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doi: 10.1097/QAD.0000000000000164
Editorial Comment

Recent cancer trends in HIV-infected individuals in the United States: clues to global cancer trends in HIV populations

Rositch, Anne F.a; Riedel, David J.b

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aDepartment of Epidemiology and Public Health

bInstitute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA.

Correspondence to Anne F. Rositch, PhD, MSPH, Department of Epidemiology and Public Health, University of Maryland School of Medicine, 10 S. Pine St. MSTF 334C, Baltimore, MD 21201, USA. Tel: +1 410 706 0071; fax: +1 410 706 0098; e-mail:

Received 15 November, 2012

Revised 20 November, 2013

Accepted 20 November, 2014

In the combination antiretroviral therapy (ART) era, cancers have become an increasingly important contributor to morbidity and mortality in people infected with HIV [1]. Various factors have been associated with increased cancer risk in this population, including depth and duration of immune suppression [2,3]; levels of circulating viremia [2–4]; high prevalence of oncogenic viruses (e.g. HPV, hepatitis B and C, etc.) [5,6]; frequent exposure to behavioral carcinogens (e.g. alcohol and tobacco) [7–9]; and aging [10]. However, numerous epidemiologic studies have documented declines in AIDS-defining cancers (ADCs), whereas more recent studies have noted a rise in many non-AIDS-defining cancers (NADCs) in this population. In particular, data from the US HIV/AIDS Cancer Match (HACM) Study, led by researchers at the National Cancer Institute, have provided a wealth of information about cancer trends in HIV-infected individuals in the US, yet the fundamental reasons for these changing rates has not been well defined. In this issue of AIDS, Robbins et al. [11] examine population-level factors as potential explanations for changing cancer trends within the HACM. The authors propose three principal influences on cancer incidence rates in HIV: changes in the demographic structure of the subpopulation itself – aging; changes in cancer incidence in the underlying general population from which the subpopulation hails – the background rate; and changes in the risk of cancer in HIV compared to the general population – changing relative risk.

The findings from this study have important implications not just for the US and other developed countries with a mature HIV epidemic, but they also may help predict future trends in resource-limited settings. A limited number of summaries on current trends [12] and future projections [13] of the global cancer burden in the general population are available. However, in resource-limited settings, population-level data on cancer trends in individuals with HIV are almost entirely unavailable. The findings of the study by Robbins et al., combined with global patterns in the general population, may help researchers and clinicians anticipate future trends in cancer in HIV populations worldwide. For example, the changing demographics of the HIV population in the US, mainly an increase in life expectancy due to widespread uptake of highly effective ART, was associated with trends in Kaposi sarcoma (declining), breast and colorectal (not changing), liver (increasing), lung (decreasing), and prostate (increasing). Thus, in the developing world, we might expect that when ART uptake is equally long-term and widespread, it will likely affect cancers that develop at older ages. However, the increased rate of cancer due to aging may be offset by the general health improvement due to ART, whereby the risk of cancer in HIV decreases relative to the general population. This was especially true for ADCs in the US, which all decreased over time in the HIV population and relative to the general population. These declines may also be attributable to the effect of ART on cancer-causing infections, such as human herpes virus 8 (HHV8), or improved screening in the HIV population.

Given the vast need for improvements in cancer screening in many developing countries that likely exceed those in the US during the 1996–2010 study period, changes in screening have the potential to greatly contribute to apparent increases in cancer in the HIV population in the future. Finally, as cancer incidence changes in the general population due to screening, changes in lifestyle, and other important risk factors, the current study finds that this will also contribute to changing patterns in HIV, mainly the NADCs. As in the US, increases in anal and liver cancers can be expected in most settings. In the US, lung cancer was declining in the HIV population along with the general population decline; however, many global settings still have high and increasing tobacco rates, and we therefore anticipate lung cancer incidence to increase until smoking cessation programs affect the population-level exposure to this carcinogen, as we have seen in the US and Europe. Two additional epidemiologic contributors to cancer trends that are not as relevant to the US and many other developed countries, but that will greatly affect background rates and cancer incidence in HIV in several developing countries, are the projected population growth and the transition from infection-associated to lifestyle-associated cancers in the coming decades.

