Cancer/Pathology

WIHS V CANCER PROJECT SUMMARY 2/4/2013 [HPV is reported separately]

Overarching aims Aim 1. To determine if the incidence of specific types of cancers is increased among HIV-infected women as compared to HIV-uninfected women and to the general population, and whether cancer incidence and survival are affected by use of HAART. Aim 2: To investigate risk factors for specific cancers (breast, cervical, lung cancer, and non-Hodgkin lymphoma) with an emphasis on potential strategies for cancer prevention and cancer therapy. Aim 3. To collect fresh-frozen tissue from biopsies of the cervix, vagina, and vulva and accompanying blood specimens and oral rinses for donation to the NCI-sponsored AIDS Cancer and Specimen Resource (ACSR). For select malignancies, to collect and donate paraffin-embedded formalin-fixed tissue specimens from WIHS women with confirmed incident cancers.

Overall Research Design and Methods: For the start of WIHS V, there are no newly proposed cancer-specific concept sheets that have requested additional funding. There are, however, several existing cancer and HPV- related projects that require the current infrastructure and activities outlined below. We will continue to identify and confirm all cancers that occur in the WIHS participants using the following ascertainment methods: (1) searches of statewide cancer registries, (2) medical record confirmation of self- reported cancer diagnoses, and (3) WIHS-initiated gynecologic biopsies. Cancers that are initially identified by self-report or death certificate via a National Death Index (NDI) search will be classified as ‘confirmed cancers’ only if they are subsequently confirmed by medical record review or cancer registry matching. The state cancer registry matches are performed every two years and the NDI is matched every year. We will document the diagnosis date, primary site/tumor type, and cancer treatment information for each cancer identified from the medical records or the WIHS gynecologic biopsy. For all cancers documented via the state cancer registries, we also obtain the ICD-O-3 coded tumor site, histological type, tumor behavior (in- situ or malignant), and treatment information directly from the registry. The Cancer WG will continue to attempt to obtain detailed pathology reports and, when deemed necessary, available biopsy specimens to confirm or refute the information obtained from the original source. WIHS continues to be a major donator to the ACSR of tissue, blood, and oral rinses from HIV-infected and comparative group of HIV-uninfected women. Our protocol involves donations from at least 10 women per WIHS site, per WIHS visit, who undergo colposcopy. If a lesion is present, the colposcopist is to biopsy the lesion, split it in two, send one section for clinical pathology review and flash-freeze the other section in liquid nitrogen. Another biopsy of nonlesion tissue is then collected and flash-frozen; also blood is collected for plasma and PBMCs, and an oral rinse is collected and frozen. These specimens are then sent to either the west coast or east coast ACSR repository according to the WHIS protocol. Corresponding demographic and clinical data are also transmitted to the ACSR by the WIHS data center (WDMAC).

Progress highlights: During WIHS IV, we were able to look more closely as specific cancers, such as cervical, lung and breast, and below are three examples of these investigations. Long-term incidence of cervical cancer in women with human immunodeficiency virus. Massad LS, Seaberg EC, Watts DH, Minkoff H, Levine AM, Henry D, Colie C, Darragh TM, Hessol NA. Cancer. 2009 Feb 1;115(3):524-30. Massad et al. reported that among women with HIV in a prospective study that incorporated cervical cancer prevention measures, the incidence of invasive cervical cancer (ICC) was not significantly higher than that in a comparison group of HIV-uninfected women. HIV as a risk factor for lung cancer in women: data from the Women's Interagency HIV Study. Levine AM, Seaberg EC, Hessol NA, Preston-Martin S, Silver S, Cohen MH, Anastos K, Minkoff H, Orenstein J, Dominguez G, Watts DH. J Clin Oncol. 2010 Mar 20;28(9):1514-9. Levine et al. reported that the incidence rates of lung cancer were similar among HIV-infected and uninfected WIHS women. Lung cancer standardized incidence ratios (SIRs) were increased in both HIV-infected and -uninfected women compared with population expectations, but did not differ by HIV status. Among HIV-infected women, lung cancer incidence rates were similar in pre-HAART and HAART eras.

WIHS Cancer Summary 2-4-13 page 1 HIV tropism and decreased risk of breast cancer. Hessol NA, Napolitano LA, Smith D, Lie Y, Levine A, Young M, Cohen M, Minkoff H, Anastos K, D'Souza G, Greenblatt RM, Goedert JJ. PLoS One. 2010 Dec 16;5(12):e14349. Hessol and colleagues used both WIHS and HERS data and found that low breast cancer risk with among women with HIV infection was specifically linked to CXCR4-using variants of HIV. These variants are thought to exclusively bind to and signal through a receptor that is commonly expressed on hyperplastic and neoplastic breast duct cells. For WIHS IV a heightened focused was placed on collaborations to increase the power and scientific validity of the cancer initiatives. Below are two recent publications resulting from the NA-ACCORD collaboration. Invasive cervical cancer risk among HIV-infected women: A North American multi-cohort collaboration prospective study. Abraham AG, Strickler HD, Jing Y, Gange SJ, Sterling TR, Silverberg M, Saag M, Rourke S, Rachlis A, Napravnik S, Moore RD, Klein M, Kitahata M, Kirk G, Hogg R, Hessol NA, Goedert JJ, Gill MJ, Gebo K, Eron JJ, Engels EA, Dubrow R, Crane HM, Brooks JT, Bosch R, D'Souza G; for the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA. J Acquir Immune Defic Syndr. 2012 Dec 18. This study found elevated incidence of ICC in HIV-infected compared to -uninfected women, and these rates increased with immunosuppression. Risk of anal cancer in HIV-infected and HIV-uninfected individuals in North America. Silverberg MJ, Lau B, Justice AC, Engels E, Gill MJ, Goedert JJ, Kirk GD, D'Souza G, Bosch RJ, Brooks JT, Napravnik S, Hessol NA, Jacobson LP, Kitahata MM, Klein MB, Moore RD, Rodriguez B, Rourke SB, Saag MS, Sterling TR, Gebo KA, Press N, Martin JN, Dubrow R; North American AIDS Cohort Collaboration on Research and Design (NA- ACCORD) of IeDEA. Clin Infect Dis. 2012 Apr;54(7):1026-34. Investigators reported that anal cancer rates were substantially higher for HIV-infected MSM, other men, and women compared with HIV-uninfected individuals, suggesting a need for universal prevention efforts. Rates increased after the early antiretroviral therapy era and then plateaued.

Collaborations within and external to WIHS: The WIHS Cancer/Pathology working group works closely with the WIHS HPV working group (many of the members overlap) to ensure the WIHS data is collected and used to the best of its ability and that newly proposed projects do not overlap. The Chairs of the WIHS Cancer/ Pathology and MACS Malignancy working groups are also in close contact and are members of both working groups. In addition, the Chairs of the WIHS Cancer/Pathology and HPV working groups are active members of the NA-ACCORD Malignancy working group and serve as advisors to the NA-ACCORD regarding the WIHS.

Collaborations with funding external to WIHS: The WIHS will continue to serve as a platform for RO-1 related studies; two recently funded studies are described below. Strickler H, PI. Grant title: Molecular Methods for Cervical Cancer Screening in HIV+ Women. The overall specific aims are: 1) to determine the relative sensitivity, specificity, PPV, and NPV of several promising molecular assays for detection of cervical pre-cancer in HIV(+) women; 2) to assess these assays in combination with one another as well as in combination with routine cytology and HC2, to determine the optimal cervical cancer screening approach in HIV(+) women; 3) to collect and store appropriate specimens from HIV(+) women to test future cervical cancer screening methods when they become available. Silverberg M, Dubrow R, PIs. Grant title: Antiretroviral therapy strategies to lower cancer risk in HIV- infected persons. The overarching goal of the current proposal is to formulate evidence-based recommendations about the optimal CD4 T-cell count at which to initiate ART and the optimal ART regimen, in order to would minimize cancer incidence among HIV-infected persons.

