Rajesh T. Gandhi, MD reviewing Borges ÁH et al. Clin Infect Dis 2016 Sep 8.
In a large randomized trial comparing immediate versus deferred antiretroviral therapy, the group that received immediate treatment had lower rates of infection-related cancers.
In the landmark START trial (NEJM JW Infect Dis Sep 2015 and N Engl J Med 2015; 373:795), more than 4600 HIV-infected patients with CD4 count >500 cells/mm3 were randomized to initiate ART immediately or to defer therapy until the CD4 count fell to <350 cells/mm3 or an AIDS-defining event occurred. In addition to reducing the overall rate of serious AIDS- and non–AIDS-related events, the immediate-ART group had a 64% lower cancer rate than the deferred group. Now, investigators have examined whether the effect of early ART on cancer was specific to infection-related cancers — which they hypothesized would be more sensitive to immune reconstitution — or to infection-unrelated cancers. Infection-related cancers were those linked to Epstein-Barr virus (non-Hodgkin lymphoma, Hodgkin lymphoma), human herpesvirus 8 (Kaposi sarcoma), or human papillomavirus (anal or cervical cancer).
Fourteen malignancies (6 infection-related) developed in the immediate-ART group and 39 (23 infection-related) in the deferred group. Compared with deferred ART, immediate ART was associated with a 74% lower rate of infection-related cancers, particularly non-Hodgkin lymphoma and Kaposi sarcoma. Infection-unrelated cancer rates were a nonsignificant 51% lower with immediate ART. Both infection-related and infection-unrelated cancers occurred in patients with high median CD4 cell counts at baseline: 671 and 638/mm3, respectively. The protective effect of immediate ART on overall cancer rates was not affected by adjusting for CD4 cell count and was only partially attenuated by adjusting for latest HIV RNA, suggesting that ART may also reduce cancer through other, unknown mechanisms.
CITATION(S):
Borges ÁH et al. Immediate antiretroviral therapy reduces risk of infection-related cancer during early HIV infection. Clin Infect Dis 2016 Sep 8; [e-pub].
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