Management of prostate cancer in HIV-positive patients

A clinical overview of people living with HIV and genitourinary cancer care

The number of people living with HIV infection has been increasing globally. Administration of antiretroviral therapy is effective in controlling the infection for most patients and, as a consequence, people living with HIV (PLWH) now often have a long life expectancy. However, their risk of developing cancer - most notably virus-related cancers - has been increasing. To date, few studies have assessed the risk of genitourinary cancers in PLWH, and robust scientific data on their treatment-related outcomes are lacking. Previous studies have noted that PLWH are at a reduced risk of prostate cancer; however, low adoption and/or availability of prostate cancer screening among these patients might be confounding the validity of this finding. In genitourinary cancers, advanced stage at diagnosis and reduced cancer-specific mortality have been reported in PLWH. These data likely reflect, at least in part, the inequity of health care access for PLWH. Notably, systemic chemotherapy and/or radiotherapy could decrease total CD4+ cell counts, which could, therefore, increase the risk of morbidity and mortality from cancer treatments in PLWH. Immune checkpoint inhibitors have become the therapeutic backbone for many advanced malignancies in the general population; however, most studies validating their efficacy have excluded PLWH owing to concerns of severe adverse effects from immune checkpoint inhibitors themselves and/or related to their immunosuppressed status. To our knowledge, no genitourinary cancer survivorship programme exists that specifically caters to the needs of PLWH. By including PLWH in ongoing cancer trials, we can gain invaluable insights that will help to improve cancer care specifically for PLWH.

Management of Localized Prostate Cancer in Men With Human Immunodeficiency Virus: Analysis of a Large Retrospective Cohort

INTRODUCTION

We aimed to characterize the clinicopathological characteristics and outcomes of HIV-positive patients with clinically localized, prostate cancer (PCa).

METHODS

A retrospective study was conducted of HIV-positive patients from a single institution with elevated PSA and diagnosis of PCa by biopsy. PCa features, HIV characteristics, treatment type, toxicities, and outcomes were analyzed by descriptive statistics. Kaplan-Meier analysis was used to determine progression-free survival (PFS).

RESULTS

Seventy-nine HIV-positive patients were included with a median age at PCa diagnosis of 61 years-old and median duration from HIV infection to PCa diagnosis of 21 years. The median PSA level at diagnosis and Gleason Score was 6.85 ng/mL and 7, respectively. The 5-year PFS was 82.5% with the lowest survival observed in patients treated with radical prostatectomy (RP) + radiation therapy (RT), followed by cryosurgery (CS). There were no reports of PCa-specific deaths, and the 5-year overall survival was 97.5%. CD4 count declined post-treatment in pooled treatment groups that included RT (P = .02).

CONCLUSION

We present the characteristics and outcomes of the largest cohort of HIV-positive men with prostate cancer in published literature. RP and RT ± ADT is well-tolerated in HIV-positive patients with PCa as seen by the adequate biochemical control and mild toxicity. CS resulted in worse PFS compared to alternative treatments for patients within the same PCa risk group. A decline in CD4 counts was observed in patients treated RT, and further studies are needed to investigate this relationship. Our findings support the use of standard-of-care treatment for localized PCa in HIV-positive patients.

OUP accepted manuscript

Background

Persons living with human immunodeficiency virus are an underserved population for evidence-based cancer treatment. Paclitaxel and carboplatin (PCb) is an active regimen against a variety of solid tumors, including several seen in excess in patients with HIV infection. We performed a pilot trial to evaluate the safety of full-dose PCb in people living with human immunodeficiency virus and cancer.

Methods

Eligible patients, stratified by concurrent antiretroviral therapy (ART) that included CYP3A4 inhibitors or not, received paclitaxel (175 mg/m²) in combination with carboplatin (target AUC 6) intravenously every 3 weeks for up to 6 cycles.

