that of HIV-uninfected MACS participants and externally with general population cancer data from the Surveillance, Epidemiology, and End Results (SEER) registry program.
The MACS analysis highlighted several interesting and important trends in AIDS-defining and non-AIDS–defining
cancers among HIV-infected individuals. The authors reported that the incidence rates of KS and NHL, which fell substantially with the widespread use of highly active antiretroviral therapy (HAART) beginning in 1996, continued to decline
through 2007, presumably because of improvements in HAART. These results are consistent with most3,4 but not all5 previous reports. It is interesting to note that, KS and NHL rates began to decline even before the introduction of HAART,5 which
perhaps may be attributable to single-agent and dual-agent antiretroviral therapies that were in use before 1996.5
Although comparing cancer rates by calendar period is useful for gauging the overall population effectiveness of
changes in antiretroviral therapy, a strength of cohorts such as that used in the MACS is that they also have data regarding
actual medication use and HIV disease markers. Even within the HAART era, not all HIV-infected individuals are receiving HAART, medication regimens vary, and the effectiveness of HAART in suppressing HIV replication and restoring
immune function may be incomplete. Analyses that consider only calendar periods cannot determine whether the decline
in risk over time is driven by a larger percentage of individuals receiving therapy or improvements in HAART regimens.
Additional studies that examine how the risk of KS and NHL varies with actual HAART use, specific medications, and
HAART effectiveness as assessed by HIV disease markers would help to clarify why the risk of KS and NHL was found to
remain elevated in the most recent HAART calendar period. Is the continuing risk because of people not taking HAART,
poor adherence with medications, ineffectiveness of HAART because of the emergence of resistant HIV, or incomplete
immune reconstitution even in people being treated with virologically suppressive regimens? Data from France indicate
that CD4 cell counts and plasma HIV RNA levels continue to be important predictors of KS and NHL risk for people
receiving HAART.6 We recognize that a challenging issue in evaluating the effect of HAART on cancer risk is confounding by indication, that is that the sickest people are prescribed HAART, which can lead to an artifactual positive association between HAART use and adverse health outcomes. Nonetheless, this methodological issue has been addressed in
recent analyses of observational data from HIV cohorts.7
In contrast to the declining trends for KS and NHL noted among HIV-infected MACS participants, Seaberg et al
reported a concerning rise in anal cancer incidence over time, including a suggestive increase within the HAART era itself.
This finding is in keeping with results from most previous studies, which have observed a stable or increasing risk of anal
cancer in the HAART era or with HAART use.8-10 HIV-infected individuals, including women and heterosexual men as
well as MSM,11 are at an increased risk of anal cancer and other human papillomavirus (HPV)-related cancers.3,8
Corresponding author: Meredith S. Shiels, PhD, MHS, Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National
Cancer Institute, 6120 Executive Boulevard, EPS 7059, Rockville, MD 20892; Fax: (301) 402-0817; [email protected]
Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
See original referenced article on pages 5507-16, this issue.
This article is a US Government work and, as such, is in the public domain in the United States of America.
DOI: 10.1002/cncr.25705, Received: July 19, 2010; Revised: August 31, 2010; Accepted: September 7, 2010, Published online October 19, 2010 in Wiley Online
Library (wileyonlinelibrary.com)
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HIV-Associated Cancer/Shiels et al
Prolonged HIV-induced immunosuppression, as indicated by an extended time spent with a low CD4 cell
count, is a risk factor for anal cancer.6 However, because
the restoration of the immune system by HAART does
not appear to reduce the risk of the immediate precursors
of anal cancer,12 it has been postulated that immune
suppression may only impact the persistence of HPV
infection and not subsequent progress to invasive malignancy.10,12,13 Because the latency period for persistent
HPV infection resulting in anal cancer may be quite long,
even decades, if the initiation of HAART is delayed,
therapy may be given to patients too late to stop the development of anal cancer, and may indirectly facilitate carcinogenesis by prolonging survival. One possibility is that
earlier HAART initiation (ie, initiation at higher CD4
cell counts) would allow for HPV clearance before the development of early precancerous lesions.
Lung cancer risk appeared higher in HIV-infected
MACS participants compared with participants not
infected with HIV, although this difference was not found
to be statistically significant. Registry linkage studies and
studies comparing with external rates have consistently
found that HIV-infected individuals had 2-fold to 3-fold
higher lung cancer rates compared with the general population.5,9,14 These associations are partially driven by the
high proportion of HIV-infected individuals who smoke
cigarettes compared with the general population. In fact,
lung cancer among HIV-infected individuals occurs
almost exclusively among smokers. Nonetheless, studies
have found an increased risk of lung cancer with HIV,
even after directly or indirectly adjusting for differences in
smoking prevalence.15,16 To the best of our knowledge,
the mechanism by which HIV infection increases lung
cancer risk remains unclear, although several hypotheses
have been proposed. HIV-infected individuals experience
increased pulmonary inflammation, repeated and chronic
pulmonary infections, and deficiencies in antioxidants
and other nutrients, all of which may act together with
tobacco use to increase lung cancer risk.17 Along these
lines, our recent analyses of US registry linkage data indicated that people with AIDS who have had repeated episodes of bacterial pneumonia are at a somewhat increased
risk of developing lung cancer.18
A major strength of the study by Seaberg et al is the
internal comparison of cancer risk within the MACS.
