Combined modality therapy for HIV-infected patients with squamous cell carcinoma of the anus: outcomes and toxicities

Efficacy and Toxicity of (Chemo)Radiation Therapy in HIV+ Patients with Squamous Cell Anal Cancer, a Subgroup Analysis of the National Multicenter Cohort FFCD-ANABASE

PURPOSE

The influence of human immunodeficiency virus (HIV) infection on clinical outcomes in patients receiving (chemo)radiation therapy (RT) for squamous cell carcinoma of the anus (SCCA) is debated. The objective of this study was to compare efficacy and safety according to HIV status in patients with SCCA treated with C/RT.

METHODS AND MATERIALS

Between January 2015 and April 2020, 488 patients with a known HIV status (17.6% HIV+) were treated with radiation therapy for SCCA and included in the FFCD-ANABASE multicentric prospective cohort. Clinical outcomes including overall survival (OS), locoregional recurrence-free survival, colostomy-free survival, response rate at 4 to 6 months, cancer-specific survival, relapse-free survival, and severe acute and late toxicity were compared between HIV+ and HIV- patients.

RESULTS

The median follow-up was 35.8 months. HIV+ patients were younger (P < .01) and predominantly male (P < .01). Intensity modulated radiation therapy was performed in 80.7% of patients, and 80.9% received concurrent chemotherapy. A higher proportion of HIV+ patients received induction chemotherapy compared with HIV- patients. No statistically significant difference in overall treatment time or severe acute and late toxicities was found between HIV+ and HIV- patients. In univariate analyses, OS (HR = 2.1 [CI 95% 1.2;3.5], P = .007), locoregional recurrence-free survival (HR = 1.7 [1.1;2.7], P = .02), and colostomy-free survival (HR = 1.7 [1.1;2.6], P = .01) were significantly shorter in HIV+ patients than in HIV- patients. Response rate, cancer-specific survival, and relapse-free survival were not significantly different. The recurrence site was significantly different according to HIV status. In the multivariate analysis, prognostic factors for OS were a World Health Organization performance status of ≥1 for the whole population, as well as HIV+ status for the subgroup of women.

CONCLUSIONS

HIV+ patients treated with chemo-RT for SCCA have poorer clinical outcomes, especially women. No difference was found in toxicity according to HIV status with intensity modulated radiation therapy technique.

Anal Cancer: The Past, Present and Future

Anal cancer is a rare cancer that accounts for about 2% of all gastrointestinal tract malignancies. Among anal cancer, squamous cell cancer is the most common malignancy. The incidence of all stages of anal squamous cell cancer has been increasing. Human papillomavirus infection and immunosuppression are major risk factors for anal cancer. The management of anal cancer has evolved over the past several decades and continues to do so. Chemoradiation therapy remains the mainstay for treatment for most patients with early-stage disease, whereas systemic therapy is the primary treatment for patients with metastatic disease. Patients with persistent disease or recurrence following chemoradiation therapy are treated with salvage surgery. Access to novel cytotoxic combinations and immunotherapy has improved the outcomes of patients with advanced disease. This review provides an overview of advances in the management of anal cancer over the past two decades. This paper reviews the epidemiology, risk factors, pathology, diagnosis, and management of localized and advanced anal squamous cell cancer, highlights current knowledge gaps in the management of anal cancer, and discusses future directions.

Factors Affecting Clinical Outcomes Among Patients Infected With HIV and Anal Cancer Treated With Modern Definitive Chemotherapy and Radiation Therapy

Purpose

Anal cancer affects a disproportionate percentage of persons infected with human immunodeficiency virus (HIV). We analyzed a cohort of patients with HIV and anal cancer who received modern radiation therapy (RT) and concurrent chemotherapy to assess whether certain factors are associated with poor oncologic outcomes.

Patients and Methods

We performed a retrospective chart review of 75 consecutive patients with HIV infection and anal cancer who received definitive chemotherapy and RT from 2008 to 2018 at a single academic institution. Local recurrence, overall survival, changes in CD4 counts, and toxicities were investigated.

Results

Most patients were male (92%) with large representation from Black patients (77%). The median pretreatment CD4 count was 280 cells/mm³, which was persistently lower at 6 and 12 months' posttreatment, 87 cells/mm³ and 182 cells/mm³, respectively (P < .001). Most (92%) patients received intensity modulated RT; median dose was 54 Gy (Range, 46.8-59.4 Gy). At a median follow-up 5.4 years (Range, 4.37-6.21 years), 20 (27%) patients had disease recurrence and 10 (13%) had isolated local failures. Nine patients died due to progressive disease. In multivariable analysis, clinically node negative involvement was significantly associated with better overall survival (hazard ratio, 0.39; 95% confidence interval, 0.16-1.00, P = .049). Acute grade 2 and 3 skin toxicities were common, at 83% and 19%, respectively. Acute grade 2 and 3 gastrointestinal toxicities were 9% and 3%, respectively. Acute grade 3 hematologic toxicity was 20%, and one grade 5 toxicity was reported. Several late grade 3 toxicities persisted: gastrointestinal (24%), skin (17%), and hematologic (6%). Two late grade 5 toxicities were noted.

Conclusions

Most patients with HIV and anal cancer did not experience local recurrence; however, acute and late toxicities were common. CD4 counts at 6 and 12 months' posttreatment remained lower than pretreatment CD4 counts. Further attention to treatment of the HIV-infected population is needed.

Current treatment and future directions in the management of anal cancer

Although rare, the rate of squamous cell carcinoma of the anus (SCCA) is rising globally. Most patients present with nonmetastatic disease and are curable with appropriate treatment, which has evolved significantly over the last several decades. Before the 1970s, SCCA was managed with radical surgery, resulting in a permanent colostomy. Researchers found that preoperative treatment with chemotherapy and concurrent radiation could achieve a pathologic complete response. After this observation, definitive therapy shifted from radical surgery to sphincter-preserving chemoradiation. Investigations into the necessity of chemotherapy and the optimal regimen found that chemotherapy with mitomycin-C and 5-fluorouracil is required for cure. Further studies evaluating the addition of induction or maintenance chemotherapy, monoclonal antibody therapy, or higher radiation doses have demonstrated no significant benefit to disease control. Advanced radiation delivery with intensity-modulated radiotherapy techniques is now considered the standard of care because of its prospectively determined, favorable acute toxicity profile compared with 3-dimensional conformal radiation. It is important to note that chemoradiation treatment response may be slow (up to 26 weeks) and should be assessed through serial clinical examinations. Today, surgical management of SCCA is reserved only for the lowest risk, early stage tumors or for recurrent/persistent disease. Current studies are evaluating radiation dose de-escalation in early stage disease and radiation dose escalation and the addition of immune checkpoint inhibitors in locally advanced cancers. In reviewing how and why modern-day treatment of SCCA was established, the objective of this report is to reenforce adherence to current treatment paradigms to assure the best possible outcomes for patients.

