Management of Head and Neck Cancers With or Without Comorbid HIV Infection in Botswana

Abstract

Objectives/hypothesis: Head and neck cancer (HNC) is the fifth most common malignancy in sub-Saharan Africa, a region with hyperendemic human immunodeficiency virus (HIV)-infection. HIV patients have higher rates of HNC, yet the effect of HIV-infection on oncologic outcomes and treatment toxicity is poorly characterized.

Study design: Prospective observational cohort study.

Methods: HNC patients attending a government-funded oncology clinic in Botswana were prospectively enrolled in an observational cohort registry from 2015 to 2019. Clinical characteristics were analyzed via Cox proportional hazards and logistic regression followed by secondary analysis by HIV-status. Overall survival (OS) was evaluated via Kaplan-Meier.

Results: The study enrolled 149 patients with a median follow-up of 23 months. Patients presented with advanced disease (60% with T4-primaries), received limited treatment (19% chemotherapy, 8% surgery, 29% definitive radiation [RT]), and had delayed care (median time from diagnosis to RT of 2.5 months). Median OS was 36.2 months. Anemia was associated with worse survival (HR 2.74, P = .001). Grade ≥ 3 toxicity rate with RT was 30% and associated with mucosal subsite (OR 4.04, P = .03) and BMI < 20 kg/m² (OR 6.04, P = .012). Forty percent of patients (n = 59) were HIV-infected; most (85%) were on antiretroviral therapy, had suppressed viral loads (90% with ≤400 copies/mL), and had immunocompetent CD4 counts (median 400 cells/mm³ ). HIV-status was not associated with decreased receipt or delays of definitive RT, worse survival, or increased toxicity.

Conclusions: Despite access to government-funded care, HNC patients in Botswana present late and have delays in care, which likely contributes to suboptimal survival outcomes. While a disproportionate number has comorbid HIV infection, HIV-status does not adversely affect outcomes.

Level of evidence: 2c Laryngoscope, 131:E1558-E1566, 2021.

Keywords: Global oncology; HIV-related neoplasms; HPV-related malignancies; Head and neck neoplasms; Radiotherapy.

Fig. 1.

Survival outcomes of head-and-neck cancer patients in Botswana by radiation therapy intent: no radiation (n = 48), non-definitive RT (n = 58), and definitive RT (n = 43).^a Abbreviations: RT, radiation therapy; Path, pathological.

Fig. 2.

Survival outcomes by HIV status: infected (n = 59) versus uninfected (n = 90).