Download Clinicopathological characteristics and management of prostate

Clinicopathological characteristics and
management of prostate cancer in the human
immunodeficiency virus (HIV)-positive population:
experience in an Australian major HIV centre
Wee Loon Ong*†, Paul Manohar*, Jeremy Millar†‡ and Peter Royce*§
*Department of Urology and ‡William Buckland Radiation Oncology Service, Alfred Health, and Departments of
†
Epidemiology and Prevention Medicine and §Surgery, Monash University, Melbourne, Vic, Australia
Objectives
To characterise clinicopathological characteristics of prostate
cancer among human immunodeficiency virus (HIV)-positive
men and to evaluate the current practice patterns in the
management of prostate cancer in these men.
Patients and Methods
We retrospectively reviewed all patients with HIV in the
State-wide HIV referral centre in Victoria, who were
diagnosed with prostate cancer from 2000 onwards. In all, 12
patients were identified, and the medical records were
reviewed to collect data on HIV parameters at the time of
prostate cancer diagnosis, as well as prostate cancer
clinicopathological characteristics, treatment details and
outcomes.
Results
At the time of prostate cancer diagnosis, eight patients had
undetectable viral load, and the median cluster of
differentiation 4 (CD4) count was 485 cells/μL. The average
age at diagnosis of prostate cancer was 63 years and the
median prostate-specific antigen (PSA) level of 11.1 ng/mL.
Four patients had Gleason 6 prostate cancer, four Gleason 7,
one Gleason 8 and three Gleason 9. Seven of the 12 patients
Introduction
HIV-positive patients are at increased risk of developing
certain cancers, especially AIDS-defining cancers (i.e. Kaposi
sarcoma, non-Hodgkin lymphoma and invasive cervical
carcinoma), as well as other HIV-related cancers, such as anal
cancer. However, prostate cancer has been reported to be less
common in the HIV-positive population [1,2]. HIV-positive
patients who were diagnosed with prostate cancer had been
reported to have very rapid cancer progression, due to the
severely depressed immune system, as well as poor response to
© 2015 The Authors
BJU International © 2015 BJU International | doi:10.1111/bju.13097
Published by John Wiley & Sons Ltd. www.bjui.org
had a positive family history for prostate cancer. Of the
patients with clinically localised prostate cancer (10), most
were treated with radiotherapy (RT): one permanent seed
brachytherapy (BT), five external beam RT (EBRT), two open
radical prostatectomies (RP), one active surveillance (AS), and
one on watchful waiting (WW). For the two patients with
metastatic disease, one had androgen-deprivation therapy and
EBRT, while the other had a combination of EBRT and
chemo-hormonal therapy with doxetacel. All patients were
followed for a median of 46 months, with three deaths
reported, none of which was a prostate cancer-specific death.
Conclusions
This is the first Australasian series on prostate cancer
management in a HIV population. With the prolonged
survival among HIV-positive men in the highly active
anti-retroviral therapy era, PSA testing should be offered
to this group of patients, especially those with a positive
family history. HIV-positive men should also be offered all
treatment options in the same manner as men in the general
population.
Keywords
prostate cancer, HIV, treatment
androgen-deprivation therapy (ADT) due to their
hypogonadal state [3].
Before highly active anti-retroviral therapy (HAART) was
available, the management of prostate cancer among
HIV-positive men was often considered secondary to the
management of HIV infection, given the poor prognosis from
HIV infection and AIDS illnesses. However, with the advent of
HAART, HIV-positive patients are living longer [4], and HIV
infection is gradually evolving into a chronic disease. In a
multinational study by the Antiretroviral Therapy Cohort
BJU Int 2015; 116, Supplement 3, 5–10
wileyonlinelibrary.com
© 2015 The Authors
6 BJU International © 2015 BJU International
Yes
Yes
9
Yes
–
RP + PLND
26
Dx, diagnosis; Int. intermediate; PLND, pelvic lymph node dissection. #, fractions; CTx, chemotherapy.
