CLINICAL NEWS
On Location ASH Meeting on Hematologic Malignancies
HIV-Associated Lymphoma: Examining Treatment
Patterns and Survival in the Antiretroviral Era
As use of antiretroviral therapy has increased, the
incidence of Hodgkin lymphoma (HL) among HIVpositive patients has fallen, though it has not disappeared. For HIV-positive patients with HL, treatment
with chemotherapy leads to similar rates of overall
survival as with HIV-negative patients. However,
without appropriate chemotherapy, odds of survival
drop significantly – stressing the importance of optimizing clinical management of HIV-associated HL.
“As clinicians, we should make all efforts to deliver
life-extending therapy to our patients,” said Adam
Olszewski, MD, assistant professor of medicine from
Alpert Medical School of Brown University in Providence, Rhode Island. Dr. Olszewski presented results
from an analysis of patients with HIV-associated
lymphoma at the 2015 ASH Meeting on Hematologic
Malignancies in Chicago. Treating HIV-associated
HL requires a balance between effective cytotoxic
treatment and the potential for infectious complications, he said.
Dr. Olszewski and co-investigators analyzed cases
of classical HL reported to the National Cancer Data
Base (NCDB) between 2004 and 2012 to examine
patterns of treatment and survival in this population.
They identified 2,090 HIV-positive and 41,845 HIVnegative patients in the NCDB (those with unrecorded status were assumed to be HIV-negative).
On average, HIV-positive patients were older than
HIV-negative patients (median age = 43 vs. 40 years),
more often male (80% vs. 53%), and black (37% vs.
11%) or Hispanic (17% vs. 8%%; p<0.00001 for all).
During the study time period, the proportion of HIVpositive patients who were black increased substantially, from 31 percent to 49 percent. “As of 2012, half
of HIV-positive Hodgkin lymphoma patients in the
United States are black, and they are at high risk of not
receiving curative chemotherapy, although it is unclear
whether this is because of health-care–related factors
or worse immune deficiency status,” the authors noted.
Clinically, patients with HIV were also more likely
to have advanced-stage disease (stage III or IV; 66%
vs. 40%) and B symptoms (64% vs. 39%).
Certain subtypes of HL were also more common
among HIV-positive patients compared with HIV-
TABLE 1.
Rates of
Histology
Nodular sclerosis
44
negative patients (p<0.00001
for all comparisons):
• extranodal HL (5% vs. 3%)
• mixed cellularity subtype
(22% vs. 11%)
• lymphocyte-depleted
subtype (3% vs. 1%)
• undetermined histology
(40% vs. 26%)
Dr. Olszewski speaks with ASH Clinical News. Watch
the interview at ashclinicalnews.org/exclusive-videos.
• less nodular sclerosis subtype (32% vs. 57%)
• uninsured status (OR=1.63; 95% CI 1.06-2.51)
The majority of HIV-positive patients received
chemotherapy (81%). This proportion remained unchanged between 2004 and 2012 (p=0.29), although
the authors did observe a decreasing trend of radiation therapy over time. Notably, the odds of receiving no treatment for HL was nearly twice as high for
early-stage HIV-positive than HIV-negative patients
(18% vs. 10%), Dr. Olszewski pointed out.
When the researchers compared receipt of chemotherapy between stage 1 or stage 2 HL patients,
they found that HIV-positive patients were more
often treated with chemotherapy alone (51% vs. 45%),
while HIV-negative patients were more likely to be
treated with a combined modality (28% vs. 41%;
p<0.0001 for all). For those with advanced-stage disease, however, HIV-positive patients were less likely
than HIV-negative patients to receive chemotherapy
(16% vs. 9%; p<0.0001).
After adjusting for age, sex, race, stage, B symptoms, and socioeconomic status (including income
and insurance status) among patients, Dr. Olszewski
noted that the odds of receiving chemotherapy decreased with age, as it did with several other factors:
• unknown histology (compared with nodular
sclerosis, OR=1.76; 95% CI 1.29-2.41)
Use of chemotherapy varied widely by hospital, but
there was no difference in chemotherapy use between
community and academic centers (p=0.47).
Prognosis among HIV-positive patients varied
according to HL subtype, but the rates of five-year
overall survival increased with receipt of standard chemotherapy across all subtypes (TABLE 1).
For instance, overall survival at five years was not
significantly different between HIV-positive and
HIV-negative patients with classic nodular sclerosis
or mixed cellularity subtypes – as long as patients
received standard chemotherapy. “In contrast, HIVpositive patients [with unknown histology disease]
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