People With HIV Less Likely to Get Treated for Nine Major Cancers

From The Center for AIDS Information & Advocacy

September 2016

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HIV-positive people proved less likely to get treated for nine major cancers -- including lung, breast, and colon cancer -- than people without HIV in a nationwide U.S. study.¹ That overall result held true regardless of what kind of health insurance people had and whether they had other illnesses besides cancer.

As people with HIV live longer thanks to antiretroviral therapy, cancer has become a more frequent cause of sickness and death. Among people with HIV, cancer is now the second-leading cause of death, according to results of a large international study.² In the general population of the United States, cancer is also the second-leading cause of death, after heart disease.³ However, people with HIV and cancer do not live as long as cancer patients without HIV.^4,5 And previous research found that people with HIV get treated for cancer less often than people without HIV.^6,7 But those previous studies did not consider the possible impact of health insurance and noncancer illnesses on cancer treatment. Because lower treatment rates in people with HIV could contribute to shorter survival in cancer patients with HIV, researchers conducted this nationwide analysis.

How the Study Worked

The study used the National Cancer Data Base to identify people between 18 and 65 years old with cancer diagnosed for the first time from 2003 through 2011. This database includes information on patients from more than 1500 centers across the United States. The researchers focused on the 10 most common cancers in people with HIV: head and neck, upper gastrointestinal (pancreas, stomach, esophagus), colon and rectum, anus, lung, female breast, cervix, prostate, Hodgkin lymphoma, and diffuse large B-cell lymphoma (the most frequent non-Hodgkin lymphoma in people with HIV).

The research team used the database to determine (1) who had HIV infection, (2) which noncancer illnesses study participants had, and (3) which patients received cancer therapy (which could include surgery, radiotherapy, chemotherapy, or any combination of these therapies). The investigators used an accepted statistical method to determine the impact of HIV infection on lack of cancer treatment. This type of analysis determines the impact of HIV regardless of whatever other factors might affect lack of cancer treatment, including insurance status and other noncancer illnesses. (Other illnesses may make cancer therapy too risky to perform.) The researchers used a similar type of analysis to pinpoint factors that predicted lack of cancer treatment in people with HIV.

What the Study Found

The study involved 10,265 people with HIV and 2,219,232 without HIV. Compared with the HIV-negative group, people with HIV were younger (median age 47 versus 55 years) and more often men (77% versus 47.6%), black (41.1% versus 13.2%), Hispanic (14% versus 5.7%), using Medicaid (32.2% versus 10.1%), using Medicare (19.6% versus 8.4%), and without health insurance (10.3% versus 5.9%). Almost three quarters of the HIV-negative group (72.5%) had private health insurance, compared with only one third (35.5%) of the HIV group. A higher proportion of people with HIV than without HIV had at least one noncancer illness (23.5% versus 17.9%). HIV-positive people were more likely to have stage 4 (advanced) cancer (37.2% versus 18.9%), and people without HIV were more likely to have stage 1 or 2 cancer (57.2% versus 33.2%).

Chances of not getting treated for anal cancer were similar in people with and without HIV infection. But for the other nine cancers, HIV-positive people had a higher chance of not getting treated (Figure 1). This analysis found a higher chance of nontreatment with HIV regardless of several other nontreatment risk factors, including age, sex, race, insurance status, noncancer illnesses, year of cancer diagnosis, and cancer stage. In an analysis that included only stage 2 to 4 prostate cancer (eliminating the least advanced stage 1, which often requires no treatment), people with HIV had almost a doubled chance of not receiving treatment compared with HIV-negative people.

 Next the researchers focused only on HIV-positive and HIV-negative people who had private health insurance. Despite having private health insurance, people with HIV infection still had a higher chance of not getting treated for seven cancers than did HIV-negative people with insurance: upper gastrointestinal, colon and rectum, lung, breast, prostate, Hodgkin lymphoma, and B-cell lymphoma (Figure 2). As in the overall analysis, HIV-positive people ran a higher chance of not getting treated regardless of other nontreatment risk factors.

Figure 2. Among HIV-positive and HIV-negative cancer patients with private health insurance, those with HIV had a higher chance of not getting treated for the seven types of cancer listed here. GI, gastrointestinal. (Credit: Teresa B. Southwell)

Finally, the researchers performed a statistical analysis to identify individual factors that predicted lack of cancer treatment in people with HIV -- regardless of whatever other risk factors a person had. The research team performed this analysis separately for two groups of cancers: lymphomas (Hodgkin lymphoma and B-cell lymphoma) and solid tumors (all cancers studied except the two types of lymphoma). Two factors independently raised chances of nontreatment for both solid tumors and lymphoma: black race and lack of private insurance (Table 1). For solid tumors, advanced cancer stage (stage 4) also predicted lack of cancer therapy. For lymphomas, advanced cancer stage raised chances of getting treated. But two other factors lowered chances of treatment for lymphoma: older age and having noncancer illnesses.

