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Cancer Trends in
North America Over
the Past Decade
Benigno Rodríguez, MD, MSc, FIDSA
Durban, 19 July 2016
DISCLOSURES
 Honoraria from Gilead
 Funding from NIH, NHLBI, NCI
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OUTLINE
 Cancer trends among PLWH in North America
 Overall frequency
 Cancer-specific patterns
 Effect of infectious etiologies and immune status
 Conclusions: Strategies to bend the trend
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Background
 A greater incidence of malignancy has been
observed among HIV-infected persons relative to
the general population since the beginning of he
epidemic
 Even after controlling for conventional risk factors
 The introduction of cART has changed the patterns
of occurrence of malignancy to various degrees
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CNICS Cancers Over Time
200
180
160
140
120
100
80
60
40
20
0
1997
1999
2001
2003
2005
ADC
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2007
2009
2011
2013
NADC* *Excluding non-melanoma skin
 Examined secular trends in 3 periods: 1996-1999.
2000-2004, 2005-2009
 N= 86,620 HIV-infected (475,660 PY of FU); 196,987
HIV-uninfected (1,847,932 PY of FU)
 Nine target cancers (centrally adjudicated); KS, NHL,
HL, lung, anal, colorectal, liver, OP, melanoma
 Key features:
 Competing risks analysis, adjusted for sex, race, and
cohort
 Cumulative cancer risk at age75
 Contrast to cancer-specific hazard rate
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Crude Cancer-specific Incidence
Rates, HIV+ and HIV-
 Same for crude cumulative incidence at age 65 or
75, except for melanoma and colorectal/OP cancer
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Decreasing Calendar Trends In Cancer
and Mortality, 1996-2009
* Significant
trend in causespecific HR only
*
*
*
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Increasing Calendar Trends In Cancer
and Mortality, 1996-2009
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Interval Summary
 ADC incidence has decreased drastically among HIVinfected persons in North America
 But risk remains massively higher than in the general
population
 Incidence and risk of certain NADCs has increased
despite the introduction of cART
 Including anal, colorectal, and liver
 At least partly d/t improved survival (no change in csHR)
 Cumulative incidence trend in HIV+ and HIV- was similar
for liver cancer, but opposite for colorectal
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Delayed vs. Immediate ART Initiation:
Effect on Cancer Incidence
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INSIGHT Study Group. NEJM 2015; 373: 9
0
HBV Vaccine Response among HIVinfected Patients and Risk of Cancer
 N=1,578; 96 (6%) developed incident cancer during follow up
HBV vaccine responders
HBV vaccine non-responders
.25
Cumulative Subhazard
.4
Cumulative hazard of cancer
Competing-risks regression
.3
.2
.1
.15
.1
.05
P=0.03*
0
0
.2
0
5
15
10
Follow-up time (years)
20
5
failrespond=0
*Adjusted for age, CD4 (nadir and time-updated), history of OI
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10
15
analysis time
20
failrespond=1
0
Effect of Viremia on NHL Incidence
 3-month lagged
viremia levels shown
 Viremia as a
continuous value was
associated with a HR
for NHL of 1.42/log10
copies/mL
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Achenbach C, et al. CID 2014; 58:1599
Conclusions
 Most ADCs have decreased dramatically, but HIV-infected
persons remain at considerable risk
 The risk of NADCs has surpassed that of ADCs in the cART
era and in some cases continues to rise
 A strong link to immune competence, persistent viremia,
and infectious etiologies suggests possible strategies to
modulate these trends:
 Early, universal, suppressive ARV therapy
 Increased screening and aggressive treatment for many NADCs
 Vigorous treatment of coinfecting oncogenic pathogens
 Reduction of residual inflammation/immune activation
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Acknowledgements
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CNICS Malignancy Data Update
• Cancer data collection through 2014
• 3,897 verified cancer diagnoses
– 66% non-KS with histopathology
– 48% KS with histopathology
• Details on diagnosis confirmation method, histopathology,
stage, grade, family history, exposures to tobacco and
alcohol
– 59% with staging (summary or TNM)
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website for distributed review
by multiple Adjudication
Committee members
DMC ascertainment of
eligible participants
transmitted to Sites
Site EMR clinical
documentation
DMC
DMC Processes, Scrubs,
and Indexes DRAs
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Abstraction (DRA)
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De-identified
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to DMC
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to individual investigator
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