HIV-Associated Anal Cancer

Anal cancer, despite being a rare malignancy, is increasing in incidence, accounting for 0.5% of all new cancer cases in the United States, with rate of new cases being 1.9 per 100,000 men and women. It is common in immunocompromised individuals, especially those with malignancy, human immunodeficiency virus (HIV) and human papillomavirus (HPV) infection. Despite similar treatment of anal cancer in both HIV-positive and negative patients, guidelines for prevention and treatment of therapy-related side effects are rarely studied. While these patients have a better prognosis on HAART, limited guidelines exist regarding appropriate therapy. There is a common link between HPV and HIV and the transmission of one is associated with increased risk of transmission of the other. HPV vaccine which is known to prevent high-grade cervical intraepithelial neoplasia is thought to also decrease the incidence of anal intraepithelial neoplasia. The association of HPV vaccine in the prevention of anal cancer in high-risk groups with HIV is a scarcely studied subject that requires further research.

Difference in toxicity between HIV-positive and HIV-negative patients with squamous-cell cancer of the anal canal treated with concomitant radio-chemotherapy

Background

The incidence of squamous cell carcinoma of the anal canal has been increasing over the last 30 years. HIV has been found to be a risk factor for the development of this disease; radio-chemotherapy (RTCT) may also be more toxic than in HIV-negative patients. The study aims at assessing whether there are any differences in terms of toxicity between HIV-positive and HIV-negative patients treated with concomitant RTCT.

Methods

Search in MEDLINE, EMBASE, CENTRAL (via Cochrane Library-Wiley), DARE, LILACS bibliographic databases. Experimental and analytical observational studies with at least two comparative arms were included: squamous-cell (SC) anal-canal cancer (ACC) treated with RTCT in HIV-positive vs. HIV-negative patients.

Results

Fifteen publications, 14 retrospective studies and 1 systematic review, were found. All radiotherapy (RT) techniques and all chemotherapeutic agents used to manage this disease were included. No differences were found in terms of duration (P=0.67) and dose (P=0.53) of RT, while CT results were contradictory. Acute and hematological toxicities were significantly higher in HIV-positive patients, while gastrointestinal, dermatological and chronic toxicities did not significantly differ between the two groups. Given the high heterogeneity of the studies, no objective comparison could be made between studies that included antiretrovirals and those that did not.

Conclusions

HIV-positive patients may be at higher risk for acute and hematological toxicity than HIV-negative patients. A precise conclusion cannot be drawn on the use of antiretrovirals, given the high heterogeneity of data.

Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review

INTRODUCTION

There is a paucity of data on incidence and mechanisms of long-term gastrointestinal consequences after chemoradiotherapy for anal cancer. Most of the adverse effects reported were based on traditional external beam radiotherapy whilst only short-term follow-ups have been available for intensity-modulated radiotherapy, and there is lack of knowledge about consequences of dose-escalation radiotherapy.

METHOD

A systematic literature review.

RESULTS

Two thousand nine hundred and eighty-five titles (excluding duplicates) were identified through the search; 130 articles were included in this review. The overall incidence of late gastrointestinal toxicity was reported to be 7-64.5%, with Grade 3 and above (classified as severe) up to 33.3%. The most commonly reported late toxicities were fecal incontinence (up to 44%), diarrhea (up to 26.7%), and ulceration (up to 22.6%). Diarrhea, fecal incontinence and buttock pain were associated with lower scores in radiotherapy specific quality of life scales (QLQ-CR29, QLQ-C30, and QLQ-CR38) compared to healthy controls. Intensity-modulated radiation therapy appears to reduce late toxicity.

CONCLUSION

Late gastrointestinal toxicities are common with severe toxicity seen in one-third of the patients. These symptoms significantly impact on patients' quality of life. Prospective studies with control groups are needed to elucidate long-term toxicity.

Prognostic and Predictive Clinicopathologic Factors of Squamous Anal Canal Cancer in HIV-Positive and HIV-Negative Patients: Does HAART Influence Outcomes?

BACKGROUND

The incidence of squamous cell carcinoma (SCC) of the anal canal has been rising over the past decades, especially in patients infected with human immunodeficiency virus (HIV). Despite the advent of potent multidrug regimens to treat HIV-termed highly active antiretroviral therapy (HAART), anal SCC rates have not declined, and the impact of HAART on anal SCC remains controversial.

AIM

The purpose of this study was to define outcomes of anal SCC treatment in HIV-positive and HIV-negative patients.

METHODS AND MATERIALS

A retrospective single-institution analysis was performed on all patients with anal SCC treated at the Johns Hopkins Hospital between 1991 and 2010. The primary outcomes measured were 5-year overall survival (5-year OS), median survival, and relapse rates.

RESULTS

Our search identified 93 patients with anal SCC. Patients had a mean age of 54 years; 37.6% were male, and 21.5% were HIV-positive. Median follow-up was 28 months. Relapse occurred in 16.1% of patients. Median time to relapse was 20 months. Relapse rates were slightly higher with HIV-positive versus negative patients (30.0 vs. 12.3%) but did not reach statistical significance (p = 0.06). Among HIV-positive patients, those who relapsed were more likely to be on HAART than those who did not relapse (83.3 vs. 14.3%, p = 0.007). 5-year OS was 58.9% for the total group of patients with no significant difference between those who relapsed versus those who did not (76.2 vs. 54.5%, p = 0.20). No survival difference was seen between HIV-positive and negative patients. Survival was associated with AJCC stage in all patients.

CONCLUSION

In our small series, HIV infection was not associated with a significantly higher relapse rate or worse 5-year OS among patients with anal SCC. HAART was associated with a higher rate of relapse in HIV-positive patients. AJCC staging predicted survival in both relapsed and non-relapsed patients regardless of HIV status.

Effect of CD4 Count on Treatment Toxicity and Tumor Recurrence in Human Immunodeficiency Virus-Positive Patients With Anal Cancer

PURPOSE

To study the effects of immunosuppression on treatment toxicity, long-term cancer recurrence risk, and survival among human immunodeficiency virus (HIV)-positive anal cancer patients.

METHODS AND MATERIALS

From a nationwide retrospective cohort of veterans with anal cancer we identified 142 HIV-positive patients with stage I-III disease, diagnosed between 2000 and 2015 and treated with definitive-intent chemotherapy and radiation. We used regression models to study the impact of pretreatment CD4 counts and longitudinal posttreatment CD4 counts on outcomes including acute toxicity, long-term ostomy rates, cancer recurrence, cancer-specific survival, and overall survival. All models were adjusted for potential confounders.

RESULTS

The median pretreatment CD4 count was 375 cells/mm³, which dropped to 157 cells/mm³ after treatment. Each 100-cell/mm³ decrease in pretreatment CD4 count was associated with an increased risk of acute hematologic toxicity (odds ratio 1.19, 95% confidence interval [CI] 1.01-1.42, P=.04) and hospitalization for hematologic toxicity (odds ratio 1.24, 95% CI 1.00-1.54, P=.049) but not gastrointestinal toxicity, tumor recurrence, or cancer-specific mortality (P>.05). Each 100-cells/mm³ decrease in posttreatment CD4 count increased the risk of recurrence by 54% (hazard ratio 1.54, 95% CI 1.09-2.17, P=.01) and cancer mortality by 46% at a trend level (hazard ratio 1.46, 95% CI 0.99-2.14, P=.06). Neither pre- nor posttreatment CD4 count influenced long-term ostomy rates or overall survival (all P>.05).