Table 1. Factors Linked to Cancer Treatment in People With HIV*
Solid Tumors†	Lymphomas
Linked to LACK of treatment
Black race (versus white)	Black race (versus white)
Medicare, Medicaid, or no insurance (versus private insurance)	Medicare, Medicaid, or no insurance (versus private insurance)
Advanced cancer stage at diagnosis (stage 4 versus stage 1)	Noncancer illness (versus none)
	Older age
Linked to GETTING treatment
	Advanced cancer stage at diagnosis (stage 4 versus stage 1)
* These factors raise chances of getting or not getting cancer therapy regardless of whatever other risk factors a person has. † Includes the eight types of cancer studied other than Hodgkin lymphoma and B-cell lymphoma.

What the Results Mean for You

This large and well-planned U.S. study shows that HIV-positive people with cancer run a higher risk of not getting cancer therapy than HIV-negative people with cancer. Because of the way the researchers designed the study, they showed that lack of health insurance or dependence on government health insurance (Medicaid or Medicare) did not explain why HIV-positive people had a lower chance of getting treated. Other factors that did not explain the lower chance of treatment with HIV versus without HIV were race, advanced cancer stage, or having another illness that might prevent cancer therapy. But when the researchers focused only on people with HIV, they found that being black raised chances of not getting cancer therapy about 40%. And having no health insurance or using Medicaid or Medicare raised chances of not getting treated even more.

The researchers who conducted this study stress that "improved access to cancer treatment is urgently needed, not only for uninsured patients but also for those with Medicaid and Medicare." Many HIV providers and cancer specialists will probably read this study, and that could make them question whether they should recommend cancer therapy for more HIV-positive people.


If you have HIV infection and learn that you have cancer, work with your HIV provider and a cancer specialist to explore cancer treatment options. If your providers do not recommend treatment and you are not satisfied with that answer, you can get an opinion from other cancer specialists. Talk to your case worker, to someone at an AIDS service organization, or to another health professional you trust if you need help getting another opinion about cancer therapy.

If you do not have health insurance, you should know that insurance is available to everyone in the United States through the Affordable Care Act. (See https://www.healthcare.gov/.) If you need help applying for medical insurance through the Affordable Care Act, talk to a case worker or social worker recommended by your HIV provider.

For several reasons, people with HIV infection may run a higher risk of getting cancer than HIV-negative people. Many cancers can be prevented by lifestyle choices (like quitting smoking) or by getting certain vaccines, like the vaccine against human papillomavirus (which can cause cervical cancer, anal cancer, and other cancers) or hepatitis B virus (which can cause liver cancer). A large U.S. study found that people who have a healthy lifestyle have a substantially lower risk of cancer.⁸ This study defined a healthy lifestyle by four factors:

• Smoking in the past or never smoking
• No or moderate alcohol drinking (1 or fewer drinks daily for women and 2 or fewer for men)
• Body mass index (weight) between 18.5 and 27.5 kg/m² (see reference 9)
• Weekly aerobic physical activity (at least 75 high-intensity minutes or 150 moderate-intensity minutes)

The researchers close their report by reminding readers that "cancer treatment not only extends survival from cancer, but also can improve quality of life, even for patients with advanced stage disease."

References

• Suneja G, Lin CC, Simard EP, Han X, Engels EA, Jemal A. Disparities in cancer treatment among patients infected with the human immunodeficiency virus. Cancer. 2016;122:2399-2407.

• Smith CJ, Ryom L, Weber R, et al; D:A:D Study Group. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet. 2014;384:241-248. 

• Centers for Disease Control and Prevention. Leading causes of death. April 2016.
  

• Biggar RJ, Engels EA, Ly S, et al. Survival after cancer diagnosis in persons with AIDS. J Acquir Immune Defic Syndr. 2005;39:293-299. 

• Coghill AE, Shiels MS, Suneja G, Engels EA. Elevated cancer-specific mortality among HIV-infected patients in the United States. J Clin Oncol. 2015;33:2376-2383.

•  Suneja G, Shiels MS, Melville SK, Williams MA, Rengan R, Engels EA. Disparities in the treatment and outcomes of lung cancer among HIV-infected individuals. AIDS. 2013;27:459-468. 

• Suneja G, Shiels MS, Angulo R, et al. Cancer treatment disparities in HIV-infected individuals in the United States. J Clin Oncol. 2014;32:2344-2350. 

• Song M, Giovannucci E. Preventable incidence and mortality of carcinoma associated with lifestyle factors among white adults in the United States. JAMA Oncol. doi 10.1001/jamaoncol.2016.0843. Published online May 19, 2016.

•   National Heart, Lung and Blood Institute. Calculate your body mass index.

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