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American study finds cervical cancer uncommon in HIV positive women

In high-income countries, the widespread availability of highly active antiretroviral therapy (HAART) has greatly decreased the risk of death from life-threatening infections among people who can adhere to and tolerate this therapy. But HAART does not fully restore the functioning of the immune system. So, while life-threatening infections are seldom seen in HAART users, other issues, such as the development of tumours, may become problematic as HIV positive people age.

One of the reasons for a heightened cancer risk is that many HIV positive people are co-infected with herpes viruses and HPV (human papilloma virus), all of which can cause cancer. In particular, HPV can cause the development of abnormal cells in the anus, cervix and penis. In some cases, these abnormal cells can transform into pre-cancerous lesions and even tumours. So regular monitoring of these tissues for any abnormal cells is an important part of health maintenance.

Since 1994, a team of American researchers has been assessing the cervical health of more than 2,000 women with HIV and others at high risk for HIV infection. Their findings suggest that over the long-term the development of abnormal cells on the cervix is common in HIV positive women. However, cases of cervical cancer were not common.

Study details

The researchers focused on women who were recruited into their study between 1994 and 1995 and who continued to participate until the end of 2004. As part of the study, every six months women underwent the following:

detailed interviews about their social and sexual histories
physical exam
gynecologic exam
Pap test

Pap test results were graded as follows:

negative (no abnormal cells detected)
ASCUS (atypical squamous cells of undetermined significance)
LSIL (low-grade squamous intraepithelial lesions)
HSIL (high-grade squamous intraepithelial lesions)
cancer

Women who had Pap smear results that were abnormal in any way then received a colposcopic exam and biopsy. If necessary, treatment of highly abnormal lesions was given.

The study team used health-related information from 2,477 women for their analysis. The average age of the women in the study was 43 years. Their HIV serostatus was as follows:

1,931 HIV positive
533 HIV negative
13 women seroconverted during the study

The major ethno-racial groups represented in the study were as follows:

54% were Black
25% were Hispanic
18% were White

Smoking history was as follows:

57% were currently smoking tobacco
16% were former smokers

Results—cervical cancer

The good news is that in this study cervical cancer was uncommon. Over a period of 10 years, there were 11 cases of cervical cancer, all of which occurred in women who were HIV positive and whose initial Pap test result was abnormal. None of the women whose initial Pap smear result was negative (no abnormal cells detected) ever developed cervical cancer.

Results—abnormal Pap test results

Although cervical cancers were uncommon in this study, abnormal Pap test results were more common among HIV positive women. The proportion of women developing different cervical lesions was as follows:

Any abnormal Pap test result

HIV positive – 77% of women
HIV negative – 50% of women

Low-grade SIL

HIV positive – 43% of women
HIV negative – 11% of women

High-grade SIL (precancerous lesions)

HIV positive – 4% of women
HIV negative – 1% of women

These differences between HIV positive and HIV negative women were statistically significant; that is, not likely due to chance alone.

In general, the risk of abnormal cervical lesions decreased over time for all women in the study. However, at each study visit, 25% of HIV positive women had an abnormal Pap test result. Fortunately, most abnormalities were low-grade, that is, not precancerous or cancers.

Other studies have found broadly similar results in HIV positive women in high-income countries.

In the present study, cervical cancer rates might have been higher had the women not been enrolled in a cervical cancer screening program where abnormal cells were identified and destroyed when necessary.

The study authors note that as HIV positive women have an increased risk for abnormal cells, regular, perhaps frequent, cervical screening with Pap tests and colposcopy and treatment (when necessary) can likely prevent the development of invasive cervical cancer.

—Sean R. Hosein

REFERENCES:

1. Strickler HD, Burk RD, Fazzari M, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus-positive women. Journal of the National Cancer Institute. 2005 Apr 20;97(8):577-86.

2. Massad LS, Seaberg EC, Wright RL, et al. Squamous cervical lesions in women with human immunodeficiency virus. Obstetrics and Gynecology. 2008 Jun;111(6):1388-1393.

3. Massad LS, Seaberg EC, Watts DH, et al. Low incidence of invasive cervical cancer among HIV-infected US women in a prevention program. AIDS. 2004 Jan 2;18(1):109-13.

Created on: 06/11/2008

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