1116
19
High
0
0
2b
5+4
2013
12
53
7.6
4
2013
11
54
269
5+4
1
1
High
8
792
<20
ADT + EBRT + CTx
Surgical specimen:
Gleason score 4 + 3, pT2c,
clear margin
ADT + 50 Gy/20# + six cycle
docetaxel
Surgical specimen:
Gleason score 5 + 4,
pT2b, clear margin
9
Yes
Yes
Yes
No
–
No
1c
1c
2b
2012
2012
2013
8
9
10
68
58
46
3.9
11.5
9.0
3+3
3+3
4+3
0
0
0
0
0
0
Low
Int
Int
6
5
23
485
485
672
<20
<20
<20
EBRT
AS
RP + PLND
46 Gy/23# + HDR
(17 Gy/2#)
74 Gy/37#
28
23
13
No
No
Yes
No
–
–
No
60
58
103
87
81
67
34
145 Gy (125I)
70 Gy/35#
70 Gy/35#
74 Gy/37#
ADT + 50Gy/20#
BT
EBRT
EBRT
EBRT
ADT + EBRT
WW
EBRT
<20
<20
810
<20
56 200
<20
49 900
586
–
471
235
405
–
347
7
9
–
22
–
20
0.25
Int
Int
Int
Int
High
Int
High
0
0
0
0
0
0
0
2a
1c
1c
1c
4
1c
1c
2002
2002
2004
2007
2008
2008
2011
1
2
3
4
5
6
7
68
70
66
61
63
79
66
8.8
8.4
12.2
11.7
134
10.8
57
3+3
4+3
3+3
4+3
5+4
3+4
4+4
0
0
0
0
1
0
0
BCF
Follow-up,
months
Treatment
details
Primary
treatment
Viral load,
copies/mL
NCCN
M
N
cT
Gleason
score
PSA level
at Dx,
ng/mL
Age at
DX, years
Year
of Dx
Prostate cancer characteristics
Of the 5334 HIV-positive men treated at our institution, 12
with a prostate cancer diagnosis were included in the present
study. Table 1 summarises the HIV parameters, prostate cancer
characteristics, treatment details and oncological outcomes in
our cohort of patients. The mean (SD) age at prostate cancer
diagnosis was 62.7 (8.9) years. At the time of prostate cancer
diagnosis, the median (range) CD4 count was 485 (235–1116)
cells/μL, with eight of the 12 patients having undetectable viral
load (<20 copies/mL). One patient had a history of AIDS
defining illness, Kaposi sarcoma, treated with radiotherapy
(RT) ≈ 16 years before their prostate cancer diagnosis. All 12
patients were on HAART treatment.
ID
Results
Table 1 Prostate cancer and HIV infection characteristics.
We retrospectively reviewed all HIV-positive patients treated
at the Alfred Health. The Alfred Health, through its infectious
disease unit, provides treatment and care for HIV patients for
the entire state of Victoria. HIV-positive patients who were
diagnosed with prostate cancer in the HAART era, from 2000
onwards were identified through the health informatics unit at
the Alfred Health. The medical records for patients who were
identified were reviewed for collection of data on HIV-related
and prostate cancer-related variables. HIV-related variables of
interest were: date of diagnosis of HIV infection, cluster of
differentiation 4 (CD4) count, and viral load at the time of
prostate cancer diagnosis, treatment details for HIV, and any
history of AIDS defining illnesses. Prostate cancer-related
variables of interest included: date of prostate cancer
diagnosis, clinicopathological characteristics of cancer (i.e.
PSA level at diagnosis, Gleason score of diagnostic biopsy,
TNM staging), treatment details and oncological outcomes.
The study was approved by the Alfred Health Ethics
Committee (Project no. 307/14).
HIV infection characteristics at the
time of prostate cancer Dx
Patients and Methods
CD4,
cells/μL
The aim of our present study was to characterise the
clinicopathological features of prostate cancer among
HIV-positive men, in a major HIV referral centre in the state
of Victoria, Australia. We also aimed to evaluate the current
practice pattern in the management of prostate cancer in this
population, as well as the oncological outcomes.
Duration of
HIV, years
Prostate cancer treatment
Follow-up
Alive
Collaboration, it has been reported that compared with the
early HAART era (1996–1999), the life-expectancy among
HIV patients at age 35 years has increased from 25 to 37.3
years in the late HAART era (2003–2005) [4]. Alongside the
prolonged survival of HIV-positive men and the widespread
use of serum PSA testing, prostate cancer is likely to become
more prevalent among the HIV-positive men, and
increasingly, urologists and oncologists will have to care for
HIV-positive men with prostate cancer. However, data on the
management of prostate cancer in this population are
extremely limited, with only a few published series, each
reporting only a handful of patients [5–10].
No
No
No
Yes
Yes
Yes
Yes
Ong et al.
