1. Slideset on: Patel P, Hanson DL, Sullivan PS, et al. Incidence of types of cancer among HIV-infected persons compared with the general population in the United States, 1992-2003. Ann Intern Med. 2008;148:728-736. This program is supported by educational grants from Jointly sponsored by Postgraduate Institute for Medicine and Clinical Care Options, LLC Non-AIDS–Defining Cancer Incidence Increased Among HIV-Infected Individuals vs General Population in Post-HAART Era

2. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Background  HIV-infected patient survival rate significantly improved by HAART –Decreased incidence of AIDS-defining infections and cancer –Longer patient survival linked with increase in several chronic conditions, eg, lipodystrophy, metabolic syndrome, osteopenia, cardiovascular disease, non-AIDS– defining cancers  Studies of non-AIDS–defining cancers in HIV-infected patients –Limited by population size and demographics –Lack of comparison to uninfected control patients –Fail to include patients at all HIV infection stages –Do not focus on trends in cancer incidence since advent of HAART  Present study compared cancer incidence rates from 2 large, prospective cohort studies of HIV-infected patients with those in the general population –Included all stages of HIV infection Patel P, et al. Ann Intern Med. 2008;148:728-736.

3. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Summary of Study Design  Cancer incidence estimated from combination of ASD [1] and HOPS [2] databases –Data not statistically different between studies, combined to better represented HIV- infected population than either study alone  Cancer incidence in HIV-infected cohorts compared with that in general population (derived from the [SEER program [3] )  Incidence rates determined for 3 observation periods [4] –Pre-HAART (1992-1995) –Early HAART (1996-1999) –Recent HAART (2000-2003)  Incidence rates reported as per 100,000 person-years 1. Farizo KM, et al. JAMA. 1992;267:1798-1805. 2. Moorman AC, et al. Ann Epidemiol. 1999;9:349-357. 3. National Cancer Institute. Available at: http://www.seer.cancer.gov. 4. Patel P, et al. Ann Intern Med. 2008;148:728-736.www.seer.cancer.gov

4. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Main Findings Patel P, et al. Ann Intern Med. 2008;148:728-736. Cancer Type, Observed Rate per 100,000 Person-Yrs (95% CI) ASD/HOPS (157,819 Person-Yrs) SEER (334,802,121 Person-Yrs) SRR* (95% CI) Anal51.4 (40.8-63.9)1.5 (1.4-1.5)42.9 (34.1-53.3) Vaginal33.9 (18.0-57.9)3.2 (3.2-3.3)21.0 (11.2-35.9) Hodgkin’s lymphoma51.4 (40.9-63.9)3.3 (3.3-3.4)14.7 (11.6-18.2) Liver31.7 (23.5-41.8)5.3 (5.2-5.4)7.7 (5.7-10.1) Lung88.8 (74.7-104.8)67.5 (67.2-67.7)3.3 (2.8-3.9) Melanoma24.7 (17.6-33.8)18.4 (18.3-18.6)2.6 (1.9-3.6) Oropharyngeal33.0 (24.6-43.3)16.1 (16.0-16.2)2.6 (1.9-3.4) Leukemia15.2 (9.8-22.7)12.2 (12.1-12.3)2.5 (1.6-3.8) Colorectal47.0 (36.9-59.0)52.0 (51.7-52.2)2.3 (1.8-2.9) Renal14.0 (8.8-21.1)13.0 (12.8-13.1)1.8 (1.1-2.7) Prostate32.7 (23.3-44.7)173.5 (172.9-174.1)0.6 (0.4-08) *Calculated as ASD/HOPS to SEER populations.

5. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Main Findings (cont’d) Patel P, et al. Ann Intern Med. 2008;148:728-736. Cancer Type, SIR Per 100,000 Person-Yrs ASD/HOPS (157,819 Person-Yrs) P Value* 1992-19951996-19992000-2003 AIDS-defining cancers  Kaposi sarcoma2628.5848.8356.3<.001  NHL1011.8494.1212.2<.001  Cervical149.9194.6134.5NS Non-AIDS–defining cancers  Anal19.048.378.2<.001  Hodgkin lymphoma34.354.764.4.03  Liver19.935.935.4NS  Lung91.993.884.9NS  Melanoma15.624.837.5<.05  Oropharyngeal29.031.036.9NS  Colorectal39.939.766.2.03  Breast56.069.996.0NS  Prostate14.738.037.5.01 *Linear trend P value: average change in incidence rate from 1992-1995 to 1996-1999 and 1996-1999 to 2000-2003.

6. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Main Findings (cont’d)  Cancer incidence rates in general population over 3 observation periods –Decreased significantly for Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and cervical, lung, and oropharyngeal cancers –Increased significantly for anal, colorectal, liver, and prostate cancers  Relative incidence of Kaposi’s sarcoma, non-Hodgkin’s lymphoma significantly decreased over time in HIV-infected population vs general population, whereas relative incidence of anal cancer increased significantly Patel P, et al. Ann Intern Med. 2008;148:728-736.

7. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Other Outcomes Patel P, et al. Ann Intern Med. 2008;148:728-736. Factors Associated With Increased Risk of Indicated Cancer Types RRP Value Acquired HIV via male-male sex  Kaposi sarcoma2.88<.001  NHL1.53<.001 Low nadir CD4+ cell count  Kaposi sarcoma8.34<.001  NHL6.03<.001  Cervical3.70.010  Anal5.82.017  Colorectal6.27.013  Lung2.42.017 HBV or HCV coinfection  Liver3.63<.001

8. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Other Outcomes (cont’d) Patel P, et al. Ann Intern Med. 2008;148:728-736. Factors Associated with Decreased Risk of Indicated Cancer Types RRP Value HAART  Kaposi sarcoma0.61<.001  NHL0.68<.001  Cervical0.48.019  Breast0.35.013  Colorectal0.50.027  Lung0.52<.003

9. clinicaloptions.com/hiv Non-AIDS–Defining Cancers in Post-HAART Era Summary of Key Conclusions  HIV-infected population had higher incidence of several types of non-AIDS–defining cancers –Relative incidence of anal cancer significantly increased over time compared with general population  HAART usage associated with decreased risk of cancer  Factors associated with increased risk of cancer –Acquired HIV via male-male sex –Low nadir CD4+ cell count  HBV or HCV coinfection Patel P, et al. Ann Intern Med. 2008;148:728-736.