CONCLUSIONS

Lower pretreatment CD4 counts were associated with acute hematologic toxicity, and lower posttreatment CD4 count levels were associated with an increased risk of tumor recurrence. These results suggest that immune surveillance may play an important role in long-term disease control in anal cancer.

Radiotherapy in patients with HIV: current issues and review of the literature

Although the introduction of highly active antiretroviral therapy has radically improved the life expectancy of patients with HIV, HIV positivity is still considered a major barrier to oncological treatment for patients with cancer because of their worse prognosis and increased susceptibility to toxic effects compared with patients who are immunocompetent. The use of radiotherapy with or without chemotherapy, immunotherapy, or molecular targeted therapy is the standard of care for several cancers. These new drugs and substantial improvements in radiotherapy techniques, including intensity-modulated radiotherapy, image-guided radiotherapy, and stereotactic ablative radiotherapy, are optimising the feasibility of such anticancer treatments and are providing new opportunities for patients with cancer and HIV. In this Review, we discuss the role of radiotherapy, with or without chemotherapy or new drugs, in the treatment of cancer in patients with HIV, with a focus on the efficacy and tolerability of this approach on the basis of available evidence. Moreover, we analyse and discuss the biological basis of interactions between HIV and radiotherapy, evidence from preclinical studies, and immunomodulation by radiotherapy in the HIV setting.

Cancer care disparities in people with HIV in the United States

PURPOSE OF REVIEW

Cancer is a growing problem in the HIV population, in large part because of aging of HIV-infected people treated with antiretroviral therapy. Overall and cancer-specific survival is worse in HIV-infected cancer patients compared with uninfected patients. One potential reason for the observed survival deficit is differences in cancer treatment.

RECENT FINDINGS

Recent population-based data suggest that HIV-infected cancer patients are less likely to receive cancer treatment compared with uninfected patients. This review describes these treatment disparities and their impact on patient outcomes, explores reasons for the disparity and highlights areas for future research.

SUMMARY

Cancer is the leading cause of non-AIDS death in HIV-infected individuals. Understanding the underlying cancer treatment disparity between HIV-infected patients and their uninfected counterparts, and developing solutions to address the problem, is of great importance to improve cancer outcomes in this growing patient population.

Optimal treatment strategies for anal cancer

OPINION STATEMENT

Squamous cell carcinoma (SCCA) of the anal canal is an underrecognized malignancy that is growing in annual incidence. Over the years, combined chemoradiation has been the mainstay of treatment for locally advanced SCCA of the anal canal. Currently, the human papilloma virus (HPV) vaccine is recommended to prevent the development of HPV and its associated precancerous lesion(s). Patients diagnosed with the human immunodeficiency virus (HIV+) are prone to develop anal cancer due to their high risk of contracting HPV infection. We will focus on the development and management of SCCA of the anal canal (both localized and metastatic), including special details on HIV-positive patients. Highlights will include the role of targeted therapy based on available literature. Our objective is to aid practicing physicians in formulating a treatment plan for both locally advanced and metastatic patients.

[Anal cancer in HIV patients]

Despite effective highly active antiretroviral treatment, anal cancer incidence has recently strongly increased in HIV-infected population. Treatment strategy in HIV-infected patients does not differ from general population. HIV-infected patients treated by chemo-radiotherapy are exposed to high-grade toxicities and should be closely monitored to deliver the optimal treatment. Close collaboration between oncologist and infectiologist is highly recommended to adjust antiretroviral therapy if necessary.

Anal cancer treatment: Current status and future perspectives

Anal cancers (AC) are relatively rare tumors. Their incidence is increasing, particularly among men who have sex with other men due to widespread infection by human papilloma virus. The majority of anal cancers are squamous cell carcinomas, and they are treated according to stage. In local and locally advanced AC, concomitant chemoradiation therapy based on mitomycin C and 5-Fluorouracil (5-FU) is the current best treatment, while metastatic AC, chemotherapy with 5-FU and cisplatin remains the gold standard. There are no indications for induction or maintenance therapies in locally advanced tumors. Many novel strategies, such as targeted therapies, vaccination, immunotherapy and photodynamic therapy are in clinical trials for the treatment of AC, with promising results in some indications.

Cancer treatment disparities in HIV-infected individuals in the United States

PURPOSE

HIV-infected individuals with cancer have worse survival rates compared with their HIV-uninfected counterparts. One explanation may be differing cancer treatment; however, few studies have examined this.

PATIENTS AND METHODS

We used HIV and cancer registry data from Connecticut, Michigan, and Texas to study adults diagnosed with non-Hodgkin's lymphoma, Hodgkin's lymphoma, or cervical, lung, anal, prostate, colorectal, or breast cancers from 1996 to 2010. We used logistic regression to examine associations between HIV status and cancer treatment, adjusted for cancer stage and demographic covariates. For a subset of local-stage cancers, we used logistic regression to assess the relationship between HIV status and standard treatment modality. We identified predictors of cancer treatment among individuals with both HIV and cancer.

RESULTS

We evaluated 3,045 HIV-infected patients with cancer and 1,087,648 patients with cancer without HIV infection. A significantly higher proportion of HIV-infected individuals did not receive cancer treatment for diffuse large B-cell lymphoma (DLBCL; adjusted odds ratio [aOR], 1.67; 95% CI, 1.41 to 1.99), lung cancer (aOR, 2.18; 95% CI, 1.80 to 2.64), Hodgkin's lymphoma (aOR, 1.77; 95% CI, 1.33 to 2.37), prostate cancer (aOR, 1.79; 95% CI, 1.31 to 2.46), and colorectal cancer (aOR, 2.27; 95% CI, 1.38 to 3.72). HIV infection was associated with a lack of standard treatment modality for local-stage DLBCL (aOR, 2.02; 95% CI, 1.50 to 2.72), non-small-cell lung cancer (aOR, 2.43; 95% CI, 1.46 to 4.03), and colon cancer (aOR, 4.77; 95% CI, 1.76 to 12.96). Among HIV-infected individuals, factors independently associated with lack of cancer treatment included low CD4 count, male sex with injection drug use as mode of HIV exposure, age 45 to 64 years, black race, and distant or unknown cancer stage.

CONCLUSION

HIV-infected individuals are less likely to receive treatment for some cancers than uninfected people, which may affect survival rates.

