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Half of women with HIV and GYN cancer do not receive standard cancer therapy.

Half of a US group of women with HIV and a gynecologic (GYN) cancer did not receive cancer treatment recommended by standard guidelines. (1) Most women with stage 1 (early) gynecologic cancer received guideline-recommended treatment. But women with advanced gynecologic cancer were less likely to receive guideline-recommended treatment, largely because of patient-related factors and side effects of cancer drugs in these women. Among women with stage 2, 3, or 4 (more advanced) cancer, those who received recommended treatment were more likely to survive at least 4 years after cancer detection.

Thanks to antiretroviral therapy, * women and men with HIV are living much longer. As people with HIV grow older, the risk of age-related diseases like heart disease and cancer also grows. Aging women face a growing threat of four gynecologic cancers--cervical cancer, endometrial (uterine) cancer, ovarian cancer, and vulvar or vaginal cancer. (2) Cervical cancer has been well studied in women with HIV because it is one of three AIDS-related cancers. But much less is known about the other three gynecologic cancers in women with HIV.

Learning more about treatment of gynecologic cancers in women with HIV is necessary to make treatment better. To improve the understanding of gynecologic cancer treatment in women with HIV, researchers at two large Maryland hospitals conducted this study. They had two main goals: (1) to see how often women with HIV received gynecologic cancer treatment according to accepted treatment guidelines, and (2) to determine how treatment according to guidelines affects survival with cancer.

How the study worked. The study involved all HIV-positive women found to have a gynecologic cancer at 1 of 2 large cancer centers in Maryland from 2000 to 2015. Researchers used medical records to determine which women had HIV and a gynecologic cancer, to identify health-related factors (like age, race, and CD4 count), and to see which women did or did not receive cancer treatment as recommended by National Comprehensive Cancer Network (NCCN) guidelines.

The research team classified all cancers by stage, with stage 1 being the least advanced cancer and stages 2 to 4 being more advanced cancers. They also determined reasons for not following cancer treatment guidelines. Those reasons could be (1) provider-related (incorrect surgical procedure or therapy chosen), (2) patient-related (including not keeping medical appointments, social factors, and refusal of therapy), (3) treatment toxicity (side effects) or other medical conditions limiting therapy, and (4) disease progression (worsening).

The researchers used standard statistical methods to determine survival of women according to cancer type, cancer stage, and treatment following or not following guidelines.

What the study found. The analysis focused on 57 women with newly detected gynecologic cancer during the 2000-2015 study period. These women had a median (midpoint) age of 46 years when cancer appeared. Fifty women (88%) were black and 7 (12%) were white. A median of 8.5 years passed between detection of HIV and detection of cancer in these women. Eight women had their HIV and cancer detected in the same year. Two thirds of women were taking antiretroviral therapy when found to have cancer, and median CD4 count stood at 315.

Among the 57 women, 26 (46%) had cervical cancer, 15 (26%) had vulvar cancer, 9 (16%) had ovarian cancer, and 7 (12%) had endometrial (uterine) cancer (Figure 1). Thirty women (53%) had stage 1 cancer (the least advanced type), and 27 (47%) had stage 2, 3, or 4 cancer

Twenty-eight women (49%) received cancer treatment that followed guideline recommendations; 29 women (51%) did not receive cancer treatment that followed guidelines. While 22 of 30 women with stage 1 cancer (73%) received treatment according to guidelines, only 6 of 27 women with stage 2, 3, or 4 cancer (22%) received treatment according to guidelines.

Among the 29 women who did not receive treatment according to guidelines, reasons included drug toxicity (side effects) in 11 women (38%), patient-related reasons in 9 (31%), other medical conditions in 5 (17%), provider-related reasons in 3 (10%), and cancer progression (worsening) in 1 (3%).

Overall survival 48 months after cancer detection was lowest for ovarian cancer (21% survived) and highest for uterine cancer (100% survived). Overall 48-month survival was 79% for cervical cancer and 77% for vulvar cancer. Among the 30 women with stage 1 cancer, almost all survived for 48 months regardless of whether they received treatment according to guidelines. But among the 27 women with stage 2, 3, or 4 cancer, 60% survived for 48 months if they received treatment according to guidelines, while 28% survived for 48 months if they did not receive treatment according to guidelines. Time since detection of HIV and CD4 count at detection of cancer did not affect overall survival.

