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Trends and risk of lung cancer among people living with HIV in the USA: a population-based registry linkage study
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Oct 2022 Lancet HIV
Background
Lung cancer is a common cancer in people living with HIV, but the risk of cancer in this group has not been investigated for over a decade. We investigated trends in relative and absolute risk of lung cancer among people living with HIV of various age groups in the USA.
Methods
In this population-based registry linkage study, we used 2001-16 data from the HIV/AIDS Cancer Match study, which links data from HIV and cancer registries from 13 regions in the USA. We included non-Hispanic White, non-Hispanic Black, and Hispanic individuals living with HIV aged 20-89 years in our study population. Average annual percentage changes in lung cancer rates were estimated with multivariable Poisson regression, and standardised incidence ratios (SIRs) and excess absolute risks were estimated comparing people living with HIV with the general US population. We used non-parametric cumulative incidence curves to estimate the 5-year cumulative incidence of lung cancer and two AIDS-defining cancers (non-Hodgkin lymphoma and Kaposi sarcoma).
Findings
There were 3426 lung cancers in 4 310 304 person-years of follow-up in our study population. Age-standardised lung cancer incidence rates in people living with HIV declined by 6% per year (95% CI -7 to -5) during 2001-16, with greater declines in the 20-29 age group (-11%, -16 to 6) than in the older age groups (eg, -3% [-6 to 1] in those aged 70-89 years). During 2013-16, the SIR of lung cancer in people living with HIV was 2·01 (95% CI 1·52 to 2·61) in those aged 40-49 years, and 1·31 (1·12 to 1·52) in those aged 60-69 years, whereas the excess absolute risk among people living with HIV was 11·87 (3·95 to 21·89) per 100 000 person-years for those aged 40-49 years and 48·23 (6·88 to 95·47) per 100 000 person-years for those aged 60-69 years. Beginning in 2011, the 5-year cumulative incidence for lung cancer (1·36%, 95% CI 1·17 to 1·53) surpassed that of Kaposi sarcoma (0·12%, 0·06 to 0·17) and non-Hodgkin lymphoma (0·45%, 0·35 to 0·56) for people living with HIV aged 60-69 years.
lung cancer is an important cancer among older people living with HIV as the cumulative incidence of lung cancer among people living with HIV aged 50 years and older surpasses that of both non-Hodgkin lymphoma and Kaposi sarcoma.
for the increasing proportion of people living with HIV who are living beyond the age of 50 years, the absolute risk of lung cancer has surpassed that of common AIDS-defining cancers and is a considerable excess risk and public health burden.
the largest excess absolute risks were among individuals aged 60-69 years and 70-89 years, although all excess absolute risks for those who were 70-89 years had 95% CIs that crossed 0 during 2013-16.
According to NHANES data, during the time periods of our study, the estimated prevalence of smoking was 26% in the general population and 47% among people living with HIV.
In addition to smoking, immunosuppression and pulmonary inflammation are likely to play a role in the development of lung cancer among people living with HIV. Lower CD4/CD8 ratios have been associated with higher incidence of lung cancer, even independent of the association with episodes of bacterial pneumonia. A study conducted in France in people living with HIV also has shown a decline of lung cancer over time and elevated risk compared with the general population, but a less elevated SIR for people living with HIV who had CD4 cell recovery and were on combination ART.
Mechanisms that have previously been attributed to both direct oncogenic effects of HIV and indirect result of immunosuppression, or risk of pulmonary infections and inflammation, might have become less relevant in over the past 15 years as fewer people living with HIV are progressing to AIDS and have severe immunosuppression.
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