HIV positivity but not HPV/p16 status is associated with higher recurrence rate in anal cancer

AIM

Human papillomavirus (HPV) is a pathogenic factor of squamous cell carcinoma in various mucosal locations, including anal carcinoma (ACA). It is also known that patients positive for HIV are at high risk of ACA. The goal of this study was to examine clinical outcome in ACA in relation to HPV/p16 positivity, histologic tumor differentiation, and HIV status. Patients with oropharyngeal cancers that are positive for HPV and show overexpression of p16 as well as having non-keratinizing/basaloid histology have been reported to have better outcomes following chemoradiation (CRT). However, such relationships in ACA remain unknown.

METHODS

Forty-two patients with SCC of the anus treated with CRT between 1997 and 2009 were identified. The tumors were subclassified as either non-keratinizing (including basaloid) or keratinizing categories. HPV testing was performed using SPF10-PCR, and all cases were immunostained for p16.

RESULTS

There were 23 men and 19 women; 43% of men and 11% of women were HIV-positive (p = 0.04). Fifty-five percent of patients had local disease (stages I and II) and 41% were stages III and IV, with 4% stage unknown. All tumors were positive for high-oncogenic risk HPVs, and all were positive with p16 immunostain. Sixty-four percent of tumors were non-keratinizing/basaloid and 36 % were keratinizing. The keratinizing tumors were more common in HIV-positive patients (67%), whereas non-keratinizing/basaloid tumors were more common in HIV-negative patients (77%) (p = 0.008). Thirty-one percent of patients had recurrence of disease, including 50% HIV-positive patients and 23% HIV-negative patients (p = 0.09). There was no difference in the recurrence rate between non-keratinizing and keratinizing tumor subtypes (p = 0.80). The 24-month recurrence-free survival for the cohort was 66% (95% CI = 46%, 81%), with HIV-positive patients having worse recurrence-free survival compared to HIV-negative patients (HR = 2.85, 95% CI = 0.95, 8.53; p = 0.06).

CONCLUSION

The regional and distant failure rate was not related to HPV/p16 positivity or histologic differentiation of ACA; however, HIV positivity appeared to be associated with a higher recurrence rate and worse recurrence-free survival.

Chemoradiotherapy for squamous cell cancer of the anal canal: a systematic review

Squamous cell cancer of the anal canal is a rare tumour for which there remains uncertainty regarding optimal therapy. A systematic review was conducted to summarise the evidence examining concurrent chemotherapy and radiotherapy or different chemotherapy regimens in combination with radiotherapy. MEDLINE, EMBASE and conference proceedings were searched for relevant randomised controlled trials. Outcomes of interest were colostomy rate, local failure, overall survival, disease-free survival, adverse effects and quality of life. Six randomised controlled trials were identified. Two trials reported lower colostomy and local failure rates for concurrent 5-fluorouracil (5-FU) plus mitomycin C (MMC) and radiotherapy compared with radiotherapy alone. The omission of MMC from this regimen resulted in higher colostomy and local failure rates and lower disease-free survival. Induction chemotherapy followed by concurrent 5-FU plus cisplatin and radiotherapy resulted in a higher colostomy rate than concurrent 5-FU plus MMC and radiotherapy. Haematological toxicity rates were lower in patients who received radiotherapy with 5-FU alone or 5-FU plus cisplatin compared with 5-FU plus MMC. No benefit was seen for the addition of induction or maintenance chemotherapy to concurrent chemoradiotherapy. The available evidence continues to support the use of radiotherapy with concurrent 5-FU and MMC as standard treatment for cancer of the anal canal to decrease colostomy and local failure rates.

Long-term effects of chemoradiotherapy for anal cancer in patients with HIV infection: oncological outcomes, immunological status, and the clinical course of the HIV disease

BACKGROUND

Despite the increasing evidence for chemoradiotherapy as standard treatment for anal cancer in patients with HIV infection, there is still some uncertainty regarding increased toxicity and adverse effects on the immune status.

OBJECTIVE

We report the clinical outcome of 5-fluorouracil/mitomycin C-based concurrent chemoradiotherapy for anal carcinoma in patients with HIV infection with an emphasis on the long-term course of CD4 counts and the HIV-related morbidity during follow-up.

DESIGN AND SETTINGS

A retrospective single-institution chart review was performed.

PATIENTS

Between 1997 and 2012, 36 HIV-positive patients were treated with standard chemoradiotherapy (median tumor dose, 54 (range, 50.4-60.4) Gy at 1.8 Gy/fraction; 5-fluorouracil, 800-1000 mg/m(2), days 1-4 or 1-5; mitomycin C, 10 mg/m(2), day 1, in the first and fifth week).

MAIN OUTCOME MEASURES

A retrospective analysis was performed with respect to tumor response, local control, cancer and overall survival, and toxicity. Immunological parameters, including pre- and posttreatment CD4 counts, viral load, and HIV-specific morbidity were recorded during follow-up.

RESULTS

Chemoradiotherapy could be completed in all patients. Acute grade 3 toxicities occurred in 17/36 patients (47%). Complete response was achieved in 31 patients (86%). Five-year local control, colostomy-free, cancer-specific, and overall survival were 72%, 87%, 77%, and 74%. The median pretreatment CD4 count significantly decreased from 367 cells/μL to 139 cells/μL, 3 to 7 weeks after completion of chemoradiotherapy (p < 0.001). Four patients (11%) experienced opportunistic illnesses during the follow-up (median, 66; range, 10-164 months).

LIMITATIONS

This study is limited by its retrospective design and its small sample size.

CONCLUSIONS

Our data confirm again that, in the highly active antiretroviral therapy era, anal cancer can be treated in HIV-positive patients with standard chemoradiotherapy, with a clinical outcome similar to their HIV-negative counterparts. The chemoradiotherapy-related decline of the CD4 counts, which remain decreased up to 6 years after chemoradiotherapy, was not associated with increased HIV-related clinical morbidity.

Epidermoid cancer of the anal canal

Anal canal cancer is a rare cancer with incidence that continues to rise. This has been in large part due to increased prevalence of immunosuppressed conditions such as organ transplantation and human immunodeficiency virus along with transmission of the human papillomavirus. Identification of high-risk groups and close monitoring of these groups can help to detect earlier stages of cancer. Chemoradiation therapy remains the mainstay of treatment with excellent outcomes. Surgery for anal canal carcinoma remains as a salvage technique for failed chemoradiation or recurrent disease.

Metastatic squamous cell carcinoma of the anus: time for a shift in the treatment paradigm?

Anal cancers are rare tumours; however, the incidence is increasing in both men and women. Changing trends in sexual behaviour, smoking, and infection with the human papillomavirus are thought to be responsible for the increase. Patients with metastatic disease have a poor prognosis, with 5-year median overall survival rates of 10% in men and 20% in women. The standard systemic treatment of metastatic disease remains cisplatin and 5-fluorouracil, and aside from several non-randomised small phase II trials there has been no real progress over the past two decades. Based on the efficacy of cetuximab in squamous cell carcinomas from other primary sites, there appears to be clinical rationale for evaluation of anti-epidermal growth factor inhibitors in anal squamous cell carcinoma. In order to facilitate research and implement more effective treatment strategies international collaboration in clinical trials incorporating tissue collection for biomarkers is essential.

