Breast cancer and HIV: a single institution review of a non-AIDS defining cancer in women in the setting of high HIV prevalence

Abstract

BACKGROUND The prevalence of HIV infection is high in sub Saharan Africa. However the impact of this high prevalence on breast cancer incidence, pathogenesis, age, stage at presentation, treatment response and toxicity in the HIV infected and uninfected female remains unknown. OBJECTIVES The study sought to characterise breast cancer in patients with a known HIV status as well as compare treatment tolerability and outcomes in HIV determinate and indeterminate patients. METHODS A search through the case notes of 382 patients with a diagnosis of breast cancer diagnosed between January 2008 and December 2011 was carried out to identify female patients with an HIV test result .Data collected from these patients included age at cancer diagnosis, demographics, breast cancer and HIV risk factors, histology, stage, CD4 count and use of antiretroviral drugs in HIV positive patients, treatment, toxicity and outcome. RESULTS A total of 92 patients were identified, 67 HIV negative and 25 HIV positive. All patients were black African. Median age at diagnosis was 42 (Range 34 to 58) for the HIV positive and 50 (Range 30 to 88) for the HIV negative patients. Median CD4 at breast cancer diagnosis was 440cells/microlitre and median known duration with HIV was 3 years for the HIV infected patients. Mode of HIV infection was confirmed heterosexual transmission in 2 patients. Seventy two percent of HIV positive patients were receiving non protease inhibitor antiretroviral drug regimens. There was no difference in presentation and pathologic features between the HIV negative and positive patients. None of the patients had a history of prior screening. All stages of breast cancer were seen with the majority of the patients presenting with advanced stage disease with no statistically significant differences in stage at presentation between the HIV positive and negative patients. Hormone receptor and Her 2 neu status was available for a total of 21/92(22.8%) patients, with 3/17(17.7%) HIV negative and1/4(25%) HIV positive patients being triple negative. HIV positive patients were more likely to have ER and PR negative and HER2 neu positive breast cancer with HIV negative patients more likely to have ER and PR positive and HER 2 neu negative disease and this difference was statistically significant. Choice of chemotherapy was not determined by HIV status in these patients. Myelosuppression was present in both HIV negative and positive patients during chemotherapy but was more pronounced in the HIV positive patients. Two of the latter had progression of HIV on treatment manifested by development ii of an opportunistic infection on treatment. Radiotherapy was well tolerated in both the HIV positive and negative patients. Default to follow up was high in this cohort. CONCLUSIONS This study suggested that whilst there was no difference in histology and stage at presentation, the natural history of breast cancer in the setting of HIV infection was worse than in the HIV uninfected patient with younger age at presentation, poor prognostic tumour biology and poor treatment tolerability. Chemotherapy for breast cancer also had an adverse impact on the natural history of HIV infection. HIV infection and immunosuppresion did not appear to have a permissive role in breast cancer development. Although the incidence of breast cancer is not increased in HIV positive women, the high prevalence of the two diseases in our population makes their coexistence in the same patient more probable.