HIV Infection and Survival Among Women With Cervical Cancer

Abstract

Purpose Cervical cancer is the leading cause of cancer death among the 20 million women with HIV worldwide. We sought to determine whether HIV infection affected survival in women with invasive cervical cancer. Patients and Methods We enrolled sequential patients with cervical cancer in Botswana from 2010 to 2015. Standard treatment included external beam radiation and brachytherapy with concurrent cisplatin chemotherapy. The effect of HIV on survival was estimated by using an inverse probability weighted marginal Cox model. Results A total of 348 women with cervical cancer were enrolled, including 231 (66.4%) with HIV and 96 (27.6%) without HIV. The majority (189 [81.8%]) of women with HIV received antiretroviral therapy before cancer diagnosis. The median CD4 cell count for women with HIV was 397 (interquartile range, 264 to 555). After a median follow-up of 19.7 months, 117 (50.7%) women with HIV and 40 (41.7%) without HIV died. One death was attributed to HIV and the remaining to cancer. Three-year survival for the women with HIV was 35% (95% CI, 27% to 44%) and 48% (95% CI, 35% to 60%) for those without HIV. In an adjusted analysis, HIV infection significantly increased the risk for death among all women (hazard ratio, 1.95; 95% CI, 1.20 to 3.17) and in the subset that received guideline-concordant curative treatment (hazard ratio, 2.63; 95% CI, 1.05 to 6.55). The adverse effect of HIV on survival was greater for women with a more-limited stage cancer ( P = .035), those treated with curative intent ( P = .003), and those with a lower CD4 cell count ( P = .036). Advanced stage and poor treatment completion contributed to high mortality overall. Conclusion In the context of good access to and use of antiretroviral treatment in Botswana, HIV infection significantly decreases cervical cancer survival.

Impact of Human Immunodeficiency Virus Infection on Survival and Acute Toxicities From Chemoradiation Therapy for Cervical Cancer Patients in a Limited-Resource Setting

“…Those studies estimated a 1.7- to 2.0-fold increased risk of death associated with HIV infection. There are, however, several key differences between our study and those prior studies that may explain our discordant findings (16, 17, 28). In contrast to our study in which only women being treated with curative CRT were included, the 3 previous studies included women being treated with both palliative and curative intent.…”

“…However, our findings are discordant with results from a previous study in Botswana by Dryden-Peterson et al (17) (2016), from an analysis of administrative datasets of women in the United States with cervical cancer by Coghill et al (16) (2015), and from a retrospective study in Brazil by Ferreira et al (28) (2017). Those studies estimated a 1.7- to 2.0-fold increased risk of death associated with HIV infection.…”

“…However, when the analysis was restricted to those women who initiated curative CRT, HIV status was not found to be a predictor of OS. Furthermore, both Dryden-Peterson et al (17) (2016) and Ferreira et al (28) (2017) were also limited by their inability to adjust for hemoglobin levels, an important clinical predictor, as well as by missing details about chemotherapy and radiation treatment history. Our study demonstrates that patients with well-controlled HIV infection who are receiving ART and initiate curative CRT have outcomes similar to those of HIV-uninfected individuals and also highlights the critical importance of prospectively measuring and accounting for all clinical-and treatment-related confounders known to affect treatment outcomes and OS.…”

“…However, the outcomes of curative chemoradiation therapy (CRT) among HIV-infected patients are not well described. Studies from the United States (16) and from Botswana (17) indicate that survival may be poorer for HIV-infected compared with HIV-uninfected women with cervical cancer; however, those studies had limited treatment data and included women unable to receive CRT.…”

Outcomes after Radiation Therapy for HIV Positive Patients with Invasive Cervical Cancer

“…Positive HIV status was associated with an HR of 3.7 (CI 95% 1.3-10.2; p=0.009) of residual tumor. -Peterson et al (2016) reported that 3-year survival for HIV positive patients was only 35% in Botswana, a rate lower to our 3-year OS rate, which could exceed 50%. In a non-VIH population, Han, Milosevic, Fyles, Pintilie & Viswanathan, (2013) showed that the 5-year OS rate was decreased in absence of brachytherapy (46% versus 58%), a rate similar to our 5-year OS.…”