Clinicopathological characteristics and management of prostate cancer among HIV-positive men
Prostate Cancer Characteristics
At the time of prostate cancer diagnosis, the median (range)
serum PSA level was 11.1 (3.9–269) ng/mL. Histopathology of
the diagnostic biopsy showed four of the 12 patients with
Gleason 3 + 3 disease, one (8%) Gleason 3 + 4, three (25%)
Gleason 4 + 3, one (8%) Gleason 4 + 4, and three (25%)
Gleason 5 + 4. Seven patients of the 12 had benign DRE at
diagnosis (cT1c). Based on the National Comprehensive
Cancer Network (NCCN) classification, 10 of the 12 patients
had clinically localised prostate cancer (one low-risk, seven
intermediate-risk, and two high-risk), while the other two had
metastatic disease at diagnosis. More than half of the
patients (seven) had a positive family history of prostate
cancer.
Treatment
After diagnosis, eight of the 10 patients with clinically
localised prostate cancer proceeded to have curative treatment
with surgery or RT. Two patients had open radical
prostatectomy (RP) as their primary treatment. Both had pT2
disease on the RP surgical specimen, with clear surgical
margin, and no lymph nodes involvement. Of the patients
who had RT, one had low-dose-rate brachytherapy (LDR-BT)
with 125I seed, while five had external beam RT (EBRT), one of
which was in conjunction with high-dose-rate BT (HDR-BT)
(17 Gy/2 fractions). One patient with low-volume Gleason 3 +
3 disease was put on active surveillance (AS) after their
prostate cancer diagnosis, while the other remaining patient,
who was diagnosed with Gleason 3 + 3 prostate cancer at the
age of 79 years, was put on watchful waiting (WW), and was
alive at last follow-up. One of the patients with nodal
involvement (cT2N1M0) was initially treated with ADT alone.
However, he was noted to have pT4 disease with bladder
invasion on TURP performed for LUTS 6 years later. He was
subsequently treated with EBRT (50 Gy/20 fractions) for local
control. Another patient with metastatic disease (cT4N1M1)
was treated with a combination of chemo-hormonal therapy,
with six cycles of docetaxel, and EBRT.
Oncological Outcomes
All patients were followed for a median (range) of 46 (9–103)
months. The LDR-BT patient has remained free of
biochemical recurrence (BCR) at 5 years follow-up. One of the
five patients treated with curative EBRT developed BCR, based
on the Phoenix definition, ≈ 7 years after completion of EBRT.
One RP patient has remained BCR-free at 1 year, while
another RP patient had a persistently elevated serum PSA level
postoperatively and was treated with salvage EBRT (60 Gy/30
fractions). The patient on AS had another repeat transperineal
saturation biopsy 2 years after diagnosis, again, confirming
low-volume Gleason 3 + 3 disease and he has remained on AS
at last follow-up. During the follow-up period, there were
three deaths reported, none of which were prostate
cancer-related deaths: one anal cancer and two ischaemic
heart disease.
Discussion
We reported on the clinicopathological characteristics,
management and the oncological outcomes of prostate
cancer in a cohort of HIV-positive men based on our
experience in a major HIV centre in Australia. While
this is a single institutional study, it is likely to be
representative of the current practice patterns in the
population, given that the Alfred Health is the state-wide
HIV treatment centre, and we would have captured most,
if not all, HIV patients with prostate cancer in the state of
Victoria. This is to our best knowledge, one of the few
published series, and the first Australasian series to
date.
Similar to findings in population-based studies in the USA [1],
the incidence of prostate cancer in HIV-positive men in
Australia was reported to be relatively low. Data-linkage
between the Australia National HIV/AIDS Registry and the
Australasian National Cancer Statistics Clearing House
(NCSCH) reported only 24 incident cases of prostate cancer
in 18 794 HIV-positive men between 1982 and 2004: 10 in the
pre-HAART era (1982–1995), six in early-HAART era
(1996–1999) and eight in late-HAART era (2000–2004) [2].
The population-based study also reported significant decline
(Ptrend = 0.026) in the standardised incidence ratio (SIR) of
prostate cancer in HIV-positive men over that period, with a
decline in the SIR to 0.27 (95% CI 0.11–0.52) compared with
the general population in the late-HAART era. However, these
numbers need to be interpreted cautiously, as they do not
necessarily represent a ‘true’ reduced risk of prostate cancer in
the HIV-positive men with HAART treatment, but instead, it
could represent an artefact driven by other development in
prostate cancer diagnosis and/or treatment around the same
period. The rapid uptake of HAART in the HIV-populations
in the 1990s [11] corresponds with the rapid rise in PSA
testing in the general population in Australia around the same
period. Since the listing of PSA testing on the Australia’s
Medical Benefits Schedule in 1988, Smith et al. [12] reported a
continuous rise in PSA testing in a population-based study in
the state of New South Wales, from 1284/100 000 men in 1989
to 6908/100 000 men in 1995 and 12 119/100 000 men in
2005. This has resulted in a corresponding rise in the
incidence of prostate cancer in the general population
(non-HIV).
