HIV infection and malignancy: Epidemiology and pathogenesis
- John F Deeken, MD
John F Deeken, MD
- Associate Professor
- Virginia Commonwealth University
- Associate Director for Medical Oncology and Clinical Research
- Inova Comprehensive Cancer and Research Institute
- Liron Pantanowitz, MD
Liron Pantanowitz, MD
- Associate Professor of Pathology
- University of Pittsburgh Medical Center
HIV-infected individuals have an increased propensity to develop malignancy [1,2]. The occurrence of an extremely high number of cases of Kaposi's sarcoma (KS) was noted early in the AIDS epidemic and many of them had an unusually aggressive clinical course. KS was therefore included as an AIDS-defining illness in early case definitions from the Centers for Disease Control and Prevention (CDC). Non-Hodgkin lymphoma (NHL) and invasive cervical carcinoma were subsequently added as AIDS-defining conditions.
The spectrum of neoplasia in HIV infected patients has changed in areas where the use of potent antiretroviral therapy (ART) is widespread. The incidence of KS and NHL has decreased markedly, but there has been a relative increase in tumor types that collectively are referred to as non-AIDS-defining cancers (NADCs) compared with the general population. NADCs now are a major factor contributing to mortality in HIV-infected people.
This topic will review the epidemiology and pathogenesis of malignancy in people infected with HIV. General management considerations for these malignancies, as well as epidemiologic features and management considerations for specific tumor types are discussed separately. (See "HIV infection and malignancy: Management considerations".)
The era of potent ART began in 1996 with the availability of the protease inhibitors. In most patients, ART causes both an immunologic response manifested by normalization CD4 lymphocyte counts and a virologic response with nearly complete suppression of HIV viral replication. Both immunologic and virologic responses are important in achieving at least partial immune restoration, thus decreasing the incidence of opportunistic infections, reducing the risk of developing NHL or KS, and prolonging survival [3,4]. (See "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient".)
AIDS-defining malignancies — The overall impact of the introduction of ART is illustrated by the Swiss HIV Cohort Study, which analyzed the incidence of AIDS-defining and non-AIDS defining cancers in 9429 patients with 54,715 years of patient follow-up . The incidence of cancers was broken down into three periods: 1985 to 1996 (pre-ART), 1997 to 2001 (early ART), and 2002 to 2006 (late ART).
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- AIDS-defining malignancies
- Non-AIDS-defining cancers
- HIV infection diagnosed during childhood
- Role of the HIV virus
- Coinfection with oncogenic organisms
- - HHV-8 infection
- - HPV infection
- - EBV infection
- - HBV and HCV infection
- - Merkel cell polyoma virus
- - Hymenolepis nana
- - Other environmental oncogenic stimuli
- Antiretroviral drugs and timing of cancer development