Increased risk of prostate cancer in HIV infection?

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.

Prostate Cancer in Sexual Minorities: Epidemiology, Screening and Diagnosis, Treatment, and Quality of Life

Prostate cancer has the highest incidence among all cancers in men. Sexual minorities, including gay and bisexual men, as well as transgender, were previously a "hidden population" that experienced prostate cancer. Although there continues to remain a paucity of data in this population, analyses from studies do not reveal whether this population is more likely to endure prostate cancer. Nonetheless, several qualitative and quantitative studies have established worse quality-of-life outcomes for sexual minorities following prostate cancer treatment. Increased awareness of this previously "hidden population" among healthcare workers, as well as more research, is warranted to gain further understanding on potential disparities faced by this growing population.

Understanding Prostate Cancer in Gay, Bisexual, and Other Men Who Have Sex with Men and Transgender Women: A Review of the Literature

PURPOSE OF REVIEW

a)Prostate cancer in sexual and gender minorities is an emerging medical and public health concern. The purpose of this review is to summarize the state of the science on prostate cancer in gay, bisexual, and other men who have sex with men (GBM) and transgender women (TGW). We undertook a literature review of all publications on this topic through February 2017. With 88 unique papers (83) on prostate cancer in GBM and 5 case reports of prostate cancer in TGW), a small but robust literature has emerged.

RECENT FINDINGS

b)The first half of this review critiques the literature to date, identifying gaps in approaches to study. The second half summarizes the key findings in eleven areas. In light of this admittedly limited literature, GBM appear to be screened for prostate cancer less than other men, but they are diagnosed with prostate cancer at about the same rate.

SUMMARY

c)Compared to other men, GBM have poorer urinary, bowel, and overall quality-of-life outcomes but better sexual outcomes after treatment; all these findings need more research. Prostate cancer in TGW remains rare and under researched, as the literature is limited to single-case clinical reports.

Preliminary results of radiation therapy for prostate cancer in human immunodeficiency virus-positive patients

OBJECTIVES

The purpose of this study was to report on the clinical outcomes of patients treated at our institution for prostate cancer (PCa) who had been previously diagnosed as Human immunodeficiency virus (HIV) positive.

METHODS

The authors conducted a retrospective study of 14 PCa/HIV patients who were being treated for PCa with external beam radiotherapy, brachytherapy, or a combination of the two. Each patient's prostate-specific antigen (PSA) level, CD4 count, and viral load were obtained before the initial radiation treatment and at the time of their most recent follow-up. In addition, 13 of 14 patients completed a quality of life survey with a social worker on staff and were examined by their radiation oncologist to assess the complications after treatment.

RESULTS

Comparing pretreatment data with the data at last follow-up, only 1 patient's PSA level remained above 1.1 ng/mL. The average CD4 count remained stable, increasing from 523 to 577 cells/mm(3), with the lowest final count at 200 cells/mm(3). Viral load increased in only 2 of 14 patients. There were no unusual rectal, urinary, or sexual complications, and no infections related to treatment.

CONCLUSIONS

Based on changes in viral load and CD4 count, radiotherapy does not appear to have a long-term negative effect on the immune system. Treatment complications are consistent with HIV-negative patients, giving no evidence that the subset of PCa/HIV patients should be treated differently from PCa patients without HIV when considering radiation therapy. More investigation will be necessary before reliable mortality and morbidity data can be assessed.

Human immunodeficiency virus-associated prostate cancer: clinicopathological findings and outcome in a multi-institutional study

OBJECTIVE

To characterize the clinicopathological findings and the outcome of human immunodeficiency virus (HIV)-infected patients diagnosed and treated for prostate carcinoma, as HIV-positive men being treated with highly active antiretroviral therapy (HAART) are living longer and thus are more likely to develop cancers such as prostate cancer.

PATIENTS AND METHODS

We performed a retrospective, multi-institutional study involving HIV-positive men with concomitant prostate carcinoma. We collected data regarding patient demographics (age, race), HIV status (CD4(+) cell count, HIV viral load, HAART), PSA level (at cancer diagnosis), symptoms and signs, radiological findings, pathology (Gleason score, stage), cancer treatment (type, side-effects), and outcome (response, survival). Accrued data was analysed using descriptive statistics.