New Directions for WIHS V: Now that WIHS follow-up time has increased, the numbers of new cancers has grown, and the study population is reaching the age where rate of several common tumors begins to rapidly rise, we are better positioned to evaluate the impact of host and viral risk factors on these malignancies. One new area of investigation for the WIHS focuses on modifiable risk factors for cancer which could lead to interventional studies of cancer prevention. Another area leverages the recently completed genotyping of five million single nucleotide polymorphisms (SNPs) in all participants, which will permit the identification of risk alleles for ancestry and candidate genes associated with cancer risk.

WIHS Cancer Summary 2-4-13 page 2 HIV Tropism and Decreased Risk of Breast Cancer

Nancy A. Hessol1, Laura A. Napolitano2,3, Dawn Smith4, Yolanda Lie2, Alexandra Levine5,12,Mary Young6, Mardge Cohen7, Howard Minkoff8, Kathryn Anastos9, Gypsyamber D’Souza10, Ruth M. Greenblatt1, James J. Goedert11* 1 Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, United States of America, 2 Monogram Biosciences, South San Francisco, California, United States of America, 3 Department of Medicine, University of California San Francisco, San Francisco, California, United States of America, 4 Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, 5 City of Hope National Medical Center, Duarte, California, United States of America, 6 Georgetown University School of Medicine, Washington D.C., United States of America, 7 Departments of Medicine, Stroger Hospital and Rush University, Chicago, Illinois, United States of America, 8 Maimonides Medical Center and State University of New York, Health Sciences Center at Brooklyn, Brooklyn, New York, United States of America, 9 Montefiore Medical Center, Bronx, New York, United States of America, 10 Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America, 11 Infections & Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryland, United States of America, 12 Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America

Abstract

Background: During the first two decades of the U.S. AIDS epidemic, and unlike some malignancies, breast cancer risk was significantly lower for women with human immunodeficiency virus (HIV) infection compared to the general population. This deficit in HIV-associated breast cancer could not be attributed to differences in survival, immune deficiency, childbearing or other breast cancer risk factors. HIV infects mononuclear immune cells by binding to the CD4 molecule and to CCR5 or CXCR4 chemokine coreceptors. Neoplastic breast cells commonly express CXCR4 but not CCR5. In vitro, binding HIV envelope protein to CXCR4 has been shown to induce apoptosis of neoplastic breast cells. Based on these observations, we hypothesized that breast cancer risk would be lower among women with CXCR4-tropic HIV infection.

Methods and Findings: We conducted a breast cancer nested case-control study among women who participated in the WIHS and HERS HIV cohort studies with longitudinally collected risk factor data and plasma. Cases were HIV-infected women (mean age 46 years) who had stored plasma collected within 24 months of breast cancer diagnosis and an HIV viral load $500 copies/mL. Three HIV-infected control women, without breast cancer, were matched to each case based on age and plasma collection date. CXCR4-tropism was determined by a phenotypic tropism assay. Odds ratios (OR) and 95% confidence intervals (CI) for breast cancer were estimated by exact conditional logistic regression. Two (9%) of 23 breast cancer cases had CXCR4-tropic HIV, compared to 19 (28%) of 69 matched controls. Breast cancer risk was significantly and independently reduced with CXCR4 tropism (adjusted odds ratio, 0.10, 95% CI 0.002–0.84) and with menopause (adjusted odds ratio, 0.08, 95% CI 0.001–0.83). Adjustment for CD4+ cell count, HIV viral load, and use of antiretroviral therapy did not attenuate the association between infection with CXCR4-tropic HIV and breast cancer.

Conclusions: Low breast cancer risk with HIV is specifically linked to CXCR4-using variants of HIV. These variants are thought to exclusively bind to and signal through a receptor that is commonly expressed on hyperplastic and neoplastic breast duct cells. Additional studies are needed to confirm these observations and to understand how CXCR4 might reduce breast cancer risk.

Citation: Hessol NA, Napolitano LA, Smith D, Lie Y, Levine A, et al. (2010) HIV Tropism and Decreased Risk of Breast Cancer. PLoS ONE 5(12): e14349. doi:10.1371/ journal.pone.0014349 Editor: Genevie`ve Cheˆne, INSERM, France Received July 16, 2010; Accepted November 19, 2010; Published December 16, 2010 This is an open-access article distributed under the terms of the Creative Commons Public Domain declaration which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. Funding: Funded in part by the Intramural Research Program of the National Cancer Institute (JJG), by other components of the National Institutes of Health, and by the Centers for Disease Control and Prevention. The WIHS is funded by the National Institute of Allergy and Infectious Diseases (UO1-AI-35004, UO1-AI-31834, UO1-AI-34994, UO1-AI-34989, UO1-AI-34993, and UO1-AI-42590) and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (UO1-HD-32632). The WIHS is co-funded by the National Cancer Institute, the National Institute on Drug Abuse, and the National Institute on Deafness and Other Communication Disorders. Funding is also provided by the National Center for Research Resources (UCSF-CTSI Grant Number UL1 RR024131). The HIV Epidemiology Research Study (HERS) was funded through Centers for Disease Control and Prevention cooperative agreements U64/CCU106795, U64/CCU206798, U64/CCU306802, and U64/CCU506831. Monogram Biosciences supported tropism testing and all assays were performed by the Monogram Clinical Reference Laboratory. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: Two authors, LAN and YL, are employed by Monogram Biosciences. All other authors declare that they have no competing interests. This does not alter the authors’ adherence to all PLoS ONE policies on sharing data and materials. * E-mail: [email protected]

Introduction infection increases the risk of several malignancies,[2] from 1980– 2002 breast cancer risk in the United States was 31% lower among Human immunodeficiency virus type-1 (HIV) envelope protein women with AIDS compared to the general population [3]. This binds to the CD4 receptor and to chemokine coreceptors CCR5 or cancer deficit was unrelated to crude measures of immune CXCR4, leading to infection and destruction of the CD4-bearing deficiency, was most pronounced before 1990, and gradually immune cells: T lymphocytes and macrophages [1]. Although HIV disappeared with improving antiretroviral therapy (ART) [3].

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The CXCR4 receptor is commonly expressed not only on case based on cohort, age (plus or minus 2 years), and date of immune cells, but also on hyperplastic and especially on malignant plasma specimen collection (within six months). breast duct cells [4–6]. CXCR4 may play an essential role in metastasis and, indirectly, earlier stages of tumor growth [4,5,7–9]. HIV Tropism Determination Linking HIV with breast cancer was the observation that The primary independent variable was HIV coreceptor usage programmed cell death (apoptosis) was induced in human breast (tropism), which was determined by the original Trofile assay cancer cell lines through binding of CXCR4-tropic, but not (Monogram Biosciences, South San Francisco CA. Figure S1). CCR5-tropic, HIV envelope protein [10]. Based on both the Women were classified as having exclusively CCR5-tropic HIV pattern of breast cancer risk in women with AIDS and the in vitro (‘‘R5’’) or as having CXCR4-tropic HIV (‘‘X4’’ or dual/mixed findings that CXCR4-tropic HIV induced apoptosis of breast tropism ‘‘R5/X4’’). The original Trofile assay has .99% cancer cells, we postulated that HIV strains tropic for CXCR4 sensitivity to detect low levels of CXCR4 and CCR5 variants may account for the reduction in breast cancer observed in HIV- that comprise at least 5–10% of a viral population, and the positive infected women. To test this hypothesis, we studied HIV tropism and negative predictive value of the assay has been verified in in women with breast cancer and in matched controls. clinical trials of CCR5 antagonists [14].

