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ASCO: Characteristics and Disparities of Care for HIV+ People with Lung Cancer

HIV positive people with lung cancer are diagnosed at a younger age and have shorter survival than HIV negative people, on average, suggesting that screening should perhaps be started earlier, according to studies presented at the 50th Annual Meeting of the American Society of Clinical Oncology (ASCO) this month in Chicago.

Lung Cancer Diagnosis

Marina Shcherba of Albert Einstein College of Medicine and colleagues analyzed the characteristics of lung cancer cases among people with HIV in a large clinical population, as well as implications for lung cancer screening.

Lung cancer is one of the more common and life-threatening cancers in people with HIV. Lung cancer accounts for about 30% of cancer deaths and 10% of non-HIV-related deaths among people with HIV, the researchers noted as background. Even after accounting for smoking, HIV positive people appear to have a 2- to 5-fold higher risk compared to the general population.

The National Lung Screening Trial (NSLT) showed that low-dose computed tomography X-ray screening led to improved survival for people at high risk for lung cancer, specifically those age 55-74 years with a history of 30 or more pack-years of smoking.

The researchers linked data from the Montefiore Medical Center/Einstein Cancer Registry (42,967 cancer cases) and the HIV Integrated Clinical Database (14,927 HIV positive patients) to identify cancer cases among people with HIV between 2000 and 2012.

Of the 935 invasive cancers in people with HIV, 90 (9.6%) were lung cancers, with 62% occurring in men and 38% in women. The median age at lung cancer diagnosis was 54 years, with about half being 35-54 years old and half 55 or older. The median CD4 T-cell count was quite low at 238 cells/mm³. Two-thirds had 30 or more pack-years of smoking, but 3% had less than 15 pack-years and 4% reported never smoking.

Adenocarcinoma was the most common lung cancer type (37%), followed by non-small cell carcinoma (30%), squamous cell (20%), and small cell (11%). A majority (58%) were diagnosed with stage IV cancer, 23% with stage III, 11% with stage II, and 8% with stage I. All patients with stage I or II underwent surgical resection, or tumor removal.

Most HIV positive lung cancer cases failed to meet NLST criteria for CT screening due to younger age (<55 years) or less smoking (<30 pack-years). "If [low-dose CT] is to be utilized in this high-risk population, age and smoking thresholds may need to be lowered," the researchers suggested. "Notably, 19% of tumors were diagnosed at stage I/II without routine screening, reinforcing the potential to identify lung cancer at a treatable stage in HIV+ persons," they added.

Disparities in Care

A second study, by Daniel Hartman Johnson from Louisiana State University Health Sciences Center and colleagues, looked at disparities in care for HIV positive people with lung cancer.

People with HIV appear to have an overall shorter survival than HIV negative people, but issues such as compliance with established guidelines, use of second- and third-line therapies, and molecular testing have not been well-studied in this population.

This analysis was a retrospective review of 18 HIV positive patients with lung cancer seen at LSU Health Center between 2002 and 2013. A majority were men and the median age at diagnosis was 49 years. Half had advanced immune suppression with a CD4 count <200 cells/mm³ at the time of cancer diagnosis, and about 40% had unsuppressed HIV.

Half the patients had stage IV lung cancer at diagnosis, while 4 had stage III, 1 had stage II, and 3 had stage I. Only 1 patient underwent cancer biomarker testing for epidermal growth factor receptor (EGFR) and none for anaplastic lymphoma kinase (ALK). None of the patients with stage IV lung cancer were offered second- or third-line therapies. In fact, two-thirds of people with stage III or IV cancer were either not treated at all or only received palliative radiation therapy.

The median overall survival in the HIV positive cohort was 5.4 months, compared with 7.2 months for untreated HIV negative patients. HIV positive survival times ranged from 5.3 months for people with stage IV cancer (vs 17.0 for HIV negatives) to 13.5 months for those with stage Ib (vs 81 months for HIV negatives). However, the number of HIV positive people with earlier stages was too small to draw statistical conclusions. Also, since so many people in this study had low CD4 counts, it is not clear whether such poor prognosis would also be expected in HIV positive people with well-preserved immune function.

"Our data show that HIV lung cancer patients are diagnosed at a younger age, do not get standard of care treatment, and have a poorer overall prognosis," the researchers concluded. "Prior studies show that 49% of stage IV patients get second-line treatment, however, none of our stage IV patients with HIV received such therapy."

"Successful strategies proven in the general population, such as molecular testing to detect mutations amenable to targeted therapy and the use of second- and third-line therapy when applicable, should be encouraged in HIV patients as well," they recommended. "Close collaboration with HIV providers to facilitate appropriate therapy and follow-up is much needed."

6/27/14

References

M Shcherba, HD Hosgood, J Lin, et al. Characteristics of HIV+ lung cancer cases in a large clinical population: Implications for lung cancer screening.50th Annual Meeting of the American Society of Clinical Oncology. Chicago, May 30-June 3, 2014 (Journal of Clinical Oncology 32:5s, 2014). Abstract 1569.

D Hartman Johnson, MA Ruiz, and RA Ramirez. Disparities in care for HIV patients with lung cancer. 50th Annual Meeting of the American Society of Clinical Oncology. Chicago, May 30-June 3, 2014 (Journal of Clinical Oncology 32:5s, 2014). Abstract e17566.