RESULTS

We identified 17 patients (mean age 59 years) with HIV-associated prostate adenocarcinoma. The mean CD4(+) count was 336 cells/mm(3) and the mean HIV viral load was 17 319 copies/mL. In all, 14 (82%) of these men were receiving HAART. Most patients were diagnosed with carcinoma after an abnormal screening PSA level. The mean PSA level was 30 ng/mL. Only six (35%) men had an abnormal prostate on examination. The mean Gleason score was 6.8, and in most cases, cancer was confined to the prostate gland. Most patients were amenable to curative treatment with hormonal therapy, radiation, and/or prostatectomy. There were no serious treatment related side-effects. One patient remained untreated. All treated patients had a complete response (undetectable PSA level). Most patients were long-term survivors. Documented death in five cases was unrelated to prostate cancer.

CONCLUSION

The management of HIV-positive men with prostate carcinoma in the HAART era is becoming increasingly important. Our data shows that in men receiving HAART, their age, PSA levels, clinical presentation, management, and outcome from treated prostate carcinoma does not appear to be significantly altered by HIV status. Therefore, we recommend that patients with prostate cancer and well-controlled HIV viraemia be managed similarly to their HIV-negative counterparts.

Serum prostate-specific antigen levels in older men with or at risk of HIV infection

OBJECTIVES

The aim of the study was to determine the rate of, and factors associated with, elevated prostate-specific antigen (PSA) levels in older men with or at risk of HIV infection.

METHODS

Using a cross-sectional analysis, we interviewed 534 men > or =49 years old at risk for HIV infection on demographics, behaviours and medical history. Laboratory testing included serum PSA level and HIV serology, and T-cell subsets for those who were HIV seropositive. Elevated PSA level was defined as >4.0 ng/mL, and men with elevated PSA levels were referred for urological evaluation.

RESULTS

Fifteen per cent of men were white, 55% black, and 23% Hispanic; median age was 53 years (range 49-80 years); 74% were sexually active; 65% currently smoked cigarettes; and 16% had taken androgens. Among 310 HIV-positive men, CD4 counts were >500 cells/microL in 31%, 200-500 cells/microL in 51%, and <200 cells/microL in 19%. Twenty men (4%) had elevated PSA. On univariate analysis, only older age was significantly associated with elevated PSA, and there was no significant difference in the number of men with elevated PSA between HIV-positive and HIV-negative men (nine of 310 vs 11 of 224; P = 0.28). On multivariate analysis, older age remained the only variable associated with elevated PSA level [reference group < or =50 years; adjusted odds ratio (OR(adj)) 1.0 for age 51-60 years; OR(adj) 5.9 (95% confidence interval 1.2-30.1) for age > or =61 years] adjusted for HIV status, family history of prostate cancer, and androgen use.

CONCLUSIONS

Among older men, PSA levels increased with age but did not differ by HIV status. The clinical use of PSA levels in older men currently do not need to be modified for those with HIV infection.

The growing problem of non-AIDS-defining malignancies in HIV

PURPOSE OF REVIEW

The incidence and spectrum of non-AIDS-defining cancers has continued to grow. As HIV-infected individuals live longer due to highly active antiretroviral therapy, their risk of dying from one of these cancers is increased. The recent literature pertaining to non-AIDS-defining cancers is reviewed.

RECENT FINDINGS

Recent epidemiological studies have identified higher rates of carcinoma of the anus, lung, breast, skin, conjunctiva, liver and prostate; hematopoietic malignancies such as Hodgkin's lymphoma, plasma-cell neoplasia and leukemia; and other neoplasms like melanoma and leiomyosarcoma in HIV-positive patients. The role of HIV-induced immunosuppression in the development of these non-AIDS-defining cancers appears less important than lifestyle habits like smoking and sun exposure, as well as coinfection with human papilloma, hepatitis B, hepatitis C and Epstein-Barr viruses.