However, given the poor prognosis from HIV infection in the
pre/early HAART era, screening for non-AIDS defining
illnesses, such as prostate cancer, has been controversial [13];
hence PSA testing was not as commonly utilised in
HIV-positive men. One feature suggesting the
© 2015 The Authors
BJU International © 2015 BJU International
7
Ong et al.
under-utilisation of PSA testing in this population is the
higher grade or stage of prostate cancer diagnosed in our
present cohort of HIV-positive patients with prostate cancer.
The introduction of PSA testing has resulted in a stage
migration in prostate cancer in the general population, with
early and more frequent detection of low-grade, low-volume
disease. Data from the population-based Victorian Prostate
Cancer Registry reported that one in four patients with
prostate cancer in the general population had NCCN low-risk
prostate cancer [14]. However, in our present cohort of
HIV-positive patients with prostate cancer, we observed a
lower proportion of patients with low-risk prostate cancer
(one in 12) and as many as three patients were diagnosed with
Gleason 5 + 4 prostate cancer, two of whom had metastatic
disease with PSA levels of >100 ng/mL at the time of
diagnosis. This is probably secondary to a lack of PSA testing,
resulting in a potential delay in cancer detection, and
subsequent diagnosis of higher grade prostate cancer in the
HIV-positive men.
Given that HIV-positive men are living longer in the HAART
era, this approach will probably change, and PSA testing in
HIV-positive population is likely to become more common
[15]. This is especially true for patients with risk factors for
prostate cancer, such as those with a positive family history.
Family history has long been recognised as one of the
strongest risk factors for prostate cancer, and having an
affected first-degree relative increases one’s risk by two- to
three-fold [16]. The fact that more than half of the
HIV-positive patients with prostate cancer in our present
cohort reported having a family history of prostate cancer
further highlights the need for PSA testing among
HIV-positive men with risk factors for prostate
cancer.
After the diagnosis, there is no universally accepted consensus
about management of prostate cancer in the HIV-positive
men. Data in the literature appeared to suggest that RT has
conventionally been the treatment method of choice for
HIV-positive patients with prostate cancer. Half of our
present cohort had curative RT with either EBRT or BT, and
reported excellent long-term oncological outcomes, with only
one BCR reported at 7 years follow-up. However, there is lack
of detailed treatment-related toxicities documented in our
present cohort of patients. The few published data have
reported that HIV-positive patients with prostate cancer do
not have increased incidence of treatment-related toxicities,
compared with the general population. Ng et al. [10] reported
one of the largest series of HIV-positive patients with prostate
cancer treated with RT based on a single institution
experience in the USA. The study included 14 patients: four
treated with 103Pd seeds, eight with EBRT + BT and two with
EBRT alone, and reported primarily on the gastrointestinal
and genitourinary toxicity. The study showed that
treatment-related complications in HIV-positive patients with
© 2015 The Authors
8 BJU International © 2015 BJU International
prostate cancer are similar to those seen in non-HIV
patients with prostate cancer, giving no evidence that
HIV-positive patients with prostate cancer should be
treated differently from non-HIV patients when
considering RT. This is consistent with a more recent
matched-cohort analysis by Kahn et al. [17], which reported
comparable disease control and toxicity outcomes after
curative EBRT in 13 HIV-positive patients with prostate
cancer and 26 matched non-HIV patients with prostate
cancer.
