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

Abstract

Purpose To prospectively compare survival between human immunodeficiency virus (HIV)-infected versus HIV-uninfected cervical cancer patients who initiated curative chemoradiation therapy (CRT) in a limited-resource setting. Methods and Materials Women with locally advanced cervical cancer with or without HIV infection initiating radical CRT in Botswana were enrolled in a prospective, observational, cohort study from July 2013 through January 2015. Results Of 182 women treated for cervical cancer during the study period, 143 women initiating curative CRT were included in the study. Eighty-five percent of the participants (122 of 143) had stage II/III cervical cancer, and 67% (96 of 143) were HIV-infected. All HIV-infected patients were receiving antiretroviral therapy (ART) at the time of curative cervical cancer treatment initiation. We found no difference in toxicities between HIV-infected and HIV-uninfected women. The 2-year overall survival (OS) rates were 65% for HIV-infected women (95% confidence interval [CI] 54%-74%) and 66% for HIV-uninfected women (95% CI 49%-79%) (P = .70). Factors associated with better 2-year OS on multivariate analyses included baseline hemoglobin >10 g/dL (hazard ratio [HR] 0.37, 95% CI 0.19-0.72, P = .003), total radiation dose ≥75 Gy (HR 0.52, 95% CI 0.27-0.97, P = .04), and age <40 years versus 40-59 years (HR 2.17, 95% CI 1.05-4.47, P = .03). Conclusions Human immunodeficiency virus status had no effect on 2-year OS or on acute toxicities in women with well-managed HIV infection who initiated curative CRT in Botswana. In our cohort, we found that baseline hemoglobin levels, total radiation dose, and age were associated with survival, regardless of HIV status.

HIV infection is not associated with the initiation of curative treatment in women with cervical cancer in Botswana

“…However, it remains controversial whether women who have cervical cancer with HIV infection have outcomes similar to those of women who have cervical cancer without HIV infection. Although some studies suggest that HIV infection may be associated with decreased survival, our previous findings in Botswana have suggested that patients with HIV infection who initiated chemoradiation treatment (CRT) with curative intent have outcomes similar to those of patients without HIV infection . The factors associated with improved survival in this group were hemoglobin levels ≥10 g/dL and total radiation dose received, but not HIV infection .…”

“…We identified the baseline hemoglobin level as a significant predictor of CRT initiation. Previous studies of locally advanced cervical cancer in WLWH, including results from our curative cohort of patients with and without HIV, have demonstrated that a low hemoglobin level at baseline is a significant, negative predictor of overall survival . Although survival outcomes may be linked to tumor biology, such as hypoxic microenvironments or aggressive phenotypes, the determination to initiate curative therapy is a clinical choice.…”

“…Although some studies suggest that HIV infection may be associated with decreased survival, our previous findings in Botswana have suggested that patients with HIV infection who initiated chemoradiation treatment (CRT) with curative intent have outcomes similar to those of patients without HIV infection . The factors associated with improved survival in this group were hemoglobin levels ≥10 g/dL and total radiation dose received, but not HIV infection . However, it is unknown whether HIV infection plays a role in the initiation of curative CRT in the modern ART era with well managed HIV infection, because of either physician bias or the sequela of HIV infection, which makes it challenging for patients with HIV infection to receive chemotherapy or curative‐dose RT .…”

“…Curative CRT included from 45 to 50 grays (Gy) of whole‐pelvis RT, weekly concurrent cisplatin (35‐40 mg/m 2 ) for 5 cycles, and high‐dose‐rate brachytherapy (7 Gy in 3‐4 fractions or 6 Gy in 4‐5 fractions) using either a tandem‐and‐ring applicator or a tandem‐and‐ovoid applicator. Details of RT planning at GPH for cervical cancer have been previously described …”

Tearing down the false walls to HIV cancer care

“…No obvious explanation on the basis of treatment was reported in that analysis, and the initiation and delivery of curative‐intent therapy did not differ according to HIV status. In contrast, in a prospective cohort study of 182 women, of whom 143 initiated curative‐intent therapy, outcomes did not differ between those with and without HIV infection …”