Evaluation of the impact of HIV serostatus, tobacco smoking and CD4 counts on epidermoid anal cancer survival

Tobacco smoking and HIV infection increase the risk of epidermoid anal cancer (EAC). No published studies have examined smoking and EAC outcomes, and the literature is discrepant regarding outcomes of HIV-positive patients with EAC. The goal of this study was to examine smoking history, HIV status and outcomes in EAC patients. We conducted a retrospective analysis of adults with invasive EAC treated in the University of Washington hospital system from 1 January 1994 to 31 December 2008. Sixty-three patients were included. Forty-seven patients (75%) had primary chemoradiation, of whom 42 (89%) completed therapy. Two patients (3%) received radiotherapy alone. Fourteen patients (22%) underwent primary surgery, of whom 11 (79%) underwent tumour excision and three (21%) abdominoperineal resection (APR). We analysed smoking history, HIV status and CD4 count (≥200 cells/μL/<200 cells/μL for HIV-positive patients) versus outcomes. Forty-five patients (71%) were in remission, and 44 (70%) were alive at last follow-up. Overall survival was significantly better for never-smokers than for ever-smokers. There were no differences in outcomes according to HIV status or CD4 counts. Patients with anal cancer who smoke have worse overall survival than non-smoking patients. HIV infection does not appear to affect anal cancer outcomes.

Chemoradiotherapy for anal cancer in HIV patients causes prolonged CD4 cell count suppression

BACKGROUND

Despite the advent of highly active antiretroviral therapy, anal cancer remains a significant health problem in human immunodeficiency virus (HIV) patients. We present the clinical features and treatment outcomes of anal cancer in 60 HIV-positive patients over a 20-year period.

PATIENTS AND METHODS

A prospective database of all HIV-positive individuals managed in a specialist unit since 1986 includes 11 112 patients (71 687 person-years of follow-up). Sixty patients with anal cancer were identified. Their clinicopathological and treatment details were analysed.

RESULTS

At anal cancer diagnosis, the mean age was 44 years (range: 28-75 years) and the median CD4 cell count was 305 mm(-3) (range: 16-1252 mm(-3)). Fifty (83%) had chemoradiotherapy (CRT). Forty-six (92%) responded, of whom 10 (22%) subsequently relapsed with locoregional (70%), metastatic disease (10%) or both (20%). The overall 5-year survival is 65% (95% confidence interval 51% to 78%). The median CD4 count fell from 289 mm(-3) before CRT to 132 mm(-3) after 3 months and to 189 mm(-3) after 1 year (P<0.05). Six patients in remission of anal cancer died of acquired immunodeficiency syndrome defining illnesses.

CONCLUSIONS

The management of anal cancer with CRT achieves similar outcomes as the general population. CRT is associated with significant prolonged CD4 suppression that may contribute to late deaths of patients in remission.

Acute toxicity of second generation HIV protease-inhibitors in combination with radiotherapy: a retrospective case series

BACKGROUND

There is little data on the safety of combining radiation therapy and human immunodeficiency virus (HIV) protease inhibitors to treat cancers in HIV-positive patients. We describe acute toxicities observed in a series of HIV-positive patients receiving modern radiation treatments, and compare patients receiving HIV protease inhibitors (PI) with patients not receiving HIV PIs.

METHODS

By reviewing the clinical records beginning January 1, 2009 from the radiation oncology department, we identified 29 HIV-positive patients who received radiation therapy to 34 body sites. Baseline information, treatment regimen, and toxicities were documented by review of medical records: patient age, histology and source of the primary tumor, HIV medication regimen, pre-radiation CD4 count, systemic chemotherapy, radiation therapy dose and fractionation, irradiated body region, toxicities, and duration of follow-up. Patients were grouped according to whether they received concurrent HIV PIs and compared using Pearson's chi-square test.

RESULTS

At baseline, the patients in the two groups were similar with the exception of HIV medication regimens, CD4 count and presence of AIDS-defining malignancy. Patients taking concurrent PIs were more likely to be taking other HIV medications (p = 0.001) and have CD4 count >500 (p = 0.006). Patients taking PIs were borderline less likely to have an AIDS-defining malignancy (p = 0.06). After radiation treatment, 100 acute toxicities were observed and were equally common in both groups (64 [median 3 per patient, IQR 1-7] with PIs; 36 [median 3 per patient, IQR 2-3] without PIs). The observed toxicities were also equally severe in the two groups (Grades I, II, III respectively: 30, 30, 4 with PIs; 23, 13, 0 without PIs: p = 0.38). There were two cases that were stopped early, one in each group; these were not attributable to toxicity.

CONCLUSIONS

In this study of recent radiotherapy in HIV-positive patients taking second generation PIs, no difference in toxicities was observed in patients taking PIs compared to patients not taking PIs during radiation therapy. This suggests that it is safe to use unmodified doses of PIs and radiation therapy in HIV cancer patients, and that it is feasible to use PIs as a radiosensitizer in cancer therapy, as has been suggested by pre-clinical results.

Efficacy and toxicity of chemoradiation in the treatment of HIV-associated anal cancer

PURPOSE

The purpose of this retrospective study is to determine the results and the toxicity of concurrent chemoradiation for squamous cell carcinoma of the anal canal in HIV-positive patients treated at a single institution.

PATIENTS AND METHODS

HIV-positive patients with squamous cell carcinoma of the canal treated at Continuum Cancer Centers-affiliated hospitals were identified from tumor registries. We reviewed hospital and treatment charts to gather data relating to demographics, HIV status including cluster of differentiation 4 (CD4) count and viral load, tumor stage, radiation and chemotherapy treatment, toxicity and local control, and survival.

RESULTS

Thirty-four patients were identified. All patients received radiation and concurrent chemotherapy consisting of either mitomycin-C and 5-fluorouracil (5-FU; 20 patients), cisplatin and 5-FU (13 patients), or 5-FU alone (1 patient). The most frequently reported severe toxicities were dermatologic (50% grade 3 or 4 toxicity) and hematologic (36% grade 3 or 4 toxicity). Actuarial local control and overall survival (OS) at 3 years were 63% and 69%, respectively.

CONCLUSION

Concurrent chemoradiation with cisplatin or mitomycin and 5-FU in HIV-positive patients provides local control and OS comparable to that observed in the HIV-negative population, with acceptable toxicity.