In conclusion, for domestic and international epidemiologists and clinicians focusing on HIV and cancer, the good news from this study is that ART appears to have a significant impact on population-level incidence of ADCs, such that with earlier treatment initiation, as is now recommended in the US and abroad, the number of ADCs should continue to decline over time. Thus, resource-limited countries, where chemotherapy and radiation therapy are largely unavailable, should consider that expanding access and use of ART may be an important additional measure of ADC prevention. In addition, as the HIV population ages and affects cancer risk evaluation of and adherence to current cancer screening guidelines will become even more important for preventing morbidity and mortality in the HIV population.

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Conflicts of interest

There are no conflicts of interest.

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1. Palella FJ Jr, Baker RK, Moorman AC, Chmiel JS, Wood KC, Brooks JT, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr 2006; 43:27–34.

2. Guiguet M, Boue F, Cadranel J, Lang JM, Rosenthal E, Costagliola D. Effect of immunodeficiency, HIV viral load, and antiretroviral therapy on the risk of individual malignancies (FHDH-ANRS CO4): a prospective cohort study. Lancet Oncol 2009; 10:1152–1159.

3. Bruyand M, Thiebaut R, Lawson-Ayayi S, Joly P, Sasco AJ, Mercie P, et al. Role of uncontrolled HIV RNA level and immunodeficiency in the occurrence of malignancy in HIV-infected patients during the combination antiretroviral therapy era: Agence Nationale de Recherche sur le Sida (ANRS) CO3 Aquitaine Cohort. Clin Infect Dis 2009; 49:1109–1116.

4. Zoufaly A, Stellbrink HJ, Heiden MA, Kollan C, Hoffmann C, van Lunzen J, et al. Cumulative HIV viremia during highly active antiretroviral therapy is a strong predictor of AIDS-related lymphoma. J Infect Dis 2009; 200:79–87.

5. Palefsky JM, Minkoff H, Kalish LA, Levine A, Sacks HS, Garcia P, et al. Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIV-negative women. J Natl Cancer Inst 1999; 91:226–236.

6. Vallet-Pichard A, Pol S. Hepatitis viruses and human immunodeficiency virus co-infection: pathogenesis and treatment. J Hepatol 2004; 41:156–166.

7. Galvan FH, Bing EG, Fleishman JA, London AS, Caetano R, Burnam MA, et al. The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol 2002; 63:179–186.

8. Browning KK, Wewers ME, Ferketich AK, Diaz P. Tobacco use and cessation in HIV-infected individuals. Clin Chest Med 2013; 34:181–190.

9. Clifford GM, Polesel J, Rickenbach M, Dal Maso L, Keiser O, Kofler A, et al. Cancer risk in the Swiss HIV Cohort Study: associations with immunodeficiency, smoking, and highly active antiretroviral therapy. J Natl Cancer Inst 2005; 97:425–432.

10. Crum-Cianflone N, Hullsiek KH, Marconi V, Weintrob A, Ganesan A, Barthel RV, et al. Trends in the incidence of cancers among HIV-infected persons and the impact of antiretroviral therapy: a 20-year cohort study. AIDS 2009; 23:41–50.

11. Robbins HA, Shiels MS, Pfeiffer RM, Engels EA. Epidemiologic contributions to recent cancer trends among HIV-infected people in the United States. AIDS 2014; 28:881–890.

12. Jemal A, Center MM, DeSantis C, Ward EM. Global patterns of cancer incidence and mortality rates and trends. Cancer Epidemiol Biomarkers Prev 2010; 19:1893–1907.

13. Bray F, Jemal A, Grey N, Ferlay J, Forman D. Global cancer transitions according to the Human Development Index (2008–2030): a population-based study. Lancet Oncol 2012; 13:790–801.


cancer; HIV/AIDS; trends; United States

© 2014 Lippincott Williams & Wilkins, Inc.


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