Share this article on:

Nonsmoking and other cofactors for Kaposi's sarcoma

Goedert, James J

doi: 10.1097/QAD.0b013e32831f4674

Infections & Immunoepidemiology Branch, National Cancer Institute, Rockville, Maryland, USA.

Received 2 October, 2008

Revised 22 October, 2008

Accepted 22 October, 2008

Correspondence to James J. Goedert, Infections & Immunoepidemiology Branch, National Cancer Institute, Rockville, MD 20852, USA. Tel: +1 301 435 4724; fax: +1 301 402 0817; e-mail:

The recent series of 28 cases of HIV-negative Kaposi's sarcoma in homo/bisexual men reported by Lanternier et al. [1], as well as the subsequent editorial comment by Colman and Blackbourn [2], highlights the strong contribution of cofactors to the development of this malignancy. The primary cause of Kaposi's sarcoma is infection with Kaposi's sarcoma associated herpesvirus (KSHV, also known as human herpesvirus 8), but the vast majority of KSHV-infected people do not develop Kaposi's sarcoma. We estimated that the annual incidence of classic Kaposi's sarcoma (cKS) is about 30/100 000 KSHV-seropositive Mediterranean men over 50 years of age, or approximately 0.3% over 10 years [3]. In contrast, the annual incidence of AIDS Kaposi's sarcoma was about 3/100 in untreated HIV-infected KSHV-seropositive homosexual men, or about 30% over 10 years [4]. This illustrates that HIV is a very potent cofactor, increasing the risk of Kaposi's sarcoma by approximately 100-fold.

There must be cofactors for non-AIDS Kaposi's sarcoma. During 2002–2006, my colleagues and I conducted a case–control study of cKS that encompassed the entire island of Sicily. As in our previous case–control study of cKS [5], the risk of cKS was three-fold lower among KSHV-seropositive people who had ever smoked at least one cigarette per week [6]. Moreover, the risk was even lower (five-fold) among current smokers and intermediate (two-fold) among former smokers. A significantly reduced risk of AIDS Kaposi's sarcoma with smoking was noted in two cohorts of HIV-infected homosexual men in the United States [7,8]. Neither Lanternier et al. [1] nor Colman and Blackbourn [2] mention nonsmoking.

In a study by Lanternier et al. [1], one of the 28 non-AIDS Kaposi's sarcoma (presumptively cKS) patients was noted to have used corticosteroids for asthma. Systematically collected data on medications would be helpful, as the risk of cKS was increased more than two-fold with asthma in our earlier study [5] and with corticosteroid use in both studies [5,6].

Diabetes mellitus may also prove to be a cofactor. Four (14%) of the 28 non-AIDS Kaposi's sarcoma patients were noted to have diabetes, although the expected prevalence in this population is unknown [1]. The risk of cKS was increased four-fold with diabetes in our recent study [6], but this was not seen in the previous study [5].

Finally, inherited susceptibility surely contributes to the development of Kaposi's sarcoma among people who have been infected with KSHV. In addition to HLA, as mentioned by Colman and Blackbourn [2], other genes that regulate innate immunity and cytokine balance could be equally important [9,10].

Identification of cofactors can lead to useful interventions to complement drugs directed against KSHV lytic replication [11]. The ultimate goal is not cKS, because the absolute risk is very low [3], but rather to reduce the very serious morbidity and mortality from Kaposi's sarcoma in Africa [12,13]. Neither I nor anyone would recommend smoking to reduce the risk of Kaposi's sarcoma. Instead, understanding the mechanism that underlies this epidemiologic association could lead to an effective prophylactic or treatment. Nicotine probably will not fulfill this function [14]. Something else will.

Back to Top | Article Outline


1. Lanternier F, Lebbé C, Schartz N, Farhi D, Marcelin AG, Kérob D, et al. Kaposi's sarcoma in HIV-negative men having sex with men. AIDS 2008; 22:1163–1168.
2. Colman R, Blackbourn DJ. Risk factors in the development of Kaposi's sarcoma. AIDS 2008; 22:1629–1632.
3. Vitale F, Briffa DV, Whitby D, Maida I, Grochowska A, Levin A, et al. Kaposi's sarcoma herpes virus and Kaposi's sarcoma in the elderly populations of 3 Mediterranean islands. Int J Cancer 2001; 91:588–591.
4. Engels EA, Biggar RJ, Marshall VA, Walters MA, Gamache CJ, Whitby D, et al. Detection and quantification of Kaposi's sarcoma-associated herpesvirus to predict AIDS-associated Kaposi's sarcoma. AIDS 2003; 17:1847–1851.
5. Goedert JJ, Vitale F, Lauria C, Serraino D, Tamburini M, Montella M, et al. Risk factors for classical Kaposi's sarcoma. J Natl Cancer Inst 2002; 94:1712–1718.
6. Anderson LA, Lauria C, Romano N, Brown EE, Whitby D, Graubard BI, et al. Risk factors for classical Kaposi sarcoma in a population-based case–control study in Sicily. Cancer Epidemiol Biomarkers Prev 2008; 17:1–9.
7. Nawar E, Mbulaiteye S, Gallant JE, Wohl DA, Ardini M, Hendershot T, et al. Risk factors for Kaposi's sarcoma among HHV-8 seropositive homosexual men with AIDS. Int J Cancer 2005; 115:296–300.
8. Hoover DR, Black C, Jacobson LP, Martinez-Maza O, Seminara D, Saah A, et al. Epidemiologic analysis of Kaposi's sarcoma as an early and later AIDS outcome in homosexual men. Am J Epidemiol 1993; 138:266–278.
9. Brown EE, Fallin D, Goedert JJ, Chen D, Whitby D, Foster CB, et al. A common genetic variant in FCGR3A-V158F and risk of Kaposi sarcoma herpesvirus infection and classic Kaposi sarcoma. Cancer Epidemiol Biomarkers Prev 2005; 14:633–637.
10. Brown EE, Fallin D, Ruczinski I, Hutchinson A, Staats B, Vitale F, et al. Associations of classic Kaposi sarcoma with common variants in genes that modulate host immunity. Cancer Epidemiol Biomarkers Prev 2006; 15:926–934.
11. Martin DF, Kuppermann BD, Wolitz RA, Palestine AG, Li H, Robinson CA. Oral ganciclovir for patients with cytomegalovirus retinitis treated with a ganciclovir implant. Roche Ganciclovir Study Group [see comments]. N Engl J Med 1999; 340:1063–1070.
12. Wabinga HR, Parkin DM, Wabwire-Mangen F, Mugerwa JW. Cancer in Kampala, Uganda, in 1989–91: changes in incidence in the era of AIDS. Int J Cancer 1993; 54:26–36.
13. Chokunonga E, Levy LM, Bassett MT, Mauchaza BG, Thomas DB, Parkin DM. Cancer incidence in the African population of Harare, Zimbabwe: second results from the cancer registry. Int J Cancer 2000; 85:54–59.
14. Goedert JJ, Scoppio BM, Pfeiffer R, Neve L, Federici AB, Long LR, et al. Treatment of classic Kaposi sarcoma with a nicotine dermal patch: a phase II clinical trial. J Eur Acad Dermatol Venerol 2008; 22:1101–1109.
© 2009 Lippincott Williams & Wilkins, Inc.