Evaluation of a Predictive Staging Model for HIV-Associated Kaposi Sarcoma in Uganda

Abstract

Background HIV-associated Kaposi sarcoma (KS) is commonly staged using the AIDS Clinical Trials Group criteria, which classify 3 variables-- tumor extent (T), immune status (I), and systemic symptoms (S) – into good risk (0) and poor risk (1). Although validated in the US and Europe, these criteria have not been systematically evaluated in sub-Saharan Africa (SSA), where the burden of KS is greatest. Methods We reviewed medical charts of adult patients with HIV-associated KS seen at the Uganda Cancer Institute from 1992–2007. Vital status at 2 years after KS diagnosis was determined from the medical chart, or by contacting the patient or next of kin. Survival estimates used Kaplan-Meier (KM) methods. Predictors were evaluated for 2 periods: 0–4 months and 4–24 months after diagnosis. Results At 2 years after diagnosis, 167 (41%) patients were alive, 156 (39%) had died, and 81 (20%) were lost to follow-up. The KM estimate of 2-year survival was 57%. S1 was associated with death in months 0–4 [HR 6.4, 95% CI (1.9–21.1)], while T1 was associated with death in months 4–24 [HR 4.0, 95% CI (1.4–11.5)]. Immune status was not associated with survival. Conclusions Systemic symptoms were strongly associated with death in the early period after KS diagnosis, while tumor status was most predictive of death in the 4–24 month period. These findings suggest that different processes may influence outcomes in early and late periods following KS diagnosis. Further studies are needed to confirm these observations and to identify better predictors of KS survival in SSA.

Three year survival among patients with aids-related Kaposi sarcoma treated with chemotherapy and combination antiretroviral therapy at Moi teaching and referral hospital, Kenya

“…As previously reported in the results, among patients with normal CD4 cell counts (> = 500/μl) at the time of initiating chemotherapy, the HR was 0.401(0.05,3.23), p value 0.391, which means the hazard of death was reduced by 60% but this was not statistically significant. A retrospective study conducted in Uganda to evaluate the validity of ACTG criteria in sub-Saharan Africa did not find baseline CD4 to be a predictor of survival in AIDS-KS patients whether in the short run or after 2 years [32]. The study reported a poor survival rate of 57% at 2 years and unexpectedly did not find cART to be a predictor of survival probably because of incomplete access to records or use of low potency anti-retroviral drugs in Uganda from 1992 to 2007 when the study participants were treated.…”

Sobrevida e Fatores Prognósticos de Pacientes com Sarcoma de Kaposi Atendidos em um Centro de Assistência de Alta Complexidade em Oncologia

“…Em investigações realizadas em centros de referência em infectologia junto a pessoas vivendo com HIV, alguns fatores prognósticos de pior sobrevida já foram descritos, quais sejam: estadiamento avançado do tumor 5,6,17,18 , doenças sistêmicas concomitantes 5,6,17 , comprometimento pulmonar e hepático 19 , diagnóstico tardio do HIV 5 , contagem de células CD4 baixa (<200 células/mm 3 ) 18,19 e detecção sorológica do herpes-vírus humano tipo 8 ao diagnóstico 18 . Nessa investigação, idade ≥50 anos e sorologia anti-HIV positiva foram os únicos fatores independentes de pior prognóstico identificados.…”

“…Nessa investigação, idade ≥50 anos e sorologia anti-HIV positiva foram os únicos fatores independentes de pior prognóstico identificados. De modo controverso, outras pesquisas não identificaram a idade como um preditor da sobrevida do SK 5,6,[17][18][19] . Os resultados deste estudo são diferentes: diante do controle por diversas variáveis de confusão, inclusive sorologia anti-HIV, o efeito da idade ≥50 anos sobre o óbito foi evidenciado.…”

“…Em estudo realizado na África do Sul entre os anos 2000 e 2007 com 6.292 pessoas vivendo com HIV, 215 (3,4%) tinham SK: os que recebiam terapia antirretroviral altamente ativa apresentaram taxa de mortalidade de 25/100 pessoas-ano e os que não recebiam, 70/100 pessoas-ano 5 . Em Uganda, onde o SK é a segunda neoplasia mais incidente na população geral 4 , um estudo conduzido com 404 indivíduos com SK associado ao HIV evidenciou probabilidade de sobrevida igual a 65,0% um ano após o diagnóstico e igual a 57,0% após dois anos 6 .…”

Beyond T Staging in the Treat All Era: Capturing the Severity and Heterogeneity of Kaposi’s Sarcoma in East Africa

“…9 Since the introduction of highly active ART in 1995, a number of significant changes in the treatment and epidemiology of KS have led to questions about whether ACTG staging is still optimal. 3,11 To address these limitations, in 2014 the WHO developed a modified staging system for KS specifically to guide treatment in resource limited settings, which is not yet in wide use, and has yet to be validated or compared to ACTG staging. 12 Ultimately, a cancer staging system should be both of prognostic value and guide therapy.…”