Methods Statistical Analyses All analyses were pre-specified. Contingency table analyses were Cohorts, Covariate Data and Specimens, and Ethics conducted to compare the distribution of participant characteris- Statement tics by case-control status, and chi-square or Fisher exact tests The study population was drawn from two large multisite measured statistical significance. Paired t-tests were used to longitudinal studies of HIV infection in women in the United measure equality of means for continuous variables. Unadjusted States, the Women’s Interagency HIV Study (WIHS) and the HIV and adjusted exact conditional, matched-pair, logistic regression Epidemiology Research Study (HERS). Study protocols were was performed. The following continuous variables were trans- reviewed and approved by the institutional review boards, and formed for the regression analyses: body mass index was divided + written informed consent was obtained from the participants. by 10, CD4 cell count was divided by 100, and HIV viral load The WIHS is a prospective study of HIV infection in women, was the log10. Variables that were significant at the P-value ,0.10 conducted in New York City, Washington D.C., Chicago, level in the unadjusted regression models were included in the Southern California and the San Francisco Bay Area. The WIHS adjusted analysis. Statistical analyses were performed using SASH methods and baseline cohort characteristics have been previously software version 9.2 [15]. described [11]. Briefly, between October 1994 and November 1995, 2056 HIV-infected and 569 uninfected women were Results enrolled. A second enrollment between October 2001 and There were 29 confirmed breast cancer cases identified, 27 in September 2002, added 737 HIV-infected and 406 HIV- the WIHS and 2 in the HERS. Of 29 confirmed breast cancer uninfected women [12]. Follow-up of the women enrolled in the cases, three were excluded due to HIV viral load ,500 copies/ WIHS is ongoing. mL, and tropism results could not be determined in three others. A The HERS was a collaborative, multicenter (Baltimore, MD; total of 23 breast cancer cases, who had a mean age of 46 years, Bronx, NY; Providence, RI; and Detroit, MI) prospective study were included in the analyses. Nearly all of these cancers were that enrolled 871 HIV-seropositive and 439 HIV-seronegative invasive infiltrating ductal carcinoma, and they were distributed women with acknowledged HIV risk behavior from April 1993 to across the years 1993–2009 (Table 1). Of 69 randomly selected January 1995. Women were enrolled on the basis of either controls, tropism could not be determined in seven, who were injection drug-use or sexual risk, as has been reported previously replaced with other cohort participants using the same random [13]. Follow-up of the women enrolled in the HERS ended in selection program. March 2000. The WIHS and HERS protocols for core study visits and the HIV Tropism in Cases and Controls questionnaires used were, by design, extremely similar. At every The characteristics of the 23 cases and 69 controls with HIV six month core visit, women participants were interviewed, tropism results are shown in Table S1. Only 2 (9%) breast cancer received a physical examination, and provided multiple gyneco- cases had CXCR4-tropic HIV, compared to 19 (28%) of the logic and blood specimens. Among HIV-infected women, blood + matched controls (Fisher’s exact P = 0.09, Table S1). Two of the samples collected at the core study visit were tested for CD4 seven replacement controls had CXCR4-tropic HIV, for a lymphocytes and HIV RNA load. prevalence of 29%, essentially the same as the originally selected controls. Compared to participants with CCR5-tropic HIV, those Selection of Cases and Controls with CXCR4-tropic HIV had lower mean CD4+ counts (213.5 vs Breast cancer cases were identified and confirmed through 389.8 cells/uL, P = 0.001) but similar mean HIV viral loads (4.4 vs medical records and state cancer registry matches, and date of 4.1 log10 copies/mL, P = 0.21). In addition, tropism was not diagnosis determined. In the WIHS, cancers were identified from associated with history of clinical AIDS or HIV viral load January 1993 through June 2009 and in the HERS from April (P = 0.26). 1993 through March 2000. Cases for the current investigation were HIV-infected women for whom we had stored plasma Breast Cancer Risk by HIV Tropism and Other Variables samples that were within 24 months (either before or after) of their In unadjusted exact conditional regression analysis of 20 cancer diagnosis and in which the HIV RNA viral load was 500 variables (Table S1), breast cancer was marginally inversely copies/mL or greater. A random sample program selected three associated with CXCR4-tropic HIV (Odds Ratio (OR) = 0.20, HIV-infected control women who did not have breast cancer, had 95% confidence interval (CI) 0.02–1.1) as well as menopause HIV RNA viral loads $500 copies/mL, and who matched to each (OR = 0.13, 95% CI 0.003–1.0), defined as not having a menstrual

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Table 1. Histopathology and years of diagnosis of the 23 in 13 of 14 cases of ductal carcinoma in situ of the breast, as well as breast cancer cases in the WIHS and HERS cohort studies. in 13 of 14 areas of atypical ductal hyperplasia of the breast [6]. However, Schmid et al did not detect CXCR4 protein in normal breast epithelium [6], consistent with scanty or absent mRNA Tumor description* Total Number expression in cells derived from mammary epithelial tissue [5]. Overall, these data imply that normal epithelial breast cells would Invasive infiltrating ductal carcinoma 16 have few targets for, and thus probably not be directly affected by, Invasive infiltrating ductal and lobular carcinoma 2 CXCR4-tropic HIV envelope. Infiltrating ductal carcinoma in situ 2 Lobular carcinoma in situ 1 CXCR4 by Cell Type Adenocarcinoma 1 The possibility that CXCR4-tropic HIV might inhibit tumor- Not specified 1 promoting macrophages [17] and that CXCR4 may differ between mononuclear and breast cells should be considered. Year of cancer diagnosis CXCR4-tropic HIV envelope first binds to a CD4 epitope on T 1993–1996 6 lymphocytes or macrophages and then undergoes a conforma- 1997–2000 3 tional change that allows the virus to bind to surface CXCR4 and enter the cell, causing death by various means including apoptosis 2001–2004 9 [1]. CXCR4-mediated apoptosis of uninfected bystander cells that 2005–2008 4 do not express CD4 has been reported, but this phenomenon 2009 1 commonly involves a degree of interaction with CD4-bearing cells [18]. In vitro experiments have reported that CD4-independent *Data obtained from medical records (pathology reports) and cancer registries (histology and behavior). interaction of CXCR4-tropic HIV mediates apoptosis of breast doi:10.1371/journal.pone.0014349.t001 cells, apparently requiring no CD4 expression or interaction to mediate conformational change of HIV and occurring without period for one year or more. Breast cancer was not associated with evidence of in vitro or ex vivo breast cell infection by HIV [10]. any other variables (exact P-values all .0.1), including CD4+ cell Conformational differences in the orientation or folding of surface count, HIV viral load, ART, race/ethnicity, and classical breast CXCR4 [19], including conformational differences between cancer risk factors (Figure 1). In multivariable analysis, cancer risk immune versus breast cells [10], may be functionally important. was reduced in women with CXCR4-tropic HIV (adjusted The additional possibility of HIV infection of breast cells should OR = 0.10, 95% CI 0.002–0.84) and with menopause (adjusted also be considered [20]. OR = 0.08, 95% CI 0.001–0.83). In additional multivariable analyses, the adjusted OR and significance level for CXCR4- Assessment of Potential Survivorship, Competing Risk, tropic HIV was not attenuated by the inclusion of CD4+ cell and Screening Biases count, use of ART, or HIV viral load in the regression models. Women with HIV infection may have other causes of morbidity and mortality that prevent them from being diagnosed with breast Discussion cancer or living long enough to develop breast cancer. With the increasing availability and potency of ART, these competing These findings show that the odds of breast cancer in women causes of morbidity and mortality are reduced, and thus HIV- with CXCR4-tropic HIV were 90% lower than in women with infected women are living longer and reaching the age of higher CCR5-tropic HIV. This is large enough to account for most of the breast cancer incidence. By matching the controls to the cases on breast cancer deficit for women with AIDS in the United States date of plasma collection we controlled for temporal trends in the [3]. Our findings support the hypothesis that the low breast cancer availability and potency of ART. We also matched the controls to incidence observed in women with HIV/AIDS is specifically the age of the cases. CD4+ cell counts were significantly lower in linked to HIV variants that bind to CXCR4, a receptor that is our participants who had CXCR4-tropic HIV. This accords with commonly expressed on hyperplastic and neoplastic breast cells. the well known tendency for patients infected with CXCR4-tropic This hypothesis was developed from three observations: 1) the virus to have more rapid HIV disease progression compared to utilization of CXCR4 as the coreceptor for HIV X4 and R5/X4 those infected with only CCR5-tropic virus [1]. However, strains [1], 2) the common and often high level expression of CXCR4-tropic HIV was not significantly associated with HIV CXCR4 in breast neoplasia [4–6], and 3) the induction of viral load or history of clinical AIDS. Moreover, in multivariable apoptosis of breast cancer cells by the specific binding of CXCR4- models that included CD4 cell count, use of ART, or HIV viral tropic HIV envelope to CXCR4 [10]. load, the significance level for CXCR4-tropic HIV was not attenuated. As a result, we have considered and minimized CXCR4 in Breast Neoplasia competing risk as much as possible and still found a significant Our data showing a reduced risk of breast cancer among association between CXCR4-tropic HIV and reduced risk of women with CXCR4-tropic HIV may reflect an effect of CXCR4 breast cancer. at an intermediate stage of breast neoplasia. Muller and colleagues Screening bias may account for a fraction of the breast cancer first observed that CXCR4 is commonly and often highly deficit. During ages 40–49, history of screening mammography expressed in primary breast cancers and in breast cancer cell was reported by a smaller fraction of HIV-positive women in our lines [5]. This observation has been replicated and extended by WIHS cohort (64%) compared to the general population many others, as reviewed by Luker and Luker [4]. Mammary stem (79%).[21] Screening mammography history after age 50 was cells express CXCR4 mRNA, as well as many other genes [16], nearly identical in the WIHS and general populations, although although the relevance of this to breast neoplasia is speculative [4]. the data were sparse.[21] Whether mammography screening is Notably, CXCR4 protein was observed by Schmid and colleagues related to HIV tropism is unknown.