Many prior studies reporting on excess cancer risk in
HIV-infected individuals have relied on comparisons
between cohort data and general population cancer rates9
or matches between HIV/AIDS and cancer registries.4,5,14
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December 1, 2010
HIV-uninfected individuals enrolled in the same cohort
study and drawn from the same source population are a
more appropriate comparison group than the general
population, because they are more similar to HIVinfected individuals with regard to their demographic,
socioeconomic, and behavioral characteristics. Furthermore, studies that include individual-level data on all
cohort participants, such as the MACS, allow for careful
control of any residual differences in these characteristics.
For example, Seaberg et al were able to restrict the analysis
to smokers and adjust for level of cigarette smoking in
their lung cancer analysis, whereas data regarding smoking
are not available in population-based registries.
Assessing the associations between HIV infection
and cancer risk within a cohort study is not without weaknesses. Registry-based studies can include more than 100
times the number of HIV-infected individuals that are
included in cohort studies such as the MACS, enabling
the detection of much smaller differences in cancer risk
between HIV-infected and HIV-uninfected populations.
In the MACS analysis, many of the comparisons between
HIV-infected and HIV-uninfected individuals were likely
underpowered, and therefore, some associations with
HIV infection may have been missed. In addition, the
MACS study included only 1 HIV risk group (MSM) and
lacked data regarding cancer risk in women. Future consortia that combine data from US and international
cohorts, include both HIV-infected and comparable
HIV-uninfected individuals, and include people from
diverse demographic groups would be ideal for studying
HIV infection and cancer risk, bridging the gap between
registry-based studies (with robust statistical power and
population representativeness) and HIV cohort studies
(with detailed individual-level data).
An additional point to note in the current MACS
analysis is that HIV-uninfected men were observed to
have 47% fewer cancers than expected based on SEER
general population rates (standardized incidence ratio
[SIR], 0.53; 95% confidence interval [95% CI], 0.430.66). Although Seaberg et al postulated that MACS participants may have been at a generally low risk for most
cancers, this apparently low risk could plausibly reflect
underascertainment of cancers. Cancers in the MACS
were, according to the authors, ascertained through interviews; abstraction and review of medical records; reports
by the patient or their next of kin; and review of vital status records, including data from the National Death
Index.2 Cancers not reported by participants or occurring
after loss to follow-up would not have been detected by
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Commentary
study personnel, potentially leading to artificially low cancer rates.
Two examples in which underascertainment appears
possible are lung and anal cancers. Because cigarette
smoking prevalence was found to be far greater in HIVuninfected MACS participants (40% of whom were current smokers) than in the US general population (24%
current smokers in 2000),19 an elevated lung cancer risk
would be expected. However, the risk of lung cancer
appeared reduced among HIV-uninfected men in the
MACS (SIR, 0.30; 95% CI, 0.11-0.66). Furthermore,
male homosexuality and receptive anal intercourse are
strong, established risk factors for anal cancer,20 but HIVuninfected MSM in the current MACS analysis manifested only a modest and nonsignificant elevation compared with men in the general population (SIR, 2.50;
95% CI, 0.30-9.03). Thus, we believe that the results
for lung and anal cancers likely reflect some degree of
underascertainment of these cancers and, by implication,
perhaps other cancers as well. If present, the underascertainment of cancers is likely nondifferential by HIV status, and thus would attenuate internal comparisons
between HIV-infected and HIV-uninfected men. This
issue emphasizes the importance of complete and accurate
cancer ascertainment in HIV cohort studies. One
approach would be to supplement the ongoing data collection activities by linking the data from cohort participants with population-based cancer registries.
Among HIV-infected individuals, HAART has
improved immune function; reduced the risk of AIDS,
including AIDS-defining malignancies; and dramatically
prolonged survival. As a result, HIV-infected individuals
are living to older ages at which the risk of non-AIDS–
defining cancers steeply increases. Thus, in the coming
years, even if the number of AIDS-defining malignancies
continues to decline, the number of non-AIDS–defining
cancers diagnosed in HIV-infected individuals will
increase. The importance of prevention, early detection,
and treatment efforts targeted toward HIV-infected individuals has also grown. Because lung cancer is the most
frequent non-AIDS–defining malignancy, smoking cessation efforts are essential to reduce morbidity and mortality. Furthermore, HIV-infected women should adhere to
specific Papanicolaou (Pap) testing guidelines tailored toward woman with HIV infection to prevent cervical cancer. In addition, future research is needed to determine
the efficacy of anal cancer screening with the Pap test in
HIV-infected MSM as well as other risk groups. Given
the ever improving life expectancy afforded by effective
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HAART, age-specific screening recommendations for colon, prostate, and breast cancers should be applied to
HIV-infected individuals as they are for the general
population.
The success of HAART at prolonging survival now
brings new challenges as HIV-infected individuals age. It
is important that we continue to build on the findings of
Seaberg et al2 and others by working toward a better
understanding of the etiology of cancer in the setting of
HIV infection. We must also devote continuing effort
and attention to cancer prevention with the goal of reducing cancer incidence, morbidity, and mortality among
HIV-infected individuals.
CONFLICT OF INTEREST DISCLOSURES
Supported by the Intramural Research Program of the National
Cancer Institute.
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