Since the introduction of HAART, the outcome of the aggressive lung malignancy non-small cell lung cancer (NSCLC) in HIV-positive individuals has improved and is now the same as HIV-negative patients, according to a study published in the August 2003 edition of the British Journal of Cancer. However, the prognosis for both groups of patients remains poor, with an average life expectancy of only four months after diagnosis of the cancer.
Although NSCLC is very rare in HIV-positive patients, HIV-infected individuals are approximately four times more likely than age and sex matched HIV-negative people to develop the condition. The reason for this is unclear, but it has been suggested that it is because HIV-positive people are more likely to smoke, are more vulnerable to infections in the lungs and have chronic immune suppression. In the pre-HAART era, NSCLC was associated with a significantly poorer outcome in HIV-positive patients. It has been suggested that this was because it involved a more aggressive form of disease, and that HIV-positive individuals received sub-optimal anti-cancer therapy because of concerns about their immune status.
The outcome of NSCLC has been little studied since the introduction of effective anti-HIV therapy, and in a retrospective study investigators at London’s Chelsea and Westminster Hospital, the UK’s largest HIV treatment centre, compared treatment and outcome of HIV-positive HAART-treated patients with age and sex matched HIV-negative controls with a similar stage of NSCLC.
Between January 1996 and October 2002, nine cases of NSCLC were identified in HIV-positive patients and 27 in HIV-negative matched controls. The HIV-positive patients had relatively advanced immune damage with an average CD4 cell count of 134 cells/mm3 and average HIV viral load was 173 copies/mL, with a third of patients having an undetectable viral load.
Average survival in both the HIV-positive and HIV-negative patients was four months. Both groups of patients received a similar number of cycles of chemotherapy, and a stable or partial response by achieved by 50% of individuals in both arms of the study. One-year survival was 11% in HIV-positive individuals and 22% in HIV-negative people.
HAART was used by seven of the HIV-positive patients at the start of chemotherapy, but two stopped due to concerns about interactions. There were no deaths in either patient group due to chemotherapy and none of the HIV patients died of HIV-related causes.
The investigators note, “before the introduction of HAART HIV-related lung cancer patients had a worse outcome than HIV-negative matched controls…This study compares the outcome of these patients since the introduction of HAART. It shows that survival of HIV-positive and HIV-negative patients is now the same, suggesting the outcome of HIV-associated NSCLC has improved.”
Possible reasons for this are fewer deaths in HIV-positive patients caused by immune deficiency and the willingness of oncologists to provide HIV patients with the same amount of chemotherapy as their HIV-negative peers. Prior to HAART chemotherapy dose modification was common.
Nevertheless, the investigators note the poor prognosis of individuals diagnosed with NSCLC, reflecting the “advanced and aggressive” nature of the disease in young people, rather than any HIV-related factors.
Given the poor prognosis of NSCLC, the investigators suggest that it would be more appropriate to stop HAART rather than modify chemotherapy if there is an interaction between them.
Further information on this website
Lung cancer - overview
Lung cancer more common in HIV-positive patients since HAART - news story
Powell T et al. Does HIV adversely influence the outcome in advanced non-small-cell lung cancer in the era of HAART? British Journal of Cancer 89: 455 –457, 2003.