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Figure 1. Breast cancer risk with each variable. Unadjusted conditional exact odds ratios (diamonds) and 95% confidence intervals (error bars) for breast cancer among 23 breast cancer cases and 69 controls from the WIHS and the HERS. Reference groups: no therapy (for current use of ART), African American (for race/ethnicity), high school degree (for education), and no alcohol consumption (for alcohol use). doi:10.1371/journal.pone.0014349.g001

Trends in HIV Tropism and ART Use Supporting Information Initial HIV infection with HIV subtype B is almost always Table S1 Characteristics of the 23 breast cancer cases and 69 CCR5-tropic, with CXCR4-tropic virus emerging later, a shift that may be retarded by highly active ART (HAART) [1]. We controls in the WIHS and HERS cohort studies. This table postulate that gradual increases in HAART use and efficacy since provides the demographic characteristics, HIV-related parame- 1996 may have been sufficient to account for the increasing trend ters, and breast cancer risk factor data, as well as univariate tests of in breast cancer incidence [3]. In 2008, 71% of HIV-infected differences between cases and controls. women in the WIHS cohort were receiving HAART [N. Hessol, Found at: doi:10.1371/journal.pone.0014349.s001 (0.10 MB unpublished data]. The observed 28% prevalence of CXCR4- DOC) using HIV in our control group and 90% lower risk of breast Figure S1 The Trofile Assay: RNA from patient plasma is cancer associated with these HIV strains, would account for most subjected to RT-PCR amplification to obtain a broad represen- of the breast cancer deficit in women with AIDS [3,22]. tation of envelope (env) genes from HIV populations. env amplification products are then inserted into ‘‘HIV env expression Limitations and Contrary Data vectors’’ (A). Patient HIV env expression vectors are co-transfected We lacked ex vivo data to support the epidemiologic association with an env-deleted ‘‘HIV genomic vector’’ (B) containing a firefly with CXCR4-tropic HIV. In addition to the reported induction of luciferase reporter gene that is used to quantify viral infectivity. apoptosis,[10] induction of various growth factors could contribute Co-transfection of HIV env expression vectors and HIV genomic to or account for the association.[7–9] Our study was very small vectors produces HIV-1 pseudoviruses (C) expressing the env and limited to U.S. women who may not be representative of the proteins derived from patient virus env sequences. Coreceptor global HIV epidemic. In our evaluation of classical breast cancer tropism is determined by measuring the ability of pseudovirus risk factors, we observed a lower risk associated with menopause. populations to efficiently infect target cells co-expressing CD4 and This association is not surprising, especially in a population with a either CXCR4 (D) or CCR5 (E) co-receptors. Co-receptor mean age of 46 years, because early menopause is known to mediated infectivity is quantified by measuring luciferase infectiv- decrease the risk of breast cancer [23]. Despite our hypothesis- ity in the CD4/CCR5 and CD4/CXCR4 target cells (portrayed driven study that included many potential risk and confounding as yellow asterisks). In the depicted example, both CXCR4+ and factors, and our exclusion of survivorship and other potential CCR5+ cells are infected by pseudoviruses using patient env and, biases by matching and statistical adjustment, the association therefore, viral tropism would be classified as ‘‘R5/X4’’ or ‘‘dual/ between CXCR4-tropic virus and breast cancer may be spurious mixed’’. To confirm co-receptor usage, CCR5 and CXCR4 entry due to an unmeasured viral or other exogenous or endogenous risk inhibitors are added to target cells (F). Viruses susceptible to factor. CCR5 and/or CXCR4 antagonists do not produce luciferase in It should be noted that during severe immune deficiency, when the corresponding target cells. env genes encoding envelope CXCR4-tropic HIV is most prevalent, risks for Kaposi sarcoma proteins capable of using the CXCR4 co-receptor, the CCR5 co- and central nervous system lymphoma are very high despite tumor receptor, or both co-receptors are shown in green, orange and expression of CXCR4 [24,25]. Nevertheless, these particular blue, respectively. malignancies are distinct as they are known to be driven by herpes Found at: doi:10.1371/journal.pone.0014349.s002 (0.27 MB PPT) virus transformation and thus may not utilize CXCR4 as a major means of oncogenesis and metastasis. It is possible that our observed association of CXCR4-tropic HIV is unique to breast Acknowledgments neoplasia due to conformational heterogeneity or variable surface Data in this manuscript were collected by the Women’s Interagency HIV expression of CXCR4 epitopes on neoplastic breast duct cells Study (WIHS) Collaborative Study Group with centers (Principal [10,19]. Investigators) at New York City/Bronx Consortium (Kathryn Anastos); Brooklyn, NY (Howard Minkoff); Washington DC Metropolitan Consor- Summary and Implications tium (Mary Young); The Connie Wofsy Study Consortium of Northern California (Ruth Greenblatt); Los Angeles County/Southern California We found a 90% lower risk of breast cancer for women who Consortium (Alexandra Levine); Chicago Consortium (Mardge Cohen); have circulating CXCR4-tropic HIV envelope, which points to Data Coordinating Center (Stephen Gange). The contents of this the possibility of a novel protective interaction between a specific publication are solely the responsibility of the authors and do not viral protein and cancer risk. The prototype selective antagonist of necessarily represent the official views of the NIH. CXCR4, AMD3100 (Plerixafor) [26], was reported to inhibit The authors also thank additional members of the HERS Study Group: apoptosis of breast cancer cells by CXCR4-tropic HIV [10], and Dr. Ellie Schoenbaum, Montefiore Medical Center and Albert Einstein other inhibitors of CXCR4 are currently in development to treat College of Medicine, Bronx, New York; Dr. Paula Schuman, Wayne State various cancers [27–29]. However, derivative studies should also University School of Medicine, Detroit, Michigan; Dr. Anne Rompalo, consider indirect pathways, such as blockade of pro-carcinogenic Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland; Dr. Charles Carpenter, Brown University School of Medicine, effects of chemokines expressed by tumor-infiltrating macrophages Providence, Rhode Island; Drs. Lytt I. Gardner, Dawn K. Smith, and [17]. Continued studies of molecular interactions [8–10], of Dora Warren, Centers for Disease Control and Prevention, Atlanta, patients with malignancies, and of populations at risk for these Georgia; and Katherine Davenny, National Institute of Drug Abuse, diseases are needed to develop insight into the roles of CXCR4 in Rockville, Maryland. The findings and conclusions in this report are those breast and other cancers, which may lead to new approaches for of the author(s) and do not necessarily represent the official position of the prevention or treatment. Centers for Disease Control and Prevention.