What the findings mean for you. This careful study of 57 women with HIV and gynecologic cancer made some important findings. First, many women know that cervical cancer-one of the three AIDS cancers--affects women with HIV more often than women without HIV. This study shows that three other gynecologic cancers--vulvar cancer, ovarian cancer, and endometrial (uterine) cancer-may also develop in HIV-positive women. In this study of 57 women with HIV, 31 (54%) had a gynecologic cancer other than cervical cancer.

Early cervical cell changes that may lead to cervical cancer can be detected by the Pap test. Guidelines call for a yearly Pap test in women with HIV, even after age 65. (3) But cervical cancer is the only gynecologic cancer that has a recommended screening test. Signals of other gynecologic cancers include unusual vaginal bleeding and any unexplained reproductive system signs that last for 2 weeks or more (4) (Table 1). The Centers for Disease Control and Prevention (CDC) has a free online guide to understanding gynecologic cancers and knowing their warning signals. Go to the link at reference 5 below.

Another major finding of this study is that women with stage 2 to 4 cancer who got treated according to gynecologic cancer guidelines had a twice-higher chance of surviving at least 4 years than women whose treatment did not follow guidelines. But about half of HIV-positive women with gynecologic cancer did not receive treatment reflecting cancer care guidelines. Sometimes the reason for this failure was understandable-such as cancer drug side effects or rapid cancer worsening. In 10% of these cases when treatment did not follow guidelines, providers recommended other treatments. In 30% of cases, the reason could be traced to the woman with cancer, such as failure to keep appointments or refusal of therapy.

It is very important for everyone with HIV--and certainly for people with HIV and cancer--to follow the advice of their HIV provider and other healthcare experts like cancer specialists. Sometimes providers and specialists can offer options for care, but varied approaches may have different results in different patients. Everyone must work together to give each person with cancer the best chance of a successful treatment strategy.


(1.) Levinson KL, Riedel DJ, Ojalvo LS, et al. Gynecologic cancer in HIV-infected women: treatment and outcomes in a multi-institutional cohort. AIDS. 2018;32:171-177.

(2.) Shiels MS, Pfeiffer RM, Gail MH, et al. Cancer burden in the HIV-infected population in the United States. J Natl Cancer Inst. 2011;103:753-762.

(3.) National Institutes of Health. AIDSinfo. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. 343.pdf

(4.) Centers for Disease Control and Prevention. Cancer prevention and control. Gynecologic cancer awareness.

(5.) Centers for Disease Control and Prevention. Inside knowledge: Get the facts about gynecologic cancer.

* Words in boldface are explained in the Technical Word List at the end of this issue.

Caption: Figure 1. Four gynecologic cancers found in 57 women with HIV were cervical cancer (in 46%), vulvar cancer (in 26%), ovarian cancer (in 16%), and endometrial (uterine) cancer (in 12%). (Illustration from Servier PowerPoint Image Bank,
Table 1. Possible signals of gynecologic cancer

Cancer    Possible signs and symptoms
          ** Unusual bleeding or discharge from the vagina, * such as
          after sex

Cervical  ** Early cancer may have no physical signals, but a Pap
          test can spot possibly
          dangerous cervical cell changes that lead to cancer

          ** Abnormal vaginal discharge or bleeding *

          ** Pain or pressure in the pelvis (below the stomach and
          between the hip bones)
          ** Abnormal vaginal discharge or bleeding *

          ** Pain or pressure in the pelvis (below the stomach and
          between the hip bones)

          ** Abdominal or back pain

          ** Bloating

          ** Feeling full too quickly or difficulty eating

          ** A change in bathroom habits, such as constipation or
          more frequent urination

          ** Persistent itching, burning, or bleeding in the vulva

          ** Change in skin color of the vulva (redder or whiter than

Vulvar    ** Skin changes in the vulva looking like rash or warts

          ** Sores or lumps on the vulva that do not go away

          ** Pain in the pelvis, especially during urination or sex

* Bleeding may be abnormal because of how heavy it is or when it

Source: Centers for Disease Control and Prevention, inside knowledge:
Get the facts about gynecologic cancer.
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Title Annotation:ARTICLE 2; gynecologic cancer
Publication:HIV Treatment: ALERTS!
Date:Dec 1, 2018
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