Results

Sixteen evaluable patients received 64 cycles of PCb, including 6 patients treated with CYP3A4 inhibiting ART (ritonavir). The adverse event profile was consistent with the known toxicity profile of PCb, with no differences between the 2 strata. There were 4 partial responses (25%, 95% CI: 7%-52%), and overall, CD4+ lymphocyte count was similar after completion of therapy (median: 310/μL) compared with baseline values (median: 389/μL). Pharmacokinetic studies in 6 patients revealed no significant differences in C_max or AUC_inf for paclitaxel between the 2 cohorts.

Conclusion

Full doses of PCb chemotherapy are tolerable when given concurrently with ART in people living with human immunodeficiency virus with cancer, including patients receiving CYP3A4 inhibitors.

ClinicalTrials.gov Identifier

NCT01249443.

Prostate cancer presentation, treatment selection, and outcomes among men with HIV/AIDS: A clinical stage, race, and age-matched contemporary analysis

PURPOSE

To compare the clinical presentation, treatment receipt, and oncologic outcomes between human immunodeficiency virus-seropositive (HIV+) and seronegative (HIV-) men with prostate cancer (CaP) matched by age, clinical stage, and race.

MATERIALS AND METHODS

A retrospective review of 3,135 men treated for CaP from 2000 to 2016 was performed. HIV+ patients (N = 46) were matched 1:2 to 3 to HIV- men (N = 137) by age, race, and clinical stage. Clinicopathologic features and primary treatment received were compared between cohorts. Associations between HIV status and progression-free, cancer-specific, and overall survival were compared by HIV status using the Kaplan-Meier method and Cox proportional hazards analysis.

RESULTS

After matching, men with and without HIV were similar with respect initial prostate-specific antigen, Gleason Sum, and Eastern Cooperative Oncology Group (ECOG) performance status. Among HIV+ men, 67.4% had a history of acquired immune deficiency syndrome, and 91.3% were on highly active antiretroviral therapy at CaP diagnosis. Among men with localized disease, HIV+ men were more likely to receive radiation (59.5% vs. 44.8%) or no therapy (13.5% vs. 4.3%) and less likely to receive surgery (16.2% vs. 30.2%), or to initiate active surveillance (10.8% vs. 16.4%; P = 0.04 overall). There were no differences in rates of clinical progression, development of castration resistance, or CaP death by HIV status. However, HIV+ status was associated with inferior overall survival (hazard ratio 2.89, P = 0.04).

CONCLUSIONS

While most HIV+ patients had a history of acquired immune deficiency syndrome; HIV was well controlled in the majority of patients at the time of CaP diagnosis. While oncologic outcomes were similar between HIV+ and HIV- men, significant differences in treatment selection were observed. Further research is necessary to understand differences in treatment election by HIV status and to define optimal CaP treatment selection in men with HIV.

HIV-1-infected cell-derived exosomes promote the growth and progression of cervical cancer

Background: Women infected with HIV are more likely to have aggressive cervical cancer, and patients with HIV infection are often more severely ill than those without HIV infection. However, the underlying mechanism for the progression of cervical cancer is not yet fully understood and requires further research.

Methods: Exosomes were isolated from cell culture supernatants using differential ultracentrifugation. Confirmation of exosome isolation was based upon identification by electron microscopy and NanoSight particle tracking analysis of the purified fraction. The function of exosomes derived from HIV-infected T-cells in cervical cancer was determined by CCK8 and Transwell invasion assays.

Results: Exosomal miR-155-5p derived from HIV-infected T-cells promotes the proliferation, migration and invasion of cervical cancer cells. Furthermore, we found that HIV-infected T-cells secrete exosomal miR-155-5p that directly targets ARID2 degradation, leading to activation of the NF-κB signaling pathway. MiR-155-5p promotes cervical cancer progression by secreting proinflammatory cytokines, including IL-6 and IL-8.