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Monogram Biosciences supported tropism testing and all assays were Author Contributions performed by the Monogram Clinical Reference Laboratory. We are sincerely thankful to the women who consented to be part of this Conceived and designed the experiments: NAH LAN JG. Performed the study. We are also grateful to Dr. Peter Bacchetti, University of California experiments: LAN YSL. Analyzed the data: NAH LAN. Contributed San Francisco, and to Drs. Anil Chaturvedi and Nilanjan Chatterjee, reagents/materials/analysis tools: DS AML MY MC HM KA GD RG. National Cancer Institute, for their statistical assistance. Wrote the paper: NAH LAN JG. PI for HERS cohort: DS. PI for WIHS site: AML MY MC HM KA RG. WIHS analysis center: GD.

References 1. Weber J, Piontkivska H, Quinones-Mateu ME (2006) HIV type 1 tropism and 16. Dontu G, Abdallah WM, Foley JM, Jackson KW, Clarke MF, et al. (2003) In inhibitors of viral entry: clinical implications. AIDS Rev 8(2): 60–77. vitro propagation and transcriptional profiling of human mammary stem/ 2. Frisch M, Biggar RJ, Engels EA, Goedert JJ; AIDS-Cancer Match Registry progenitor cells. Genes Dev 17(10): 1253–70. Study Group (2001) Association of cancer with AIDS-related immunosuppres- 17. Robinson SC, Scott KA, Wilson JL, Thompson RG, Proudfoot AE, et al. (2003) sion in adults. JAMA 285(13): 1736–45. A chemokine receptor antagonist inhibits experimental breast tumor growth. 3. Goedert JJ, Schairer C, McNeel TS, Hessol NA, Rabkin CS, et al. (2006) Risk of Cancer Res 63(23): 8360–5. breast, ovary, and uterine corpus cancers among 85,268 women with AIDS. 18. Ahr B, Robert-Hebmann V, Devaux C, Biard-Piechaczyk M (2004) Apoptosis of Br J Cancer 95(5): 642–8. uninfected cells induced by HIV envelope glycoproteins. Retrovirology 1: 12. 4. Luker KE, Luker GD (2006) Functions of CXCL12 and CXCR4 in breast 19. Baribaud F, Edwards TG, Sharron M, Brelot A, Heveker N, et al. (2001) cancer. Cancer Lett 238(1): 30–41. Antigenically distinct conformations of CXCR4. J Virol 75(19): 8957–67. 5. Muller A, Homey B, Soto H, Ge N, Catron D, et al. (2001) Involvement of 20. Toniolo A, Serra C, Conaldi PG, Basolo F, Falcone V, et al. (1995) Productive chemokine receptors in breast cancer metastasis. Nature 410(6824): 50–6. HIV-1 infection of normal human mammary epithelial cells. AIDS 9(8): 859–66. 6. Schmid BC, Rudas M, Rezniczek GA, Leodolter S, Zeillinger R (2004) CXCR4 21. Preston-Martin S, Kirstein LM, Pogoda JM, Rimer B, Melnick S, et al. (2002) is expressed in ductal carcinoma in situ of the breast and in atypical ductal Use of mammographic screening by HIV-infected women in the Women’s hyperplasia. Breast Cancer Res Treat 84(3): 247–50. Interagency HIV Study (WIHS) Prev Med 34(3): 386–92. 7. Burger JA, Kipps TJ (2006) CXCR4: a key receptor in the crosstalk between 22. Chaturvedi AK, Mbulaiteye SM, Engels EA (2008) Underestimation of relative tumor cells and their microenvironment. Blood 107(5): 1761–7. 8. Liang Z, Brooks J, Willard M, Liang K, Yoon Y, et al. (2007) CXCR4/CXCL12 risks by standardized incidence ratios for AIDS-related cancers. Ann Epidemiol axis promotes VEGF-mediated tumor angiogenesis through Akt signaling 18(3): 230–4. pathway. Biochem Biophys Res Commun 359(3): 716–22. 23. Colditz GA, Rosner B (2000) Cumulative risk of breast cancer to age 70 years 9. Sauve K, Lepage J, Sanchez M, Heveker N, Tremblay A (2009) Positive according to risk factor status: data from the Nurses’ Health Study. feedback activation of estrogen receptors by the CXCL12-CXCR4 pathway. Am J Epidemiol 152(10): 950–64. Cancer Res 69(14): 5793–800. 24. Smith JR, Falkenhagen KM, Coupland SE, Chipps TJ, Rosenbaum JT, et al. 10. Endo M, Inatsu A, Hashimoto K, Takamune N, Shoji S, et al. (2008) Human (2007) Malignant B cells from patients with primary central nervous system immunodeficiency virus-induced apoptosis of human breast cancer cells via lymphoma express stromal cell-derived factor-1. Am J Clin Pathol 127(4): CXCR4 is mediated by the viral envelope protein but does not require CD4. 633–41. Curr HIV Res 6(1): 34–42. 25. Uccini S, Scarpino S, Ballarini F, Soriani A, Chilosi M, et al. (2003) In situ study 11. Barkan SE, Melnick SL, Preston-Martin S, Weber K, Kalish LA, et al. (1998) of chemokine and chemokine-receptor expression in Kaposi sarcoma. WIHS Collaborative Study Group. Epidemiology 1998; 9(2): 117–25. Am J Dermatopathol 25(5): 377–83. 12. Bacon MC, von Wyl V, Alden C, Sharp G, Robison E, et al. (2005) The 26. Hatse S, Princen K, Bridger G, De Clercq E, Schols D (2002) Chemokine Women’s Interagency HIV Study: an observational cohort brings clinical receptor inhibition by AMD3100 is strictly confined to CXCR4. FEBS Lett sciences to the bench. Clin Diagn Lab Immunol 12(9): 1013–9. 527(1-3): 255–62. 13. Smith DK, Warren DL, Vlahov D, Schuman P, Stein MD, et al. (1997) Design 27. Moyle G, DeJesus E, Boffito M, Wong RS, Gibney C, et al. (2009) Proof of and baseline participant characteristics of the Human Immunodeficiency Virus activity with AMD11070, an orally bioavailable inhibitor of CXCR4-tropic HIV Epidemiology Research (HER) Study: a prospective cohort study of human type 1. Clin Infect Dis 48(6): 798–805. immunodeficiency virus infection in US women. Am J Epidemiol 146(6): 28. Thoma G, Streiff MB, Kovarik J, Glickman F, Wagner T, et al. (2008) Orally 459–69. bioavailable isothioureas block function of the chemokine receptor CXCR4 in 14. Gulick RM, Lalezari J, Goodrich J, Clumeck N, DeJesus E, et al. (2008) vitro and in vivo. J Med Chem 51(24): 7915–20. Maraviroc for previously treated patients with R5 HIV-1 infection. N Engl J Med 29. Iwasaki Y, Akari H, Murakami T, Kumakura S, Dewan MZ, et al. (2009) 359(14): 1429–41. Efficient inhibition of SDF-1alpha-mediated chemotaxis and HIV-1 infection by 15. SAS Institute Inc, ed. (2008) SAS/STAT User’s Guide, Version 9.2. CaryNorth novel CXCR4 antagonists. Cancer Sci 100(4): 778–81. Carolina: SAS Institute Inc.

