1. Nguyen ML, Sumbry A, Reddy D, Harvey K, Gunthel C, Wang W, Tsui C, Ziemer D, del Rio C, Young JL Increased Incidence of Non AIDS-related Malignancies and Earlier Age at Occurrence In an Urban Outpatient HIV Clinic INACS

2. Current SEER Registries 6 Cities – Atlanta – Detroit – LA – San Francisco – San Jose – Seattle 11 States – Alaska natives – Arizona Indians – California – Connecticut – Hawai – Iowa – Kentucky – Louisiana – New Jersey – New Mexico – Utah

3. Background AIDS and cancer registries linkage compared to 17 SEER regirstries (1980-2002) 1 HOPS and ASD [compared to 17 SEER Registries] (1992 – 2003) 2 Johns Hopkins HIV/AIDS Cohort [compared to Detroit cancer registry] (1996-2005) 3 Increase in incidence in : ano-rectal cancer,hepatocellular cancer, Hodgkin lymphoma,lung cancer and head and neck cancer 1-Engels et al. AIDS 2006: 20: 1645-1654 2-Patel et al. Ann Int Med 2008:148:728-736 3-Long et al. AIDS 2009: 22:489-496

4. Background HIV/AIDS cancer match study versus 17 SEER registries (1980-2006) 1 – People with HIV getting cancer at an earlier age – After accounting for underlying population age distributions, the authors found either no difference or very small differences in the observed and expected ages at diagnosis for most cancers 1-Shiels et al. CROI2010

5. INACS Objective: To investigate the incidence of non-AIDS defining cancers (NADC) and age at diagnosis of NADC in the HAART era in an outpatient HIV/AIDS urban clinic in the southeastern USA.

6. Methods Setting: Grady Infectious Disease Program (IDP) at the Ponce de Leon Health Center (Ponce Clinic) Design: Retrospective study of 8,300 patients (2000-2007). Incidence was examined using Poisson analysis. Data sources: - Clinic visit records matched by name, medical records and birth date to Grady Health System cancer registry. - Included are all patients who contributed person time from 1/1/2000 until the earliest of the following: cancer diagnosis, death, loss to follow up or 12/31/2007.

7. Ponce Clinic Demographics Study Sample N= 8,300 Males n = 6,189 (75%) Females n= 2,111 (25%) Age (mean)39.638.7 Race Black Caucasian Hispanic Other 4495(73%) 1379 (22%) 209 (3%) 106 (2%) 1849 (88%) 150 ( 7%) 66 (3%) 46 (2%) Year of enrollment 2000 – 2002 2003 – 2007 3672 (59%) 2517 (41%) 1238 (59%) 873 (41%) Mean person-years attending clinic 2.66 2.94

8. Distribution of Cancer Cases in Study Cohort Total Cancer Cases 2000-2007 N=512 AIDS-Defining Cancer N=320 Non AIDS-Defining Cancer N=192 Kaposi Sarcoma (182) Non-Hodgkin Lymphoma (124) Cervical Cancer (14) Lung Cancer(40) Anal Rectal Scc(24) Head And Neck Cancer Scc(22) Prostate Cancer(18) Hodgkin Lymphoma(16) Liver Cancer (10) Breast Cancer (11) Other (51)

9. Cancer Patient Demographics Cancer Patients N=186/8300 (2.2%) Males N= 142/6189 (2.3%) 8.6/1000 pt-years Females n= 44/2111(2.1%) 8.7/1000 pt-years Race: Black Caucasian 112(79%) 30(21%) 40(91%) 4 (9%) Age at HIV diagnosis37.9 ± 11.241.9 ± 12 Age at cancer diagnosis46.9 ± 10.848.1 ± 10.9 Nadir CD4 count (cells/mm3)129.4 ± 140214.1 ± 214.1 CD4 count at cancer diagnosis263.4 ± 260344.0 ± 250 On HAART at cancer diagnosisNo: 63(44%) Yes: 74(52%) No: 26(60%) Yes: 18(40%) Undetectable VL at cancer diagnosis14/81 (17.3%)3/28 (10.7%) Average years at IDP to cancer diagnosis 3.9±2.633.91± 2.96

10. Cancers incidence in Ponce Clinic Patients Compared to Atlanta Metro Area CancersNSIR * p- value Anal/rectal SCC Hodgkin’s Lymphoma Hepatocellular cancer Head and neck cancer SCC Lung cancer Breast cancer Prostate cancer 24 16 10 22 40 11 18 67.6 19.7 9.5 8.7 4.5 1.6 0.5 <0.001 0.78 0.02 *SIR=standardized incidence ratio =number observed cancers at IDP/ number expected cancers standardized by age, race and gender

11. Average Age at NADC Diagnosis IDP versus Metro Atlanta population CancerAge at cancer IDP Age at cancer Atlanta Anal/Rectal SCC40.955.114.2 Hodgkin’s Lymphoma39.741.7* 2 Liver43.759.515.8 Head and Neck50.760.0 9.3 Lung51.666.314.7 Breast44.957.7 6.8 Prostate53.464.411.0 *not statistically different at p<0.05

12. Strengths and limitations Strengths: – Relatively homogeneous cohort: patients all very immunosuppressed, came from the same clinic Limitations: – Retrospective study – missing data, inability to follow up intriguing questions, inability to control for individual risk factors such as smoking, CD4 count, viral load, or other cancer risk factors – Underestimation

13. Conclusion Similar to published studies, IDP patients had a higher incidence of NADC than the metro Atlanta general population. Cancers with the highest SIR were those associated with an infectious etiology (anal SCC, HL, liver cancer and head and neck SCC). Interestingly, the rate for anorectal SCC is 68 times that of the general population. IDP patients are getting those cancers at an earlier age than the metro Atlanta general population. Cancer screening in HIV infected patients should be considered at an earlier age than in the general population.

14. Acknowledgments Emory University: Carlos del Rio, MD Kevin J Farrell, MD Mitchell Klein, PhD Jeffrey Lennox, MD John L. Young, PhD Yun W Wang, PhD CFAR : Kimberley Hagen, PhD CFAR 03, NIH supplement to P30 AI050409 INACS team: Clifford Gunthel, MD Kira Harvey, BA Deepa Reddy, MD Anitra Sumbry, MPH Circe Tsui, BS Grady Health System: Dorothy Ziemer, MSW IDP medical records staff Grady cancer registry staff IDP patients

15. Thank you for your attention

17. Cancers incidence in Ponce Clinic Patients Compared to 17 SEER Registries CancersNSIR * p- value Anal/rectal SCC Hodgkin’s Lymphoma Hepatocellular cancer Head and neck cancer SCC Lung cancer Breast cancer Prostate cancer 24 16 10 22 40 11 18 88.6 19.2 8.0 8.1 4.0 1.6 1.0 <0.001 0.78 0.50 *SIR=standardized incidence ratio =number observed cancers at IDP/ number expected cancers standardized by age, race and gender