SUMMARY

It is unclear whether the growing number of reports on non-AIDS-defining cancers reflects a true increased incidence or merely the product of increased surveillance, detection and reporting. Highly active antiretroviral therapy not only promotes longevity in the HIV-positive population, but may increase their risk of developing cancer like Hodgkin's lymphoma. Assertive prevention strategies are needed to adequately deal with non-AIDS-defining cancers in an aging and growing HIV-positive population.

Radical prostatectomy in patients infected with human immunodeficiency virus

OBJECTIVE

To present the complications and early outcomes in a small series of men infected with human immunodeficiency virus (HIV) and treated with radical prostatectomy (RP) for prostate cancer, and to review reports on surgery in HIV-positive patients.

PATIENTS AND METHODS

During 2002-2005, seven men infected with HIV underwent RP at our institution. For the five patients whose HIV status was known before surgery, we retrospectively examined preoperative variables, including HIV-specific data (clinical category, CD4+ lymphocyte count, viral load, duration of HIV diagnosis, and opportunistic infections), and the complications and early outcomes after RP.

RESULTS

Before RP all the patients were in the Center for Disease Control clinical category A (asymptomatic HIV infection). The CD4+ counts before RP ranged from 269-870 cells/microL and viral loads ranged from <50-18 700 copies/mL. Three patients were on highly active anti-retroviral therapy (HAART) at the time of surgery. After RP, two patients had incisional wound infections, including one requiring re-hospitalization for intravenous antibiotics. During the follow-up (median 26 months) none of the patients progressed to acquired immunodeficiency syndrome or developed biochemical recurrence of prostate cancer. One healthcare worker was exposed to contaminated urine and placed on prophylactic therapy, but has not sero-converted.

CONCLUSIONS

The risk of peri-operative complications in HIV-positive patients can be minimized by carefully selecting the patient and procedure, and by measuring routine and HIV-specific preoperative variables. The two infectious complications in this series were in patients with less favourable preoperative factors, i.e. the lowest CD4+ count and the highest viral load. Further experience is needed to determine whether the risk of surgical infections is higher in this cohort. However, our results are consistent with reports from other surgical specialities that surgery in asymptomatic HIV-positive patients is safe and effective.

Disseminated, lethal prostate cancer during human immunodeficiency virus infection presenting with non-specific features

INTRODUCTION

Prostate cancer is a very infrequent occurrence in persons aged 55 years or less, and it has been rarely reported in HIV-infected patients (10 overall cases so far); therefore, an increased incidence compared with the general population has not been established, although a younger age seems more frequent among population with HIV disease.

CASE REPORT

We report a case of metastatic prostate cancer occurred in a 53-year-old HIV-infected man, admitted due to non-specific signs, and symptoms: impaired general conditions, fever, weight loss, fatigue, and exertional dyspnea. A remarkable anemia and an aortic systolic murmur were the prominent initial findings, while AIDS-related conditions were not suspected due to a sustained CD4+ count and a contained viremia, which never required antiretroviral therapy. Repeated red blood cell transfusions and an empiric, combined antimicrobial therapy were promptly carried out, under the suspicion of infectious endocarditis, but no appreciable improvement of clinical conditions was achieved. Subsequently, our patient complained not only of an increasingly severe pain at the root of his left thigh, together with overcoming dysuria and urgency, but also urinary tract infection that was rapidly ruled out. During the diagnostic workup for an HIV-associated fever of undetermined origin, a bone marrow biopsy disclosed a metastatic prostatic cancer, with elevated prostate specific antigen (PSA) and acid phosphate levels. An abdominal-pelvic ultrasonography and computerized tomographic scan allowed to detect a dyshomogeneous endopelvic expansive mass with extrinsic compression of the urinary bladder, and involvement of the last lumbar vertebra, large portions of pelvis, and the proximal epiphysis of the right femur. A skeleton scintigraphy pointed out multiple hypercaptation (areas of concentrated traces of radioactivity) areas with involvement of cranial, cervical, dorsal, lumbar, and sacral vertebrae, as well as the pelvis and upper portions of both femurs. Despite therapeutic attempts, our patient deceased after seven weeks due to an overwhelming disseminated intravascular coagulation (DIC).