PLoS ONE | www.plosone.org 6 December 2010 | Volume 5 | Issue 12 | e14349 Table S1. Characteristics of the 23 breast cancer cases and 69 controls in the WIHS and HERS cohort studies. Cases Controls Participant characteristic N (%) N (%) P-value CXCR4-tropic 2 (8.7) 19 (27.5) 0.09* Menstrual period in the last 12 months 0.11 Yes 17 (73.9) 38 (55.1) No 6 (26.1) 31 (44.9) HIV RNA viral load [mean log10] [3.96] [4.21] 0.24** 500 – 4,000 copies 6 (26.1) 20 (29.0) 0.83 4,000 – 49,000 copies 11 (47.8) 28 (40.6) ≥50,000 copies 6 (26.1) 21 (30.4) CD4+ cell count/ mm3 [mean] [372] [342] 0.58** <200 4 (17.4) 23 (33.3) 0.39* 200 – 499 14 (60.9) 33 (47.8) ≥500 5 (21.7) 13 (18.8) Current HIV therapy 0.75* None 15 (65.2) 35 (50.7) Mono therapy 2 (8.7) 10 (14.5) Combination 1 (4.4) 4 (5.8) HAART 5 (21.7) 20 (29.0) Ever used ART 0.21 Yes 15 (65.2) 54 (78.3) No 8 (34.8) 15 (21.7) Ever used HAART 0.55 Yes 11 (47.8) 38 (55.1) No 12 (52.2) 31 (44.9) Self-reported clinical AIDS diagnosis 0.19 Yes 9 (39.1) 38 (55.1) No 14 (60.9) 31 (44.9) Age, years [mean] [46.3] [46.0] 0.91 31-40 5 (21.7) 21 (30.4) 0.72 41-50 10 (43.5) 26 (37.7) > 50 8 (34.8) 22 (31.9) Race/ethnicity 0.74* White, non-Hispanic 2 (8.7) 12 (17.4) White, Hispanic 2 (8.7) 4 (5.8) African American 15 (65.2) 40 (58.0) Other 4 (17.4) 13 (18.8) Educational attainment 0.37* < High school 10 (43.5) 22 (31.9) High school 10 (43.5) 25 (36.2) Some college 2 (8.7) 17 (24.6) ≥ 4 years college 1 (4.3) 5 (7.3)

Cases Controls Participant characteristic N (%) N (%) P-value Age at menarche [mean] [12.6] [13.0] 0.43** <12 3 (16.7) 12 (20.3) 0.68* 12-13 11 (61.1) 28 (47.5) >13 4 (22.2) 19 (32.2) Missing 5 10 Number of term births [mean] [3.0] [2.3] 0.19** 0 4 (17.4) 12 (17.4) 0.54* 1-2 8 (34.8) 32 (46.4) ≥3 11 (47.8) 25 (36.2) Current cigarette smoker 0.45 No 7 (30.4) 27 (39.1) Yes 16 (69.6) 42 (60.9) Alcohol use in past six months 0.17* None 9 (39.1) 36 (52.2) <3 drinks per week 6 (26.1) 22 (31.9) 3-13 drinks per week 6 (26.1) 10 (14.5) ≥14 drinks per week 2 (8.7) 1 (1.5) History of injection drug use 0.27 No 11 (47.8) 42 (60.9) Yes 12 (52.2) 27 (39.1) HCV positive at baseline 0.38 No 8 (36.4) 32 (47.1) Yes 14 (63.6) 36 (52.9) Missing 1 1 Body mass index 0.98* Underweight <19.8 2 (9.1) 5 (7.8) Normal 19.8-26.0 9 (40.9) 30 (46.9) Overweight 26.1-29.0 4 (18.2) 11 (17.2) Obese >29.0 7 (31.8) 18 (28.1) Missing 1 5 Ever used oral contraceptives 0.60 Yes 17 (73.9) 47 (68.1) No 6 (26.1) 22 (31.9) Ever used hormone replacement therapy 0.31* Yes 2 (13.3) 13 (29.6) No 13 (86.7) 31 (70.4) Missing 8 25

* Fisher’s exact test; ** Equality of mean

VOLUME 28 ⅐ NUMBER 9 ⅐ MARCH 20 2010

JOURNAL OF CLINICAL ONCOLOGY ORIGINAL REPORT

HIV As a Risk Factor for Lung Cancer in Women:

From the City of Hope National Medical Data From the Women’s Interagency HIV Study Center, Duarte; Keck School of Medicine, University of Southern California, Los Alexandra M. Levine, Eric C. Seaberg, Nancy A. Hessol, Susan Preston-Martin, Sylvia Silver, Angeles; University of California, San Mardge H. Cohen, Kathryn Anastos, Howard Minkoff, Jan Orenstein, Geraldina Dominguez, Francisco, CA; Johns Hopkins School of and D. Heather Watts Public Health, Baltimore; National Cancer Institute; Eunice Kennedy Shriver ABSTRACT National Institutes of Child Health and Human Development, National Institutes Purpose of Health, Rockville, MD; George Wash- Prior reports of an increased risk of lung cancer in HIV-infected individuals have not always ington University School of Medicine and included control groups, nor considered other risk factors such as tobacco exposure. We sought Health Sciences, Washington DC; to determine the role of HIV infection and highly active antiretroviral therapy (HAART) on lung Departments of Medicine, Stroger (formerly Cook County Hospital) and cancer incidence in 2,651 HIV-infected and 898 HIV-uninfected women from the Women’s Rush University, Chicago, IL; Montefiore Interagency HIV Study (WIHS). Medical Center, Bronx; and the Methods Maimonides Medical Center and State A prospective study of the incidence rates of lung cancer was conducted, with cases identified University of New York, Health Sciences Center at Brooklyn, NY. through medical records, death certificates, and state cancer registries. Standardized incidence ratios (SIRs) were calculated to compare lung cancer incidence among HIV-infected and unin- Submitted August 14, 2009; accepted November 11, 2009; published online fected WIHS participants, with population-based expectations using the Surveillance, Epidemiol- ahead of print at www.jco.org on ogy, and End Results registry. Behavioral characteristics in the WIHS were compared to US February 22, 2010. women by age and race adjusting the population-based data from the National Health and

WIHS is funded by Grants No. UO1-AI- Nutritional Examination Survey (NHANES) III. 35004, UO1-AI-31834, UO1-AI-34994, Results UO1-AI-34989, UO1-AI-34993, and Incidence rates of lung cancer were similar among HIV-infected and uninfected WIHS women. UO1-AI-42590 from the National Institute Lung cancer SIRs were increased in both HIV-infected and -uninfected women compared with of Allergy and Infectious Diseases and by Grant No. UO1-HD-32632 from the population expectations, but did not differ by HIV status. Among HIV-infected women, lung cancer National Institute of Child Health and incidence rates were similar in pre-HAART and HAART eras. All WIHS women with lung cancer Human Development; co-funded by the were smokers; the risk of lung cancer increased with cumulative tobacco exposure. WIHS women National Cancer Institute, the National were statistically more likely to smoke than US women studied in NHANES III. Institute on Drug Abuse, and the National Institute on Deafness and Other Commu- Conclusion nication Disorders; and by UCSF-CTSI HIV infection is strongly associated with smoking behaviors that increase lung cancer risk. The role Grant No. UL1 RR024131 from the of HIV itself remains to be clarified. National Center for Research Resources.

