The majority of HIV-positive women diagnosed with gynaecological cancer do not receive treatment recommended by cancer guidelines, according to research conducted in the United States and published in AIDS. Women whose care did not match guideline standards had poorer survival compared to women who received the recommended care. Toxicity and patient factors were the main reasons why women did not receive treatment recommended in guidelines.
“To our knowledge, there is no case series describing guideline-specific care and outcomes in HIV-infected women with gynecologic cancers,” comment the authors. “As these cancers increase, our ability to meet the standard of care and to understand the impact of standard-of-care treatment in this population is critical.”
The development of highly effective and safe antiretroviral therapy means that most people living with HIV have a good chance of surviving well into old age. Diseases associated with ageing, including a range of non-AIDS-defining cancers, are an increasingly important cause of serious illness and death in people with HIV.
Previous research has shown that HIV-positive people who have cancer are less likely to receive guideline-recommended treatment compared to cancer patients in the general population.
With the exception of cervical cancer, the treatment and outcomes of gynaecological cancers in HIV-positive women have received little attention in the medical literature.
Investigators designed a retrospective study involving women who were diagnosed with gynaecological cancer while receiving HIV care at two clinics in Baltimore between 2000 and 2015.
The investigators described the type of cancer, whether their treatment met National Comprehensive Cancer Network (NCCN) guidelines and compared outcomes according to adherence to these guidelines.
A total of 57 women were diagnosed with gynaecological cancer: 26% with vulvar cancers; 46% with cervical cancers; 16% with ovarian cancers and 12% with uterine cancers.
The majority (53%) were diagnosed with stage I cancers, the remaining 47% with stage II-IV cancers. Women with ovarian cancer were much more frequently diagnosed with later-stage cancers: 89% were diagnosed with stage II-IV cancers.
Median age at cancer diagnosis was 46 years and 88% of women were black. Common co-morbidities included hypertension (32%), diabetes (7%) and viral hepatitis co-infection (30%). A fifth of women had a history of injecting drug use and a quarter had a psychiatric condition such as depression, anxiety or bipolar mood disorder.
The median interval between HIV diagnosis and cancer diagnosis was 8.5 years. Median CD4 cell count at the time of cancer diagnosis was 315 cells/mm3. Two-thirds of women were receiving antiretroviral therapy at the time their cancer was diagnosed. The median viral load was 400 copies/ml and 18 women had an undetectable viral load.
Overall, 49% of women received guideline-adherent care. Women with stage I disease were more likely to receive care that met NCCN guidelines compared to women with stage II-IV disease (73% vs 22%).
Common reasons why women did not receive care that met guidelines standards were toxicity (38%), patient-related issues such as loss to follow-up (31%), co-morbidities (17%), practitioner-related issues (10%) and cancer progression (3%). Toxicity was the main reason (43%) why women with stage II-IV cancers didn’t receive the recommended treatment.
Overall 48-month survival differed between the type of cancer: 100% for uterine cancers; 79% for cervical cancers; 77% for vulvar cancers and 21% for ovarian cancers.
Survival differed according to cancer type and treatment. Nearly all the women with stage I cancer were alive after 48 months, regardless of adherence to NCCN guidelines (adherence: 94% vs non-adherence, 100%). For women with stage II-IV malignancy, however, 48-month survival was 60% for women whose care met guideline standards compared to 28% for those with non-adherent care (p = 0.05).
“Further research is necessary to define treatment-related limitations and interactions for women receiving both cART [combination antiretroviral therapy] and cancer-related treatments, and also to compare matched patients who are not infected with HIV,” conclude the authors. “As treatment for gynecological cancers continue to evolve, this will include not only chemotherapy, radiation, and surgery, but will incorporate targeted and immunotherapies. This study highlights the critical need to expand our understanding of best practice for the treatment of HIV-infected women with gynecological cancers, particularly those with advanced disease.”
Levinson, KL et al. Gynecologic cancer in HIV-infected women: treatment and outcomes in a multi-institutional cohort. AIDS 32: 171-77, 2018.