Most HIV-positive patients die of cancer. In the latest issue of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2011; 108[8]: 117-22), Manfred Hensel’s research group presents epidemiological data.

The authors surveyed all German hospital outpatient clinics and ambulatory care centers specializing in the treatment of HIV patients in the period from 2000 to 2007 and were thus able to analyze the largest collection of data on the incidence of cancer in HIV patients ever assembled in Germany. It first became clear in the early 1980s that HIV infection is associated with malignancies. Kaposi sarcoma, cervical cancer, and non-Hodgkin’s lymphoma were found particularly often in immune-deficient populations. These “Aids-defining” tumors have since become less frequent, but other types of cancer such as anal carcinoma, Hodgkin’s lymphoma, lung cancer, and skin cancer are coming to the fore. Because most patients infected with HIV die of these malignancies, the authors recommend tumor screening for HIV-positive persons.

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Background: Cancer is now the leading cause of death in persons with HIV. In this study, we gathered current epidemiological data on Aids-defining (AD) and non-Aids-defining (NAD) malignancies among HIV-positive patients in Germany.

Methods: From 2000 to 2007, all 35 specialized HIV outpatient clinics and 189 HIV ambulatory care centers in Germany were contacted and asked to fill out a structured questionnaire on the incidence of malignancies in HIV-positive patients during multiple periods of observation.

Results: 552 evaluable data sets were reported. 253 (45.8%) of the reported malignancies were AD. Among the 299 cases (54.2%) of NAD malignancies, there were 214 solid tumors, including 71 anal carcinomas (23.7% of all NAD malignancies), and 85 hematopoietic malignancies, including 29 cases of Hodgkin’s lymphoma (9.7% of all NAD malignancies). The high percentage of NAD malignancy remained constant throughout the entire period of the study. Only a single case of primary cerebral lymphoma was reported after 2001. The number of patients with Hodgkin’s lymphoma rose steadily from 2000 to 2007.

Conclusion: The spectrum of HIV-associated malignancies has changed since the early days of the HIV epidemic. In Germany, NAD malignancies have become more common than AD malignancies. In particular, anal carcinoma and Hodgkin’s lymphoma are much more common among persons with HIV than in the general population. Persons with HIV need more intensive preventive care for cancer than noninfected persons do.

Cite this as:
Hensel M, Goetzenich A, Lutz T, et al.: HIV and cancer in Germany. 
Dtsch Arztebl Int 2010; 107(8): 117–22.  DOI: 10.3238/arztebl.2010.0117

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The association between human immunodeficiency virus   (HIV)/acquired   immune   deficiency syndrome (Aids) and cancer has been known since the early 1980s (e1). Particularly Kaposi sarcoma, invasive cervical   carcinoma,  and   non-Hodgkin’s   lymphoma (NHL)  have been found more frequently in HIV- infected and immune-deficient patients. The introduction of combined antiretroviral therapy (cART) in 1996 was followed by dramatic changes in the morbidity and mortality of HIV infection and especially in the spectrum of malignancies observed in HIV-infected patients. The incidence of Aids-defining (AD) malignancies has steadily declined, while the incidence of other malignancies,  such as Hodgkin’s lymphoma,  invasive anal carcinoma, lung cancer, skin cancer, and hepatocellular carcinoma presents new challenges to those responsible for the treatment of these patients (1).

Today malignant diseases are the commonest cause of death (2) and one of the most frequent reasons for hospitalization (3)  in HIV-positive patients.  The longer survival time as a result of cART only partially explains the growing incidence of non-Aids-defining (NAD) malignancies.  The pathogenesis of these tumors is highly varied: some are associated with oncogenic viruses (e.g., Hodgkin’s lymphoma and anal carcinoma), while others are influenced by environmental factors such as smoking and sunlight (e.g.,  lung cancer and skin cancer). The frequency of NAD malignancies has been described with increasing clarity in recent years, but the precise associations remain unclear (3–8).

Ground-breaking investigations into the treatment of HIV-associated lymphomas have been conducted in Germany in the past few years (9–12), yet hardly any data exist on the epidemiology of HIV-associated cancers in Germany (13–15).

In the study reported here we set out to update and extend the DAGNAE study group’s data on the epidemiology of AD and NAD malignancies in the HIV-positive population in Germany in the years 2000 to 2003 and to describe the trends in these illnesses over the past decade. Our findings provide the basis for an urgently required updated recommendation for tumor screening in HIV-positive individuals.

Patients and methods
In the year 2000 the HIV and Oncology Core Group of the German Study Group of Physicians in Private Practice Treating HIV-Infected Patients (Deutsche Arbeitsgemeinschaft niedergelassener Ärzte in der Versorgung HIV-Infizierter,  DAGNAE)  cooperated with the Association of Hematologists and Oncologists in Primary Care in Germany (Berufsverband der niedergelassenen Hämatologen und Onkologen,  BNHO)  to initiate a proj ect whose goal was to create a database of HIV- associated malignancies.  An easy-to-use structured questionnaire was designed and sent to all members of DAGNAE and all specialized HIV outpatient clinics in Germany (n = 35) at the following time points: in 2002 for the incidence period 2000 to 2001,  in 2003 for 2002,  in 2006 for 2005,  and in 2008 for 2007.  The questionnaire was also available to the HIV physicians and DAGNAE members on the DAGNAE website and in the quarterly newsletter. The membership of DAGNAE embraces 189 HIV ambulatory care centers with a total of 235 regular members of the study group.

The questionnaire was kept simple to increase the chance of a high response rate (Table 1). It asked for information on all newly diagnosed AD and NAD hematological neoplasms and solid tumors. The details requested were date of diagnosis,  tumor stage,  tumor treatment, and response to treatment. The United States Centers for Disease Control (CDC) stage of HIV and (from 2002 onwards)  the patient’s sex were also recorded.

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KEY MESSAGES
● Malignancies are increasingly responsible for morbidity and mortality in HIV-infected persons.
● The so-called non-Aids-defining malignancies have now come to the fore.
● Particularly anal carcinoma and Hodgkin’s lymphoma show a pronounced increase in relative incidence.
● The HIV-associated malignancies occur earlier and have a more aggressive course.
● A general recommendation for intensified cancer screening seems warranted.

Manfred Hensel, Armin Goetzenich, Thomas Lutz, Albrecht Stoehr, Arend Moll, 
Jürgen Rockstroh, Nicola Hanhoff, Hans Jäger, Franz Mosthaf

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