The contents of this publication are solely J Clin Oncol 28:1514-1519. © 2010 by American Society of Clinical Oncology the responsibility of the authors and do not necessarily represent the official Given these uncertainties, we wished to as- views of the National Institutes of Health. INTRODUCTION Presented in part in oral format at the certain the incidence of lung cancer among International Conference on AIDS- HIV-infected women enrolled in the Women’s In- Related Malignancies and Other Immu- Highly active antiretroviral therapy (HAART) has teragency HIV Study (WIHS) in the pre-HAART nodeficiencies, Bethesda, MD, been associated with a remarkable decline in the versus HAART eras, comparing incidence data to September 26-27, 2005. incidence of AIDS-defining cancers.1-3 However, an that from a group of HIV-uninfected WIHS partic- Authors’ disclosures of potential con- increase in certain non-AIDS defining cancers, in- flicts of interest and author contribu- ipants, all of whom were observed over prolonged 4-8 tions are found at the end of this cluding lung cancer, has been reported. The num- periods, and in whom behavioral characteristics article. ber of HIV-infected persons with lung cancer is were carefully documented. We also examined risk Corresponding author: Alexandra M. relatively small, and not all studies have confirmed factors and disease characteristics of lung cancer Levine, MD, City of Hope National an increase in risk.9-11 among HIV-infected versus uninfected participants. Medical Center, 1500 East Duarte Rd, Duarte, CA 91010; e-mail: alevine@ Factors associated with development of lung coh.org. cancer in HIV-infected persons have included his- METHODS 8 © 2010 by American Society of Clinical tory of cigarette smoking, lung disease, and pro- Oncology longed duration of HIV infection. The actual role Study Cohort 0732-183X/10/2809-1514/$20.00 of profound HIV-related immunodeficiency re- WIHS is a cohort study of women with or at risk for 6,8,11-13 DOI: 10.1200/JCO.2009.25.6149 mains unclear. HIV infection, observed at six sites (Bronx/Manhattan,

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NY; Brooklyn, NY; Metropolitan Washington, DC, and surrounds; Northern California; Southern California; and Chicago, IL).14,15 The cohort included Table 1. Baseline Characteristics of the WIHS Participants at Study Entry by HIV Status (N ϭ 3,549) 3,766 women enrolled during two recruitment waves: October 1994 to No- vember 1995, and October 2001 to September 2002. HIV-infected and HIV -uninfected women were recruited from similar sources and frequency HIV Positive Negative matched on age, race/ethnicity, and risk for HIV acquisition. Semi-annual Characteristic No. % No. % P visits included interviewer-administered questionnaires, physical and gyneco- All 2,651 100.0 898 100.0 logical examinations, and collection of biologic specimens. Study protocols Age group, years were reviewed and approved by each institutional review board; informed Ͻ 30 622 23.5 360 40.1 ءconsent was obtained from all participants. 30-39 1,265 47.7 340 37.9 Ͻ .001 The 3,678 women who gave additional written consent for cancer ascer- 40-49 651 24.6 176 19.6 tainment through state registries were eligible. We excluded three women with 50ϩ 112 4.3 22 2.4 lung cancer before enrollment, and another 126 women without known lung Race/ethnicity cancer, seen only at baseline. All analyses were conducted using the remaining Non-Hispanic Black 1,499 56.5 492 54.8 3,549 women (94%), and were based on data entered into the database by Non-Hispanic White 396 14.9 126 14.0 .37 March 31, 2008; follow-up was censored on September 30, 2006, to allow for Latina/Hispanic 681 25.7 247 27.5 lags in reporting and confirmation of incident cancers. Other 75 2.8 33 3.7 Study Outcome Highest education level attained All incident lung cancers were confirmed through medical record re- Did not graduate from HS 1,014 38.3 316 35.4 ء views of self-reported lung cancers, and/or through matching to statewide HS graduate 795 30.0 274 30.7 .12 cancer registries (most recently performed in 2008), and the national death Post-HS education 838 31.7 302 33.9 index. Lung cancer pathology reports were reviewed. Annual household income, $ Fewer than 6,000 698 27.1 271 31.4 ءExposures and Potential Confounders 6,000-11,999 862 33.5 236 27.3 .57 The primary independent variables included HIV serostatus, history of 12,000-29,999 698 27.1 212 24.5 tobacco use, and HAART use. HIV serology was tested by enzyme-linked 30,000 or greater 315 12.2 145 16.8 immunosorbent assay with Western blot confirmation. Smoking history was Currently employed 632 23.9 301 33.6 Ͻ .001 summarized at baseline using a categoric variable indicating never/former/ Medical insurance coverage 2,187 83.2 548 61.5 Ͻ .001 current use; and, among current smokers, quantification of the total cumula- Alcohol consumption during past 12 tive exposure in pack-years (total number of years smoking cigarettes times the months, drinks per week ءaverage number of packs smoked/day). To account for selection by indication Does not drink alcohol 1,230 47.6 351 38.8 Ͻ .001 bias resulting from the administration of HAART to women with more ad- Fewer than 3 787 30.4 267 30.3 vanced HIV, the population effectiveness of HAART at reducing lung cancer 3 or more 569 22.0 263 29.9 incidence was assessed by comparing the incidence rates during the pre- Among drinkers, No. of drinks/week HAART (1994 to 1996) and HAART (1997 to 2006) eras. The onset of the Mean 7.9 8.9 HAART era was set at 1997, since Ն 25% of HIV-infected participants first SD 19.1 18.3 reported HAART use at that time. We also evaluated age, sex, race, education, Median 1.5 2.5 income, employment status, insurance coverage, history of alcohol consump- IQR 0.5-6.0 1.0-9.0 tion, body mass index (BMI), CD4 cell count, and HIV RNA levels. Cigarette smoking history Never smoked 852 32.3 274 30.6 External Comparison Groups Former smoker 429 16.3 107 12.0 .001 SEER. Surveillance, Epidemiology and End Results (SEER) is an ongo- Current smoker 1,356 51.4 514 57.4 ing population-based surveillance program, documenting cancer incidence Lifetime cigarette consumption and survival using selected US state cancer registries.16 We used age-, sex-, and among current smokers, race-specific cancer incidence data from SEER from 1994 to 2004 to estimate pack-years ء the number of lung cancers expected in WIHS. The SEER “site recode” num- Lower than 10 713 53.3 291 58.0 .07 ber 22030 was used to identify lung cancer cases in SEER, including cancers 10-20 383 28.6 133 26.5 with International Classification of Diseases O-2 site codes C34.0 to C34.9. Higher than 20 243 18.2 78 15.5 National Health and Nutrition Examination Survey III. The third Na- Mean 13.0 11.6 tional Health and Nutrition Examination Survey (NHANES III) used a com- SD 19.7 15.7 plex multistage cluster sampling of the US civilian, noninstitutionalized Median 9.0 7.5 population to develop a cohort to investigate risk factors to explain differences IQR 3.8-16.5 2.5-15.0 in health in the US population.17 A random sample was selected and interviews Body mass index, kg/m2 were conducted in three waves from 1988 to 1994. We used the NHANES III Lower than 20.0 225 8.8 74 8.6 cohort to obtain population-based estimates of the prevalence of identified 20.0-24.9 871 34.1 271 31.3 ء lung cancer risk factors.17-19 The 17,699 women included in NHANES III were 25.0-29.9 758 29.7 247 28.5 .04 used to generate the US population–based control group to which we com- 30.0 or higher 697 27.3 274 31.6 pared the WIHS women on behavioral characteristics. Mean 27.3 28.2 SD 6.8 7.3 Statistical Analyses Median 25.9 26.5 Baseline characteristics in WIHS were quantified descriptively. Compar- IQR 22.4-30.5 22.9-32.1 isons between HIV-infected and -uninfected women were performed using ␹2 tests of homogeneity and trend. Lung cancer incidence rates were estimated as Abbreviations: WIHS, Women’s Interagency HIV Study; HS, high school; SD, standard deviation; IQR, interquartile range. .Test of trendء (the number of incident cancers divided by total number of person-years (PYs follow-up. Statistical comparisons between HIV-infected and -uninfected women, and between the pre-HAART and HAART eras, assumed a Poisson distribution for lung cancer incidence rates. To compare the observed number www.jco.org © 2010 by American Society of Clinical Oncology 1515 Information downloaded from jco.ascopubs.org and provided by UCSF KALAMANOVITZ LIB CKM on March 29, 2010 from 128.218.97.140. Copyright © 2010 by the American Society of Clinical Oncology. All rights reserved. Levine et al

