Overall, palliative care use is low among people living with HIV (PLWH) who have cancer, according to findings recently presented at the virtual 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved (Abstract PO-123). This research emphasizes the importance of efforts to better understand and address this issue.
"In the U.S., people living with HIV are more likely to experience higher stage-adjusted cancer-specific mortality, compared to their HIV-negative counterparts," said study author Jessica Y. Islam, PhD, MPH, in the Cancer Epidemiology Program at the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla. "[Research has demonstrated] that across several cancer sites, including colorectal, breast, and lung cancer, people living with HIV are more likely to die due to their cancer. The reasons for these disparities remain unclear and are an active area of research."
One potential contributor to disparities and mortality among people living with HIV is receipt of curative treatment, according to Islam, who noted that prior research has shown that people living with HIV are less likely to receive any form of curative cancer treatment compared to their HIV-negative counterparts, even after taking into consideration factors such as sex, age at diagnosis, race/ethnicity, stage at diagnosis, and year of cancer diagnosis.
"An unexplored area of cancer treatment receipt among people living with HIV is the use of palliative care," Islam explained. "In 2014, the National Comprehensive Cancer Network recommended that cancer patients should be referred or begin to receive palliative care from diagnosis and should continue to be offered palliative care along the care continuum until the end of life.
"Cancer patients who receive palliative care have improved quality of life and higher survival, particularly non-small cell lung cancer patients," she continued. "As such, palliative care use can be an important contributor to the alleviation of disparities in cancer-related mortality we observed among people living with HIV in the U.S."
Study Design
Islam and colleagues sought to compare the use of palliative care by HIV status among patients with cancer in the U.S. To do so, they used data from more than 19 million patients (18-90 years old) in the National Cancer Database who were diagnosed between 2004 and 2018.
The researchers selected the 11 most common cancers diagnosed among PLWH, which included Kaposi sarcoma, Hodgkin lymphoma, diffuse large B-cell lymphoma (DLBCL), and cancers of the head and neck, upper gastrointestinal tract, colorectum, anus, lung, female breast, cervix, and prostate.
For the purposes of this study, palliative care was defined as any surgery, radiation, systemic therapy, or pain management treatment with non-curative intent. They determined HIV status from reported comorbidities using the ICD-9-CM diagnosis codes 04200-044.90, 07593, and V0800, as well as ICD-10-CM codes B20-B22, B24, and Z21, Islam noted during her presentation.
"Multivariate logistic regression was used to examine associations between HIV status and palliative care use by cancer site and stage at diagnosis and adjusted for age at diagnosis, race/ethnicity, gender, insurance, geographic region, comorbidity index, and cancer diagnosis year," according to the study authors.
Key Findings
The study population included 52,306 HIV-positive and 19,115,520 HIV-negative cancer cases. Overall, Islam noted that the common disease types among PLWH observed in the dataset included lung, colorectal and anal cancer, as well as DLBCL and Kaposi sarcoma.
"Importantly, people living with HIV were more likely to have Stage IV cancer compared to HIV-negative cancer patients," she outlined. "People living with HIV and cancer were more likely to be male, non-Hispanic Black, and low income. [They] were also less likely to be privately insured compared to their HIV-negative counterparts."
Among people living with HIV and cancer, overall, 4.9 percent received any form of palliative care, Islam reported. When the researchers stratified by cancer stage, they found that PLWH with Stage I-III disease at diagnosis were more likely to receive palliative care compared to their HIV-negative counterparts. Conversely, the data showed that PLWH with Stage IV cancer at diagnosis were less likely to receive palliative care.
"And when we look at this using multivariable analyses, we see that those with Stage IV cancer, who are highly recommended to receive palliative care, have 30 percent lower odds of receiving any form of palliative care compared to their HIV-negative counterparts, whereas those with Stage I-III have 96 percent higher odds of receiving palliative care," Islam said.
The researchers also conducted analyses by cancer site and found that Stage IV lung and colorectal HIV-positive cancer patients were 20 percent and 28 percent less likely, respectively, to receive palliative care than HIV-negative cancer patients.
Additionally, Islam noted that PLWH with Stage I-III colorectal and breast cancer were more likely to use palliative care. "We also saw a similar association with those with Stage I through Stage III head and neck and anal cancer," she added. "Also, across stages of DLBCL, HIV-positive cancer patients were also more likely to use palliative care than others."
Given their observation that PLWH with Stage I-III cancer were more likely to receive palliative care, the researchers were interested in the patterns of curative cancer treatment receipt among this specific category. Interestingly, Islam and her colleagues observed that, regardless of palliative care use, people living with HIV who were diagnosed with Stage I-III cancer were less likely to receive any form of cancer treatment.
"Overall, utilization of palliative care is low among people living with HIV and cancer," Islam reiterated, while summarizing her presentation. "Importantly, people living with HIV diagnosed with Stage IV cancer, including lung and colorectal cancer patients, were less likely to receive palliative care compared to their HIV-negative counterparts."
This is the most important finding of the analysis, according to Islam, since it has been established that patients who are diagnosed at this late stage should be referred to palliative care per the NCCN guidelines. This is particularly true for lung cancer patients diagnosed with Stage IV disease, she added, "given there are very clear and randomized controlled specific data showing the benefits of palliative care use among non-small cell lung cancer, including extension of survival and improved quality of life.
"And also, importantly, people living with HIV with non-metastatic disease are more likely to receive palliative care, however, less likely to receive curative care, reinforcing prior data that curative treatment is not offered to cancer patients with HIV," Islam concluded.
Catlin Nalley is a contributing writer.