US study shows importance of access to chemotherapy for HIV-positive patients with Hodgkin lymphoma

HIV is associated with poorer outcomes in patients diagnosed with Hodgkin lymphoma, according to US research published in AIDS. Analysis of the National Cancer Data Base revealed a 66% five-year survival rate for patients with HIV compared to 80% for the general population.

The poorer survival rate associated with HIV was driven mainly by lower rates of chemotherapy administration, which in turn was associated with high rates of poverty and markers of social exclusion. However, HIV-positive patients with classic presentation of Hodgkin lymphoma who received chemotherapy had survival rates comparable to those observed in the HIV-negative population.

“We found that a significant proportion (18%) of HIV-infected Hodgkin lymphoma patients do not receive treatment for this curable cancer, which is 1.7 times higher than in the HIV-negative population,” comment the authors. “Nonreceipt of chemotherapy correlated with unfavourable socioeconomic variables, including black race, lack of health insurance and residence in high-poverty areas.”

Hodgkin lymphoma is a cancer of the lymph nodes and lymphatic system. Incidence of Hodgkin lymphoma among people with HIV is up to 20 times higher than that seen in the general population. The cancer can be treated successfully in most people, especially if diagnosed early. Findings from observational cohort studies suggest that HIV-positive patients can have comparable disease outcomes to HIV-negative individuals, provided they receive antiretroviral therapy and appropriate cancer treatment. In contrast, population-based research has consistently shown that patients with HIV have poorer overall survival, with a five-year estimate of approximately 63%.

Chemotherapy is essential for the curative treatment of classic presentations of Hodgkin lymphoma. A team of investigators therefore hypothesised that the poor survival rates observed in HIV-positive patients enrolled in population-based studies could be due to suboptimal delivery of chemotherapy. To test this theory, they studied information from the National Cancer Data Base to evaluate management patterns and survival trends in Hodgkin lymphoma patients according to HIV infection status.

The National Cancer Data Base covers at least 70% of cancer diagnoses in the US. The investigators extracted the records of patients who were diagnosed with Hodgkin lymphoma between 2004 and 2012. Information was available on the HIV status of each patient. For those with HIV, details of CD4 cell count and use of antiretroviral therapy were available.

Patients were classified according to race and ethnicity. Lymphoma was staged as favourable, unfavourable, or advanced. Household income and area of residence were used as markers of socioeconomic status, and data were also gathered on type of treatment centre and health insurance status.

A total of 43,935 Hodgkin lymphoma patients were recorded during the study period and 5% (2090) were HIV positive.

Compared to patients in the general population, patients with HIV were older, more likely to be male and a significantly higher proportion were Hispanic or Black. The majority of HIV-positive individuals lived in urban areas, had a low household income and had Medicaid health insurance, consistent with their low income and disability status.

Two-thirds of patients with HIV had advanced Hodgkin lymphoma. HIV-positive Hodgkin lymphoma was more likely to be extranodal, the most frequent sites being bone marrow (46% of extranodal cases), gastrointestinal tract (28%) and head and neck (13%).

Nodular sclerosis was the most common subtype in both HIV-positive and HIV-negative patients. Patients with HIV were more likely to have undetermined histologic types (40% vs. 26%).

In terms of treatment, 81% of patients with HIV received chemotherapy (12% in combination with radiotherapy), 13% received any radiotherapy and 16% had no therapy. Treatment rates were significantly lower than those seen in the HIV-negative population (87%, 31%, 9%, respectively; all p < 0.00001).  

Early stage disease was less likely to be treated in patients with HIV than in HIV-negative individuals (28% vs. 41%).

Factors associated with HIV-positive people not receiving chemotherapy were older age, male sex, insurance type, living in low income areas, early stage disease and undetermined disease histology.

Patients were followed for a median of 51 months. The overall five-year survival for patients with HIV was 66%, significantly lower than the 80% observed in HIV-negative patients. HIV-positive patients also had poorer survival when outcomes were stratified according to Hodgkin lymphoma disease stage.

Chemotherapy was key to improved survival in patients with HIV.

For patients with classic Hodgkin lymphoma who received chemotherapy, there was no significant difference in the risk of death between HIV-positive and HIV-negative individuals.

Analysis of HIV-positive patients treated with chemotherapy showed that poorer survival was associated with advancing age, underdetermined histological type and insurance type.

“The fact that survival with active treatment is not influenced by HIV status in patients with classical subtypes of Hodgkin lymphoma underscores the need for an aggressive approach,” conclude the authors. “Patients with undetermined histology require particular attention due to worse prognosis and high risk of nontreatment.”