HIV- positive anal cancer: an update for the clinician

Anal cancer used to be a rare cancer traditionally associated with elderly women. There are approximately 5260 cases per year in the U.S. (1). The onslaught of the Human Immunodeficiency Virus (HIV) virus has led to a change in anal cancer demographics. Anal cancer is on the rise in the U.S and the number of anal cases documented has quadrupled in the past 20 yrs correlating with the rise of the HIV epidemic. The incidence of anal cancer is 40 to 80 fold higher in the HIV positive (HIV+) population when compared to the general population (2). With the advent of highly active antiretroviral therapy (HAART), HIV+ patients are living longer as less are progressing to AIDS. As a consequence non AIDS defining cancers such as anal cancer are on the rise. Factors implicated in the etiology of anal cancer in HIV+ patients include (Human papillomavirus) HPV virus status, sexual habits, and a history of smoking. HPV 16 and receptive anal intercourse (RAI) increase the risk of anal cancer by 33% over the general population. In the general population, the rate of anal cancer is approximately 0.9 cases per 100,000. In patients with a history of RAI, the rate approaches 35 cases per 100,000 which is equivalent to the prevalence of cervical cancer (3). Smokers are eight times more likely to develop anal cancer. There has been much discussion about tailoring treatment decisions in HIV+ patients with anal cancer. This review focuses on squamous cell carcinomas of the anal canal which comprise 80 to 90% of all anal cancers diagnosed and highlight key issues in the management of HIV+ anal cancer patients including recent clinical trials.

Anal squamous cell carcinoma in the HIV-positive patient

Epidermoid carcinoma of the anal canal is uncommon. The incidence of this disease has increased in HIV-positive men who have sex with men and the disease process is different from in HIV-negative patients. Modern therapy of HIV with highly active antiretroviral therapy (HAART) has improved the overall survival of HIV patients and allowed effective therapy for those who develop epidermoid carcinoma of the anal canal. This article describes the disease process and current treatment options.

The role of cytology (Pap tests) and human papillomavirus testing in anal cancer screening

OBJECTIVE

To assess anal oncogenic human papillomavirus (HPV) and anal cytology as screening tests for detecting high-grade anal intraepithelial neoplasia (AIN 2+), as this is an immediate anal cancer precursor.

DESIGN

Cross-sectional study of 401 HIV-positive men who have sex with men (MSM). The endpoint was histologically confirmed AIN 2+ obtained by high-resolution anoscopy. Cytology and biopsy specimens were assigned random numbers and independently assessed by two pathologists.

METHODS

We did concomitant anal cytology, anal HPV testing and HRA with directed biopsies without knowing the results of each intervention. The main outcome measures were the sensitivity, specificity, negative predictive value and positive predictive value of anal cytology and oncogenic HPV for the detection of AIN 2+.

RESULTS

Cytology was abnormal in 67% of patients: high-grade squamous intraepithelial lesion, 12%; low-grade squamous intraepithelial lesion, 43% and atypical squamous cells of undetermined significance, 12%. Biopsies were abnormal in 68% of patients: AIN 2+, 25% and AIN 1, 43%. HPV was detected in 93% with multiple HPV types in 92% and oncogenic HPV types in 88%. Test performance characteristics for the detection of AIN 2+ using any abnormality on anal cytology were: sensitivity 84%, specificity 39%, negative predictive value 88% and positive predictive value 31%; using oncogenic HPV: sensitivity 100%, specificity 16%, negative predictive value 100% and positive predictive value 28%.

CONCLUSION

Anal cytology and HPV detection have high sensitivity but low specificity for detecting AIN 2+. HIV-positive men who have sex with men have a high prevalence of AIN 2+ and require high-resolution anoscopy for optimal detection of high-grade anal dysplasia.

Primary radiation therapy for head-and-neck cancer in the setting of human immunodeficiency virus

PURPOSE

To analyze outcomes after radiation therapy for head-and-neck cancer among a cohort of patients with human immunodeficiency virus (HIV).

METHODS AND MATERIALS

The medical records of 12 patients with serologic evidence of HIV who subsequently underwent radiation therapy to a median dose of 68 Gy (range, 64-72 Gy) for newly diagnosed squamous cell carcinoma of the head and neck were reviewed. Six patients (50%) received concurrent chemotherapy. Intensity-modulated radiotherapy was used in 6 cases (50%). All patients had a Karnofsky performance status of 80 or 90. Nine patients (75%) were receiving antiretroviral therapies at the time of treatment, and the median CD4 count was 460 (range, 266-800). Toxicity was graded according to the Radiation Therapy Oncology Group / European Organization for the Treatment of Cancer toxicity criteria.

RESULTS

The 3-year estimates of overall survival and local-regional control were 78% and 92%, respectively. Acute Grade 3+ toxicity occurred in 7 patients (58%), the most common being confluent mucositis (5 patients) and moist skin desquamation (4 patients). Two patients experienced greater than 10% weight loss, and none experienced more than 15% weight loss from baseline. Five patients (42%) experienced treatment breaks in excess of 10 cumulative days, although none required hospitalization. There were no treatment-related fatalities.

CONCLUSIONS

Radiation therapy for head-and-neck cancer seems to be relatively well tolerated among appropriately selected patients with HIV. The observed rates of toxicity were comparable to historical controls without HIV.

Toxicity of head-and-neck radiation therapy in human immunodeficiency virus-positive patients

PURPOSE

To examine the acute morbidity of high dose head and neck RT and CRT in patients with infected with HIV.

METHODS AND MATERIALS

All HIV-positive patients who underwent radiation therapy for head and neck cancer in our department between 2004 and 2008 were reviewed. Treatment related data were examined. All treatments were delivered with megavoltage photon beams or electron beams. Patients were evaluated by an attending radiation oncologist for toxicity and response on a weekly basis during therapy and monthly after treatment in a multidisciplinary clinic. Acute toxicities were recorded using the Radiation Therapy and Oncology Group (RTOG) common toxicity criteria. Response to treatment was based on both physical exam as well as post-treatment imaging as indicated.

RESULTS

Thirteen patients who underwent RT with a diagnosis of HIV were identified. Median age was 53 years and median follow-up was 22 months. Twelve had squamous cell carcinoma and one had lymphoproliferative parotiditis. Median radiation dose was 66.4 Gy and median duration of treatment was 51 days. The median number of scheduled radiotherapy days missed was zero (range 0 to 7). One patient (8%) developed Grade 4 confluent moist desquamation. Eight patients (61%) developed Grade 3 toxicity.

CONCLUSION

Based on our results, HIV-positive individuals appear to tolerate treatment for head and neck cancer, with toxicity similar to that in HIV-negative individuals.

Radiotherapy for patients with the human immunodeficiency virus: are special precautions necessary?

Shortly after the onset of the acquired immunodeficiency syndrome (AIDS) epidemic in the 1980s, reports of radiation-associated toxicity in patients with the human immunodeficiency virus (HIV) and AIDS began to appear in the medical literature. Although the majority of reports have focused on AIDS-defining malignancies such as Kaposi sarcoma, greater-than-expected toxicity after a course of radiotherapy or chemoradiotherapy has also been documented in cancers not generally classified as being related to HIV. With improved antiretroviral therapies, HIV patients are living longer and have the potential to develop a variety of HIV-associated and nonassociated malignancies that require treatment, including radiotherapy. This review reports the published data regarding the interactions of HIV, AIDS, and antiretroviral therapy with radiotherapy and implications for the management of malignancies in patients with HIV.

