Transcript sample slide 1 - View the full AIDS 2016 programme

Cancer Trends in
North America Over
the Past Decade
Benigno Rodríguez, MD, MSc, FIDSA
Durban, 19 July 2016
DISCLOSURES
 Honoraria from Gilead
 Funding from NIH, NHLBI, NCI
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OUTLINE
 Cancer trends among PLWH in North America
 Overall frequency
 Cancer-specific patterns
 Effect of infectious etiologies and immune status
 Conclusions: Strategies to bend the trend
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Background
 A greater incidence of malignancy has been
observed among HIV-infected persons relative to
the general population since the beginning of he
epidemic
 Even after controlling for conventional risk factors
 The introduction of cART has changed the patterns
of occurrence of malignancy to various degrees
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CNICS Cancers Over Time
200
180
160
140
120
100
80
60
40
20
0
1997
1999
2001
2003
2005
ADC
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2007
2009
2011
2013
NADC* *Excluding non-melanoma skin
 Examined secular trends in 3 periods: 1996-1999.
2000-2004, 2005-2009
 N= 86,620 HIV-infected (475,660 PY of FU); 196,987
HIV-uninfected (1,847,932 PY of FU)
 Nine target cancers (centrally adjudicated); KS, NHL,
HL, lung, anal, colorectal, liver, OP, melanoma
 Key features:
 Competing risks analysis, adjusted for sex, race, and
cohort
 Cumulative cancer risk at age75
 Contrast to cancer-specific hazard rate
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Crude Cancer-specific Incidence
Rates, HIV+ and HIV-
 Same for crude cumulative incidence at age 65 or
75, except for melanoma and colorectal/OP cancer
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Decreasing Calendar Trends In Cancer
and Mortality, 1996-2009
* Significant
trend in causespecific HR only
*
*
*
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Increasing Calendar Trends In Cancer
and Mortality, 1996-2009
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Interval Summary
 ADC incidence has decreased drastically among HIVinfected persons in North America
 But risk remains massively higher than in the general
population
 Incidence and risk of certain NADCs has increased
despite the introduction of cART
 Including anal, colorectal, and liver
 At least partly d/t improved survival (no change in csHR)
 Cumulative incidence trend in HIV+ and HIV- was similar
for liver cancer, but opposite for colorectal
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Delayed vs. Immediate ART Initiation:
Effect on Cancer Incidence
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INSIGHT Study Group. NEJM 2015; 373: 9
0
HBV Vaccine Response among HIVinfected Patients and Risk of Cancer
 N=1,578; 96 (6%) developed incident cancer during follow up
HBV vaccine responders
HBV vaccine non-responders
.25
Cumulative Subhazard
.4
Cumulative hazard of cancer
Competing-risks regression
.3
.2
.1
.15
.1
.05
P=0.03*
0
0
.2
0
5
15
10
Follow-up time (years)
20
5
failrespond=0
*Adjusted for age, CD4 (nadir and time-updated), history of OI
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10
15
analysis time
20
failrespond=1
0
Effect of Viremia on NHL Incidence
 3-month lagged
viremia levels shown
 Viremia as a
continuous value was
associated with a HR
for NHL of 1.42/log10
copies/mL
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Achenbach C, et al. CID 2014; 58:1599
Conclusions
 Most ADCs have decreased dramatically, but HIV-infected
persons remain at considerable risk
 The risk of NADCs has surpassed that of ADCs in the cART
era and in some cases continues to rise
 A strong link to immune competence, persistent viremia,
and infectious etiologies suggests possible strategies to
modulate these trends:
 Early, universal, suppressive ARV therapy
 Increased screening and aggressive treatment for many NADCs
 Vigorous treatment of coinfecting oncogenic pathogens
 Reduction of residual inflammation/immune activation
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Acknowledgements
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CNICS Malignancy Data Update
• Cancer data collection through 2014
• 3,897 verified cancer diagnoses
– 66% non-KS with histopathology
– 48% KS with histopathology
• Details on diagnosis confirmation method, histopathology,
stage, grade, family history, exposures to tobacco and
alcohol
– 59% with staging (summary or TNM)
CNICS Digital Record Abstraction
(DRA)
CNICS Sites
DRAs uploaded to secure
website for distributed review
by multiple Adjudication
Committee members
DMC ascertainment of
eligible participants
transmitted to Sites
Site EMR clinical
documentation
DMC
DMC Processes, Scrubs,
and Indexes DRAs
University of Washington
Digital Record
Abstraction (DRA)
text files, graphics
De-identified
DRAs uploaded
to DMC
DRAs securely transmitted
to individual investigator
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