Marie-Josèphe Horner1,2, Steady Chasimpha3, Adrian Spoerri4, Jessie Edwards1, Julia Bohlius4, Hannock Tweya5, Petros Tembo5, Franklin Nkhambule6, Eddie Moffo Phiri6, William C Miller7, Kennedy Malisita6, Sam Phiri5,8,9, Charles Dzamalala3,10, Andrew F Olshan1,11, Satish Gopal1,2,10,11,12,13. 1. Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. 2. University of North Carolina Project-Malawi, Lilongwe. 3. Malawi Cancer Registry, Blantyre, Malawi. 4. Institute of Social and Preventive Medicine, University of Bern, Switzerland. 5. Lighthouse Trust, Kamuzu Central Hospital, Lilongwe. 6. Queen Elizabeth Central Hospital HIV Clinic, Blantyre, Malawi. 7. Department of Epidemiology, College of Public Health, Ohio State University, Columbus. 8. Department of Public Medicine, University of Malawi, Blantyre. 9. Department of Medicine, University of North Carolina at Chapel Hill, Blantyre. 10. University of Malawi College of Medicine, Blantyre. 11. Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill Lilongwe, Malawi. 12. University of North Carolina Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill Lilongwe, Malawi. 13. Malawi Cancer Consortium & Regional Center of Research Excellence for Non-Communicable Diseases, Lilongwe, Malawi.
Abstract
BACKGROUND: With antiretroviral therapy (ART), AIDS-defining cancer incidence has declined and non-AIDS-defining cancers (NADCs) are now more frequent among human immunodeficiency virus (HIV)-infected populations in high-income countries. In sub-Saharan Africa, limited epidemiological data describe cancer burden among ART users. METHODS: We used probabilistic algorithms to link cases from the population-based cancer registry with electronic medical records supporting ART delivery in Malawi's 2 largest HIV cohorts from 2000-2010. Age-adjusted cancer incidence rates (IRs) and 95% confidence intervals were estimated by cancer site, early vs late incidence periods (4-24 and >24 months after ART start), and World Health Organization (WHO) stage among naive ART initiators enrolled for at least 90 days. RESULTS: We identified 4346 cancers among 28 576 persons. Most people initiated ART at advanced WHO stages 3 or 4 (60%); 12% of patients had prevalent malignancies at ART initiation, which were predominantly AIDS-defining eligibility criteria for initiating ART. Kaposi sarcoma (KS) had the highest IR (634.7 per 100 000 person-years) followed by cervical cancer (36.6). KS incidence was highest during the early period 4-24 months after ART initiation. NADCs accounted for 6% of new cancers. CONCLUSIONS: Under historical ART guidelines, NADCs were observed at low rates and were eclipsed by high KS and cervical cancer burden. Cancer burden among Malawian ART users does not yet mirror that in high-income countries. Integrated cancer screening and management in HIV clinics, especially for KS and cervical cancer, remain important priorities in the current Malawi context.
BACKGROUND: With antiretroviral therapy (ART), AIDS-defining cancer incidence has declined and non-AIDS-defining cancers (NADCs) are now more frequent among human immunodeficiency virus (HIV)-infected populations in high-income countries. In sub-Saharan Africa, limited epidemiological data describe cancer burden among ART users. METHODS: We used probabilistic algorithms to link cases from the population-based cancer registry with electronic medical records supporting ART delivery in Malawi's 2 largest HIV cohorts from 2000-2010. Age-adjusted cancer incidence rates (IRs) and 95% confidence intervals were estimated by cancer site, early vs late incidence periods (4-24 and >24 months after ART start), and World Health Organization (WHO) stage among naive ART initiators enrolled for at least 90 days. RESULTS: We identified 4346 cancers among 28 576 persons. Most people initiated ART at advanced WHO stages 3 or 4 (60%); 12% of patients had prevalent malignancies at ART initiation, which were predominantly AIDS-defining eligibility criteria for initiating ART. Kaposi sarcoma (KS) had the highest IR (634.7 per 100 000 person-years) followed by cervical cancer (36.6). KS incidence was highest during the early period 4-24 months after ART initiation. NADCs accounted for 6% of new cancers. CONCLUSIONS: Under historical ART guidelines, NADCs were observed at low rates and were eclipsed by high KS and cervical cancer burden. Cancer burden among Malawian ART users does not yet mirror that in high-income countries. Integrated cancer screening and management in HIV clinics, especially for KS and cervical cancer, remain important priorities in the current Malawi context.
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