While data in the Victorian Prostate Cancer Registry reported
>40% of patients with prostate cancer (regardless of NCCN
risk categories) in the non-HIV population in the state of
Victoria were treated primarily with RP [14], we reported a
much lower proportion of patients with prostate cancer who
were treated with RP in our present cohort of HIV-positive
patients with prostate cancer, with only two of the 12 having
RP, and both occurred in very recent years. This is similar to
the proportion reported in the literature. In a recent study of
43 HIV-positive and 86 matched HIV-negative patients with
prostate cancer treated in a single institution in the USA, there
were a significantly lower proportion of HIV-positive patients
who had open RP (16%) compared with HIV-negative prostate
cancer patients (57%) (P < 0.001) [18]. In other smaller
studies, Levinson et al. [5] reported only one of 10
HIV-positive patients with prostate cancer treated in a single
institution in the USA had RP, while in another
multi-institutional cohort of 17 HIV-positive patients with
prostate cancer in the USA, Pantanowitz et al. [6] reported
three (18%) patients who had RP. The lower proportion of
utility of surgery for prostate cancer management in
HIV-positive men is probably due to a combination of factors
including the potentially higher perioperative complication
rates in the immunosuppressed population, and the concern of
occupational risk to the surgical team. In a retrospective
review of RP performed in five HIV-positive patients at the
Memorial Sloan Kettering Cancer Centre, Huang et al. [7]
reported two patients with wound infections, including one
(who had the lowest CD4 counts) requiring hospitalisation for
i.v. antibiotics. It has been suggested that with the use of
minimally invasive surgical approaches, which may reduce the
healthcare workers’ exposure to HIV-positive material, and
careful selection of surgical candidate, including assessment of
CD4 counts and viral loads, RP could potentially be offered to
more HIV-positive patients with prostate cancer in the future
[7].
Apart from curative treatment with RT and surgery, we also
reported one patient who was put on AS and another on WW.
Patients with HIV often have underlying anxiety, which might
precede their HIV infection, triggered by the HIV diagnosis,
or develop over the course of their dealing with the HIV
infection [19]. There were concerns in the past that putting
patients on AS might evoke psychological stress, given that
Clinicopathological characteristics and management of prostate cancer among HIV-positive men
patients are living with ‘untreated’ prostate cancer. Hence,
putting HIV-positive patients on AS could potentially
aggravate the underlying anxiety. However, a recent review by
Bellardita et al. [20] showed that patients with prostate cancer
on AS can have favourable anxiety scores, and a relatively
good quality of life. In fact, the HIV-positive patient in our
present cohort has remained on AS for >2 years since
his initial diagnosis of low-volume low-grade prostate
cancer.
Despite the lack of guidelines on prostate cancer management
specific to the HIV-positive population, a recent study
reported that HIV-positive men were mostly treated in
accordance with the NCCN guideline recommendation [18].
In a cohort of 43 HIV-positive patients with prostate cancer
treated in a single institution in the USA, Murphy et al. [18]
reported two patients who were deemed to have received
inappropriate treatment: one patient was over-treated, due to
presence of other medical comorbidities, while another patient
who was put on WW was considered under-treated. The
author concluded that the difficulty in life-expectancy
estimation in this group of patients as the cause of under- or
over-treatment of prostate cancer. This highlighted the need
for a multidisciplinary approach, not only involving urologists
and oncologists but HIV specialists, in the management of
prostate cancer among HIV-positive patients. It has been
previously reported that input from a multidisciplinary team
has led to high impact changes in the management plan in
about one quarter of the uro-oncological cases [21]. This will
definitely help minimise the likelihood of inappropriate
management among HIV-positive men.
In conclusion, our present study showed a lower proportion of
low-risk prostate cancer in the HIV-positive population
compared with the general population in the state of Victoria.
HIV-positive patients were offered the full spectrum of
prostate cancer treatment options (ranging from AS to radical
surgery to palliative chemotherapy), with most patients being
treated with RT. We think our review suggest that in Australia,
as men with HIV are living longer, well into their 70s [4], they
should be offered PSA testing and all potential treatment
options in the same manner as men in the general
population: that is, taking into account all co-morbidities and
their life-expectancy in a shared decision-making
framework.
Acknowledgements
The authors would like to thank Paul Hougham
(Information Analyst at the Clinical Performance Unit/ Health
Informatics, Alfred Health) and Robin Smith (Research
Manager at the William Buckland Radiotherapy Centre, Alfred
Health) for assistance with patient identification and data
extraction from the Alfred Health electronic medical
records.
Conflict of Interest
Nil to disclose.
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Correspondence: Wee Loon Ong, Department of Urology,
Alfred Health, Commercial Road, Prahran, VIC 3181,
Australia.
e-mail: [email protected]
10
© 2015 The Authors
BJU International © 2015 BJU International
Abbreviations: ADT, androgen-deprivation therapy; AS, active
surveillance; BCR, biochemical recurrence; (HDR)(LDR)-BT,
(high-dose-rate) (low-dose-rate) brachytherapy; CD4, cluster
of differentiation 4; (EB)RT, (external beam) radiotherapy;
HAART, highly active anti-retroviral therapy; NCCN, National
Comprehensive Cancer Network; RP, radical prostatectomy;
SIR, standardised incidence ratio; WW, watchful waiting.