Contributing Factors in NADC

The incidence of non–AIDS-defi ning cancers (NADCs) has increased by greater than 3-fold over the past 10 years and has now surpassed that of AIDS-defi ning cancers (ADCs) in HIVinfected patients. Some of this increase is associated with the longer survival and aging of patients in the potent antiretroviral therapy era, but some also appears to be associated with direct effects of HIV that increase susceptibility to such cancers. Early reports in the 1980s suggested that malignancies might constitute a second “epidemic” within the AIDS epidemic (Monfardini et al, AIDS, 1989). Kaposi sarcoma and non-Hodgkin lymphoma (NHL) initially accounted for the majority of malignancy-associated morbidity and mortality in HIV disease. With the advent of effective antiretroviral therapy, NADC as a cause of death in people with HIV has increased from less than 1% in the pre–potent antiretroviral therapy era to as high as 13% (Stein et al, Am J Med, 1992; Bonnet et al, Cancer, 2004). A report on cancer trends in HIVinfected patients between 1989 and 2002 showed that there has been an overall decline in cancer incidence from 77 cases to 12 cases per 1000 patient-years, refl ecting a decline in incidence of ADC. During this period, however, the incidence of NADCs increased from 3.3 to 10.9 cases per 1000 patient-years (relative risk, 3.3; 95% confi dence interval [CI], 1.7-6.6) (Bedimo et al, Clin Infect Dis, 2004). Among types of malignancies, incidences of Kaposi sarcoma and central nervous system lymphoma have decreased, those of prostate and breast cancer have remained relatively constant, and those of other lymphomas (eg, NHL and Hodgkin disease) and of cervical, anal, and lung cancers have increased (Table 1).