CONCLUSIONS

The non-specific clinical presentation of our case (mimicking other generalized or focal illnesses), and the final, lethal complication (DIC) pose striking problems related to the differential diagnosis during HIV disease, while the rapid evolution into an advanced, complicated, and widely metastatic disease with extensive bone marrow invasion which preceded the appearance of local signs-symptoms, and the lethal overwhelming DIC, deserves attention by specialists who care for HIV-infected subjects.

Approach to management of clinically localized prostate cancer in patients with human immunodeficiency virus

OBJECTIVES

To evaluate the approach to management of localized prostate cancer (PCa) in patients with human immunodeficiency virus (HIV) in the highly active antiretroviral therapy era.

METHODS

A retrospective analysis was performed on 10 HIV-positive patients who recently presented with elevated prostate-specific antigen levels and clinically localized PCa.

RESULTS

At the diagnosis of PCa, the average patient was 54.0 years old, had been HIV positive for 8.75 years, had a CD4 count of 417, a prostate-specific antigen level of 9.2 ng/mL, and a Gleason score of 6. Eight of the patients had risk factors for PCa--either African-American descent (n = 6) or a positive family history (n = 2). The treatment was laparoscopic radical prostatectomy in 1, potency-preserving androgen deprivation in 1, cryosurgery in 1, brachytherapy in 2, observation in 2, and external beam radiotherapy in 3.

CONCLUSIONS

Screening of all HIV-positive men should be initiated at age 40 if they have either a positive family history of prostate cancer or are of African-American descent. Asymptomatic HIV-positive patients should be offered all therapeutic PCa treatment options.

Prostate carcinoma among men with human immunodeficiency virus infection

BACKGROUND

Several malignancies are known to occur more frequently in individuals with human immunodeficiency virus (HIV) infection. To determine the incidence of prostate carcinoma in men with HIV infection, the authors initiated a prostate carcinoma screening program in a large HIV clinic.

METHODS

Beginning in February 2002, monitoring of prostate-specific antigen (PSA) levels and digital rectal examination (DRE) were included in the routine annual health maintenance provided to men with HIV infection age > or = 35 years who were followed in the infectious disease clinic at the Naval Medical Center San Diego. All men with prostate carcinoma in this population over the last 2 years were reviewed. Demographic data (age, ethnicity), duration of HIV infection, laboratory values (CD4 counts and HIV viral load), and medication use were determined by medical record review. Men with elevated PSA levels (levels above age-adjusted PSA values or PSA velocity > or = 0.75 ng/mL per year) or abnormal DRE results were referred for urologic evaluation. Comparisons between groups were performed using a logistic regression model and the Fisher exact test. Multivariate analysis was performed by logistic regression to determine relations between prostate carcinoma and patient characteristics.

RESULTS

Two hundred sixty-nine men age > or = 35 years (mean age, 43.4 years; range, 35-72years) underwent prostate carcinoma screening by DRE, and 216 men also received PSA testing. Overall, 56.3% of the patients were white, 28.7% were African American, and 15% were of other racial ethnicity. Of the 216 men, 7 (3.2%) had elevated PSA values, and none had abnormal DRE results. Three patients were diagnosed with prostatitis (PSA range, 3.3-25.7 ng/mL), and 1 patient had high-grade prostatic intraepithelial neoplasia, which was determined after a biopsy was performed. Repeat PSA evaluations were within normal limits for the remaining three patients. Review of the cohort during the 2-year period before the current study was initiated revealed 5 additional cases of prostate neoplasia. Prostate carcinoma was common (4 of 11 men, 36.4%) in men age > 60 years and occurred with relatively preserved CD4 counts (mean, 509 cells/mm(3)). In multivariate analysis, African-American race (P = 0.020) and duration of HIV infection (P = 0.047) were found to be associated with the development of prostate carcinoma.

CONCLUSIONS

Prostate carcinoma screening identified abnormal PSA values in 3.2% of the HIV-positive cohort, many associated with prostatitis. Prostate carcinoma was common in older men and was associated with duration of HIV infection. As the life expectancy of men with HIV infection increases, prostate carcinoma screening will become increasingly important in this population.

WITHDRAWN:Epidemiology of prostate cancer and its precursors

Ahead of Print article withdrawn by publisher.