Conclusions: In conclusion, we demonstrate that intercellular crosstalk between HIV-infected T-cells and cervical cancer is mediated by exosomes from HIV-infected T-cells that contribute to the malignant progression of cervical cancer, providing potential targets for the prevention and treatment of HIV-associated cervical cancer.

Is There an Optimal Curative Option in HIV-Positive Men with Localized Prostate Cancer? A Systematic Review

Aims

We aimed to compare the outcome of curative treatment options in localised Prostate Cancer (PCa) amongst HIV positive (HIV+) men.

Methods

A systematic search of the Cochrane Library of Systematic Reviews, the Scopus and PubMed databases was performed (January 1995 to November 2015) using pre-determined search terms. Outcome measures for comparison included the rate of biochemical failure (BCF), survival benefit and complications.

Results

A total of 14 eligible articles were identified for inclusion, representing a total of 202 HIV+ men with PCa. Radical Prostatectomy was performed in 40/153 compared to 109/153 patients undergoing alternative (non-surgical) treatments options. Only 3 studies compared outcomes within their respective study cohort. One study (n = 10) reported BCF results with 1/2 BCF patient in the surgical arm vs. 1/8 BCF positive patients in the non-surgical arm (mean 46 months follow-up), while two other studies reported no occurrences of BCF within both arms of their studies.

Conclusion

Due to paucity in the literature, there is insufficient evidence to support a certain treatment modality arm specifically for HIV+ men with localized PCa. An individualized management algorithm seems feasible within this cohort, until more definitive studies are performed.

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.

Cancer Treatment in Patients With HIV Infection and Non-AIDS-Defining Cancers: A Survey of US Oncologists

PURPOSE

HIV-infected individuals with non-AIDS-defining cancers are less likely to receive cancer treatment compared with uninfected individuals. We sought to identify provider-level factors influencing the delivery of oncology care to HIV-infected patients.

METHODS

A survey was mailed to 500 randomly selected US medical and radiation oncologists. The primary outcome was delivery of standard treatment, assessed by responses to three specialty-specific management questions. We used the χ(2) test to evaluate associations between delivery of standard treatment, provider demographics, and perceptions of HIV-infected individuals. Multivariable logistic regression identified associations using factor analysis to combine several correlated survey questions.

RESULTS

Our response rate was 60%; 69% of respondents felt that available cancer management guidelines were insufficient for the care of HIV-infected patients with cancer; 45% never or rarely discussed their cancer management plan with an HIV specialist; 20% and 15% of providers were not comfortable discussing cancer treatment adverse effects and prognosis with their HIV-infected patients with cancer, respectively; 79% indicated that they would provide standard cancer treatment to HIV-infected patients. In multivariable analysis, physicians comfortable discussing adverse effects and prognosis were more likely to provide standard cancer treatment (adjusted odds ratio, 1.52; 95% CI, 1.12 to 2.07). Physicians with concerns about toxicity and efficacy of treatment were significantly less likely to provide standard cancer treatment (adjusted odds ratio, 0.67; 95% CI, 0.53 to 0.85).

CONCLUSION

Provider-level factors are associated with delivery of nonstandard cancer treatment to HIV-infected patients. Policy change, provider education, and multidisciplinary collaboration are needed to improve access to cancer treatment.

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.

[Consensus statement on the clinical management of non-AIDS defining malignancies. GeSIDA expert panel]

This consensus document has been prepared by a panel of experts appointed by GeSIDA. This paper reviews the recommendations on the most important non-AIDS defining malignancies that can affect patients living with AIDS. Lung cancer, hepatocellular carcinoma, anal carcinoma and other less frequent malignancies such as breast, prostate, vagina or colon cancers are reviewed. The aim of the recommendations is to make clinicians who attend to this patients aware of how to prevent, diagnose and treat this diseases. The recommendations for the use of antiretroviral therapy when the patient develops a malignancy are also presented. In support of the recommendations we have used the modified criteria of the Infectious Diseases Society of America.