Treatment of anal carcinoma in immune-compromised patients

BACKGROUND

Immune-compromised populations show an increased incidence of anogenital tract neoplasms. This study was undertaken to evaluate local control (LC), overall survival (OS) and toxicity in immune-compromised patients with anal carcinoma treated with radiotherapy with or without chemotherapy.

METHODS

We identified 25 patients with anal carcinoma and human immunodeficiency virus (HIV) infection or history of solid-organ transplant on chronic medical immune-suppression. Median age and follow-up were 44 years and 26 months respectively. AJCC T-stages were Tis (4%), T1 (8%), T2 (58%) and T3 (29%). N-stages were N0 (79%), N1 (4%), N2 (13%) and N3 (4%). One patient had metastatic disease at diagnosis. Seventy-five percent received concurrent chemoradiotherapy. Median radiation dose to the primary tumour was 50 Gy.

RESULTS

One-, 3- and 5-year LC without salvage therapy was 87%, 87% and 70% respectively. One-, 3- and 5-year actuarial OS was 96%, 73% and 61% respectively. One-, 3- and 5-year OS was 100% for treatment time (TT) <50 days and 57%, 38% and 0% for TT > or =50 days (p=0.0009). All patients had acute grade 2-3 skin toxicity. Acute grade 3-4 gastrointestinal (GI), genitourinary (GU) and haematological toxicity occurred in 8%, 0% and 38%. Late grade 3-4 skin, GI and GU toxicity occurred in 8%, 4% and 0%.

CONCLUSIONS

Most HIV-positive and organ transplant patients receiving radiotherapy with or without chemotherapy experience acute toxicity but few have chronic complications. T-stage and CD4 level in HIV-positive patients predict for LC. T-stage and TT predict for OS.

Concurrent chemoradiotherapy with 5-fluorouracil and mitomycin C for invasive anal carcinoma in human immunodeficiency virus-positive patients receiving highly active antiretroviral therapy

PURPOSE

To report the clinical outcomes of chemoradiotherapy (CRT) for anal carcinoma in human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy.

PATIENTS AND METHODS

Between 1997 and 2008, 21 HIV-positive patients who were receiving highly active antiretroviral therapy were treated with CRT (50.4 Gy at 1.8 Gy/fraction plus a 5.4-10.8-Gy external boost; 5-fluorouracil, 1,000 mg/m(2), Days 1-4 and 29-32; and mitomycin C, 10 mg/m(2), Days 1 and 29). A retrospective analysis was performed with respect to the tumor response, local control, cancer-specific and overall survival, and toxicity. The immunologic parameters, including pre- and post-treatment CD4 count, viral load, and acquired immunodeficiency syndrome-specific morbidity was recorded during follow-up (median, 53 months; range, 10-99).

RESULTS

CRT could be completed in all 21 patients with a reduction in the chemotherapy dose and/or interruption of radiotherapy in 5 and 5 cases, respectively. Acute Grade 3 toxicity occurred in 8 (38%) of the 21 patients. A complete response was achieved in 17 patients (81%), and tumor persistence or early progression was noted in 4 (19%). Six patients (29%) died, 5 of cancer progression and 1 of treatment-related toxicity. The 5-year local control, cancer-specific, and overall survival rate was 59%, 75%, and 67%, respectively. The median CD4 count significantly decreased from 347.5 cells/microL before CRT to 125 cells/microL 3-7 weeks after CRT completion (p <.001). In 6 (32%) of 19 patients, an increase of the HIV viral load was noted. Both parameters returned to the pretreatment values with additional follow-up.

CONCLUSION

Our data have confirmed that in the highly active antiretroviral therapy era, HIV-related anal cancer can be treated with standard CRT without dose reductions. Close surveillance of the immunologic parameters is necessary.

Epidermoid anal cancer prognosis comparison among HIV+ and HIV- patients

BACKGROUND

Previous studies suggest a poor prognosis of epidermoid anal cancer in HIV+ patients.

AIM

To investigate the long-term outcome of epidermoid anal cancer in HIV+ and HIV- patients in the highly active antiretroviral treatment (HAART) era.

METHODS

We included all patients with epidermoid anal cancer referred to six hospitals from 1998 to 2004.

RESULTS

In all, 151 patients (44 HIV+, 107 HIV-) were reviewed retrospectively for 27 (median of 16-44) months. HIV+ patients were male (100% vs. 27%, P < 0.001) and younger (45 vs. 62 years old, P < 0.001) than HIV- patients. No significant differences were observed in the tumour stage, pelvic radiotherapy dose or concomitant chemotherapy, according to the HIV status. After chemoradiotherapy, similar numbers of HIV+ and HIV- patients had grade III-IV toxicity. A complete response was obtained in 82% and 75% (N.S.) of cases, respectively. The disease-free survival rates were 77% and 67% (N.S.) and the overall survival rates were 85% and 84% (N.S.), respectively, after 3 years of follow-up. Duration of HIV infection, viral load and CD4 count had no effect on the survival rate of HIV+ patients with EAC.

CONCLUSIONS

The clinical outcome of HIV+ patients with epidermoid anal cancer is similar to that of HIV- patients. Therefore, the same therapeutic guidelines should be applied to both populations.

Radiation therapy for HIV-associated diffuse large cell non-Hodgkin lymphoma

PURPOSE

To report the clinical experience with external beam radiotherapy (RT) for AIDS-related lymphoma (ARL) with or without the involvement of the central nervous system (CNS) in HIV-infected patients.

PATIENTS AND METHODS

Clinical outcome of 24 HIV-seropositive patients with ARL treated with RT from 1995 to 2004 was reviewed, testing factors associated with outcome.

RESULTS

After 1 and 5 years, the overall survival was 65% and 35%, respectively. The mean RT dose was 31 Gy after normalization to fractions of daily 2 Gy (range, 7.8-47.2 Gy). Radiotherapy dose was associated with survival in univariate (P = .04) and multivariate analysis (P = .01). Other factors in univariate analysis associated with outcome were viral load (VL), highly active antiretroviral therapy (HAART), ARL stage, and CNS involvement. Patients with CNS involvement achieved complete response in 46% and improved clinical performance was seen in 73%.

CONCLUSIONS

After chemotherapy, RT in combination with HAART is highly active, and RT should be encouraged especially after suboptimal responses to induction treatment.

HIV and anal cancer outcomes: a single institution's experience

PURPOSE

The purpose of this study is to identify the effect of HIV status on outcome of treatment for squamous-cell carcinoma of the anal canal.

METHODS

A retrospective review was performed on all patients with squamous-cell carcinoma of the anal canal treated at a single academic institution between January 1996 and December 2006.

RESULTS

Our search identified 87 (21 HIV-positive) patients who had invasive squamous-cell cancer. The median follow-up was 38 months. Eighty-five percent of HIV-negative patients and 81 percent of HIV-positive were identified as complete responders at 6 weeks after completion of combined modality therapy. Eight percent of HIV-negative and 29 percent of HIV-positive patients developed recurrent disease after 6 months (P = 0.0009). Overall survival for HIV-negative and HIV-positive patients was 71 percent and 73 percent, respectively.

