Survival of patients with Kaposi’s sarcoma in the South African antiretroviral treatment era: A retrospective cohort study

Abstract

Background When South Africa implemented its antiretroviral treatment (ART) programme in 2004, the model for treating HIV-positive Kaposi sarcoma (KS) patients shifted from symptomatic palliation to potential cure. Objective To evaluate survival and changes over time in AIDS-KS patients treated at a tertiary academic hospital oncology unit (the Steve Biko Academic Hospital (SBAH) medical oncology unit) in Pretoria in the context of ART availability in South Africa. Methods We conducted a retrospective review of electronic and paper records of KS patients who accessed cancer care between May 2004 and September 2012. We used Kaplan Meier survival functions to estimate one- and two-year survival, and Cox regression models to identify changes over time and prognostic factors. Results Our study included 357 AIDS-KS patients, almost all of whom were black Africans (353; 99%); 224 (63%) were men. Median age at cancer diagnosis was 37 years (interquartile range 30–43 years); and median baseline CD4 count was 242 (IQR 130–403 cells/μL). Most patients received ART (332; 93%) before or after KS diagnosis; 169 (47%) were treated with chemotherapy and 209 (58%) with radiation therapy. The mortality was 63% lower (adjusted HR 0.37; 95% CI 0.19–0.73) in the late (2009–2012) than in the early (2004–2008) ART period. Receiving chemotherapy (adjusted HR 0.3; 95% CI 0.15–0.61) and poor risk ACTG KS stage (adjusted HR 2.88; 95% CI 1.36–6.09) predicted mortality. Conclusion Our results show that large national ART roll-out programmes can successfully reduce KS-related mortality at the individual patient level. If ART coverage is extended, KS-associated morbidity and mortality is likely to drop.

Establishing a multidisciplinary AIDS-associated Kaposi’s sarcoma clinic: Patient characteristics, management and outcomes

“…The proportion of T1 patients receiving chemotherapy (52.8%) and RT (25.0%) differs from treatment patterns previously reported in the same geographical area and in Gauteng Province, in that patients were more likely to receive chemotherapy than RT. [5,6] This is in keeping with international guidelines and the current protocol of the MKSC in which chemotherapy with combination bleomycin and vincristine or paclitaxel as single agent is used in all patients considered fit for chemotherapy. Radiotherapy is reserved for chemoresistant or highly localised lesions, or patients with life threatening localised lesions when chemotherapy cannot be started urgently.…”

“…[15] High rates of lower limb and oral cavity involvement are in keeping with other SA cohorts. [5,6,11] The relatively low number of recorded pulmonary KS cases (11.9%) could be explained by the limited access to computed tomography scanning and the difficulty in distinguishing KS from PTB on plain chest films. Three of the 4 patients diagnosed with pulmonary KS were also on TB treatment.…”

“…[5,12,19] Recently a 2year OS rate of 79% was reported in an SA cohort treated in the late ART era, but this cohort included only 56.6% poorrisk patients compared with the 90.5% reported here and excluded patients with visceral disease. [6] A Nigerian AIDSKS cohort with minimal access to chemotherapy reported a 1year mortality rate of 22% and 1year OS of 50 55%. [20] Overall, the outcomes are still markedly inferior to those of international cohorts.…”

“…Despite retrospective cohorts suggesting that the addition of chemotherapy to ART may improve survival, this has not been prospectively validated. [5,6,19] In the T1 cohort, the addition of chemotherapy to ART improved 2year OS markedly from 35.3% to 77.3%. When T1 patients who were responding optimally to ART are excluded, 2year OS without chemotherapy falls to 15.4%.…”

Reduction of Kaposi’s Sarcoma-Associated Herpesvirus Latency Using CRISPR-Cas9 To Edit the Latency-Associated Nuclear Antigen Gene

“…study from South Africa had indicated a 2-year survival rate of less than 80% with chemotherapy or radiotherapy (4). The KS epidemic has run parallel to the HIV-1 epidemic, especially in sub-Saharan Africa where the HIV-1/AIDS epidemic continues and antiretroviral therapy (ART) has only recently become more widely available (5).…”