September 15, 2016
HIV-positive people run a higher risk of not getting treated for several major cancers, regardless of insurance status or comorbidities, according to analysis of 2.2 million nonelderly cancer patients in the United States. Among people with HIV, black race and lack of private insurance predicted not receiving cancer therapy, according to the study.
Cancer has become the second leading cause of death in people with HIV. And HIV-positive people have higher cancer-specific mortality than people without HIV. Yet evidence indicates that cancer patients with HIV are less likely than HIV-negative people to get treated for cancer. Because previous work on cancer treatment disparities with HIV did not account for insurance status or comorbidities, U.S. investigators conducted a new study with analyses adjusted for those confounders and others.
Researchers used the U.S. National Cancer Data Base (NCDB) to identify people 18 years old or older who had their first cancer diagnosis between 2003 and 2011. They focused on the 10 most common cancers in people with HIV: head and neck, upper gastrointestinal (GI), colorectal, anal, lung, breast, cervical, prostate, Hodgkin lymphoma and diffuse large B-cell lymphoma. The investigators used ICD-9-CM codes to identify cancer patients with HIV infection. The analysis excluded people 65 years old or older. For each cancer site, the researchers used multivariate logistic regression analysis adjusted for age, sex, race/ethnicity, insurance status, comorbidities and other variables to determine the impact of HIV status on lack of cancer treatment. In people with HIV, the investigators used multivariate logistic regression to identify predictors of lack of cancer treatment.
For nine of the 10 cancers assessed, multivariate analysis determined that people with HIV had higher odds of going untreated after adjustment for insurance status, comorbidities and other variables: head and neck (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.09 to 2.01), upper GI tract (aOR 2.62, 95% CI 2.04 to 3.37), colorectal (aOR 1.70, 95% CI 1.17 to 2.48), lung (aOR 2.46, 95% CI 2.19 to 2.76), breast (aOR 2.14, 95% CI 1.16 to 3.98), cervical (aOR 2.81, 95% CI 1.77 to 4.45), prostate (aOR 2.16, 95% CI 1.69 to 2.76), Hodgkin lymphoma (aOR 1.92, 95% CI 1.66 to 2.22) and diffuse large B-cell lymphoma (aOR 1.82, 95% CI 1.65 to 2.00). Anal cancer was the only cancer for which chances of treatment did not differ significantly by HIV status (aOR 1.20, 95% CI 0.83 to 1.71, P = .333).
In an analysis restricted to HIV-positive and negative cancer patients with private health insurance, people with HIV had higher adjusted odds of going untreated for all cancers except head and neck cancer, anal cancer and cervical cancer, and there was a trend toward higher odds of no treatment for cervical cancer (aOR 2.73, 95% CI 0.80 to 9.29, P = .108).
Among HIV-positive cancer patients, multivariate analysis identified two independent predictors of no treatment for both solid tumors and lymphomas: black race versus white race (aOR 1.42 for both solid tumors and lymphomas) and Medicaid, Medicare or no insurance versus private insurance. For solid tumors, stage-4 versus stage-1 cancer independently predicted lack of treatment (aOR 2.60, 95% CI 1.93 to 3.51). But for lymphomas, stage 2, 3 or 4 lowered odds of no treatment compared with stage 1. For lymphomas, age 45 years or older predicted lack of treatment (aOR 1.29, 95% CI 1.11 to 1.50 for 45 to 54 years versus younger; aOR 1.30, 95% CI 1.05 to 1.60 for 55 to 64 years versus younger than 45). And for lymphomas, a comorbidity index of 1 or ≥2 compared with 0 independently raised the odds of no treatment.
The researchers believe their findings "suggest that cancer care providers and policy makers need to devote special attention to the HIV-infected patient population to understand and address the factors driving differential cancer treatment, which may include lack of management guidelines and clinical trial data." They stress that the cancer treatment disparity between patients with and without HIV is assuming greater importance because people with HIV are living longer and cancer treatment improves quality of life even for patients with advanced cancer.
Mark Mascolini writes about HIV infection.
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