CONCLUSIONS

HIV-positive patients respond equally to combined modality therapy but have recurrences more frequently than patients who are HIV negative. Overall survival in these two groups is equivalent.

Marked increase in the incidence of invasive anal cancer among HIV-infected patients despite treatment with combination antiretroviral therapy

OBJECTIVE

To describe the cases of anal cancer that appeared in the French Hospital Database on HIV between 1992 and 2004 and to study risk factors of anal cancer.

METHODS

We examined the incidence rates of anal cancer between 1992 and 2004 and the risk associated among 86,322 HIV-infected patients included in the French Hospital Database on HIV.

RESULTS

We identified 132 cases of anal cancer, including 124 cases in men (94%), of whom 75% had sex with men. Median age at diagnosis was 42.8 years (interquartile range: 36.9-49.4). At diagnosis, 103 patients (78%) were receiving combination antiretroviral therapy for a median of 37.1 months (interquartile range: 4.5-59.8). Median survival after anal cancer diagnosis was 5 years. The respective overall incidence rates of anal cancer per 100,000 person-years between 1992 and March 1996, April 1996 to 1998 and between 1999 and 2004 were 11 (95% confidence interval, 4-17), 18 (95% confidence interval, 10-27) and 40 (95% confidence interval, 32-47). The risk of anal cancer was higher among men who have sex with men. After adjustment for age at inclusion in the study, as well as gender, the HIV transmission group, the nadir CD4 cell count and AIDS status, the incidence was higher in the years 1999-2004 than in between 1992 to March 1996 (hazard ratio, 2.5; 95% confidence interval, 1.2-5.3), with no change in the years 1999-2004.

CONCLUSION

The incidence of anal cancer has increased among HIV-infected patients in France since 1996. Although an ascertainment bias cannot be excluded, data indicate that combination antiretroviral therapy does not prevent anal cancer in these patients. This supports the urgent need for developing anal cancer screening programs for HIV-infected men who have sex with men.

High-resolution anoscopy targeted surgical destruction of anal high-grade squamous intraepithelial lesions: a ten-year experience

PURPOSE

This study was designed to determine whether high-resolution anoscopy and targeted surgical destruction of anal high-grade squamous intraepithelial lesions is effective in controlling high-grade squamous intraepithelial lesions while preserving normal tissues.

METHODS

Retrospective review of 246 patients with high-grade squamous intraepithelial lesions treated with high-resolution anoscopy-targeted surgical destruction from 1996 to 2006, with at least one follow-up at a minimum two months with physical examination, high-resolution anoscopy, cytology, and biopsy when indicated.

RESULTS

Lesions were extensive in 197 patients (81 percent); 207 (84 percent) were men, and 194 (79 percent) were immunocompromised (HIV or other). Persistent disease occurred in 46 patients (18.7 percent), requiring planned staged therapy; 10 required surgery. Recurrent high-grade squamous intraepithelial lesions occurred in 114 patients (57 percent) at an average 19 (range, 3-92) months; 26 of these required surgery. All other patients were retreated in-office with high-resolution anoscopy-directed therapies. Complications were seen in nine patients (4 percent). Despite treatment, three patients progressed to invasive cancer (1.2 percent). At their last visit, 192 patients (78 percent) had no evidence of high-grade squamous intraepithelial lesions.

CONCLUSIONS

High-resolution anoscopy-targeted destruction combined with office-based surveillance and therapy is effective in controlling high-grade squamous intraepithelial lesions and is superior to reports of expectant management or traditional mapping procedures.

Squamous cell carcinoma of the anal canal: utilization and outcomes of recommended treatment in the United States

BACKGROUND

Over the past two decades, recommended treatment for squamous cell carcinoma of the anal canal has shifted from surgery to primary chemoradiation. Resection is now reserved for persistent or recurrent disease. Our objectives were (1) to evaluate treatment trends over the past 20 years, (2) to assess contemporary treatment utilization, and (3) to examine the impact of recommended vs nonguideline treatment on survival.

METHODS

From the National Cancer Data Base (1985-2005), 38,882 patients with anal canal cancer were identified. Regression models were used to assess factors associated with use of nonguideline treatment (vs chemoradiation +/-surgery). Univariate and multivariate methods were used to assess the impact of treatment on survival.

RESULTS

From 1985 to 2005, the use of chemoradiation increased significantly with a concomitant decrease in treatment with surgery alone (P < .0001). However, only 74.9% (5014 of 6696) of patients underwent primary chemoradiation therapy in 2003-2005. Overall, 22.7% (1523 of 6696) of patients received treatment that was not concordant with established guidelines: primary surgery (13.0%) and primary chemotherapy or radiation (9.7%). Patients were significantly less likely to receive guideline treatment if male, older, black or Hispanic, more severe comorbidities, or Stage I (vs Stage II or III). Patients undergoing chemoradiation ( +/- surgery) had higher 5-year survival rates than patients who received nonguideline treatment (64% vs 58%; hazard ratio 0.82, 95% confidence interval [95% CI] 0.77-0.87; P < .0001).

CONCLUSION

Primary chemoradiation therapy has supplanted surgical treatment and is associated with better outcomes; however, nearly a quarter of patients are still receiving treatment that is not concordant with established guidelines.

Human immunodeficiency virus-associated squamous cell cancer of the anus: epidemiology and outcomes in the highly active antiretroviral therapy era

PURPOSE

To evaluate and determine predictors of squamous cell carcinoma of the anus (SCCA) outcomes in the highly active antiretroviral therapy (HAART) era for HIV-positive and -negative individuals using large national Veterans Affairs (VA) Administration databases.

PATIENTS AND METHODS

We used the VA administrative databases to perform a retrospective cohort study in 1,184 veterans diagnosed with SCCA between 1998 and 2004. We calculated HIV infection rates and used logistic regression to identify epidemiologic factors that were associated with HIV infection. Kaplan-Meier curves and Cox proportional hazards models were calculated to compare survival between HIV-positive and HIV-negative veterans.

RESULTS

In our cohort, 175 patients (15%) were HIV positive. The median age of the HIV-negative and -positive patients was 63 and 49 years, respectively (P < .001). Individuals with HIV were eight times more likely to be male (P = .01) and three times more likely to be African American (P < .001). There were no differences between HIV-positive and HIV-negative individuals in the receipt of treatment. The 2-year observed survival rates were 77% and 75% among HIV-positive and HIV-negative individuals, respectively. In multivariate Cox analysis, significant predictors of survival were age, sex, metastasis at diagnosis, and comorbidity score. HIV infection did not affect survival.

CONCLUSION

A noteworthy proportion of individuals with SCCA in the VA system are HIV positive. HIV-associated SCCA seems mainly to be a disease among younger men. Survival of SCCA is equivalent between HIV-positive and HIV-negative individuals in the HAART era. Treatment should not be withheld or deintensified based on HIV status.