Table 2. Unadjusted Lung Cancer Incidence in the Women’s Interagency HIV Study HAART Era v Pre-HAART Era Parameter All Pre-HAART Era:1994-1996 HAART Era:1997-2003 Rate Ratio 95% CI All Observed No. with cancer 14 3 11 PYs 25,000 4,059 20,941 0.71 0.19 to 3.97 IR per 100,000 PYs 56.0 73.9 52.5 HIV positive Observed No. with cancer 12 2 10 PYs 18,825 3,221 15,604 1.03 0.22 to 9.69 IR per 100,000 PYs 63.7 62.1 64.1 HIV negative Observed No. with cancer 2 1 1 PYs 6,175 838 5,337 0.16 0.002 to 12.3 IR per 100,000 PYs 32.4 119.3 18.7 Rate ratio for HIV positive v HIV negative 1.97 0.52 3.42 95% CI 0.44 to 18.1 0.03 to 30.7 0.49 to 148.4

Abbreviations: HAART, highly active antiretroviral therapy; PY, person-years; IR, incidence rate.

of lung cancers in the WIHS to the expected number documented by SEER 100,000 PYs (Table 2). The incidence rates did not differ by HIV status between January 1, 1994, and December 31, 2004, we computed standardized (exact P ϭ .58). Further, incidence rates did not differ between pre- 20 21 incidence ratios (SIRs) and exact 95% CIs adjusted for age (5-year catego- HAART and HAART eras in the cohort as a whole (exact P ϭ .81) or ries), sex, and race (African American, Latina/Hispanic, other white, and in the HIV-infected women. other). SIRs by HIV serostatus and calendar time were compared using SIR regression. Because of the small number of observed lung cancer cases, all Unadjusted lung cancer incidence rates were significantly associ- incidence analyses were performed using exact statistical methods. Possible ated with older age (Table 3). Further, lung cancer incidence was differences in behavioral or demographic characteristics between WIHS and highest among non-Hispanic blacks when compared with the com- US women were determined comparing baseline characteristics. Data from bined nonblack groups (incidence rate ratio, 10.1; 95% CI, 1.5 to 431; NHANES III women were directly adjusted to age and race distributions in Table 3). Black women were significantly more likely to be current WIHS, using Longenecker’s approach.22 Statistical comparisons of cross- smokers at baseline (59% v 45%; P Ͻ .001) but among current smok- sectional data were performed using Wilcoxon rank-sum and ␹2 tests of homogeneity and trend. All analyses used SAS, version 9.1 (SAS Institute, ers, black women reported significantly lower pack-years compared to Cary, NC) or StatXact 8.0 (Cytel Software Corporation, Cambridge, MA). P nonblack women (median, 7.5 v 10.0 PYs; P ϭ .008). values lower than .05 indicated statistical significance. Comparison of WIHS to the US Population RESULTS Fourteen incident lung cancers were observed in WIHS, while between four and five were expected based on population-based age WIHS Cohort and race-specific rates from SEER (Table 4). Overall, the SIR for lung Median age at enrollment of all 3,549 WIHS participants was 34.9 cancer in WIHS was 3.0 (95% CI, 1.7 to 5.1). The excess lung cancer years (interquartile range [IQR], 29.3 to 40.4), and was higher in burden did not vary by HIV status (exact Pϭ.85), nor by pre-HAART HIV-infected women (35.6 v 32.4 years; P Ͻ .001; Table 1). The versus HAART eras (exact P ϭ .96). racial/ethnic composition of both groups was similar. At their baseline Because other recognized risk factors for lung cancer might ex- visit, HIV-infected women were less likely to be currently employed, plain the excess incidence rate in WIHS, we compared the WIHS or to drink alcohol, and were more likely to have medical insurance cohort characteristics to those in the age- and race-adjusted US female (including Medicaid) than the HIV-uninfected comparators. The population, using NHANES III data, reweighted to match the age and HIV-infected women had lower baseline BMI. Two thirds of WIHS race distributions of WIHS. Our adjustment yielded identical age and participants reported a history of smoking. While fewer HIV-infected race distributions in the two cohorts (data not shown). When com- than uninfected women were current smokers, the median lifetime pared with the NHANES III women, the WIHS participants had cigarette consumption for current smokers was higher among HIV- significantly (P Ͻ .05) less education, lower annual household in- infected women. The median lifetime cigarette consumption among comes, were less likely to be employed, have medical insurance cover- all WIHS women who reported smoking at enrollment was 8.4 pack- age, or have a BMI higher than 30. A higher percentage of WIHS years (IQR, 3.5 to 16.0). participants had consumed alcohol during the past 12 months (54.4% v 37.5%). A higher percentage of WIHS participants (both Lung Cancer Incidence HIV infected and uninfected) had history of smoking cigarettes With 25,000 PYs follow-up, and median follow-up for individual (68.0% v 37.2%; P Ͻ .001). Among current smokers at enrollment in women of 5.8 years (IQR, 4.8 to 12.1), we observed 14 incident lung the two studies, the cumulative exposure (pack-years) was more than cancers, yielding an overall lung cancer incidence rate of 56.0 per 50% higher in WIHS.

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Table 3. Unadjusted Lung Cancer Incidence in WIHS by Age, Race, Table 4. Standardized Incidence Ratios for Lung Cancer Incidence in the Smoking History, and HIV Status Women’s Interagency HIV Study Compared With the Surveillance, Epidemiology and End Results Program No. of Lung IR/100,000 Parameter Cancers PYs PYs No. of Lung Observed Cancers Standardized Age (P Ͻ .0001) Person- Incidence Younger than 30 0 3,242 0 Parameter Years Observed Expected Ratio 95% CI 30-39 1 9,444 10.6 Overall 25,000 14 4.60 3.04 1.66 to 5.10 40-49 4 9,247 43.3 HIV positive 18,825 12 3.65 3.28 1.70 to 5.74 50 and older 9 3,067 293.4 HIV negative 6,175 2 0.95 2.11 0.25 to 7.61 Race (P ϭ .056) Pre-HAART era Non-Hispanic Black 13 14,047 92.5 (1994-1996) 4,059 3 0.48 6.22 1.28 to 18.19 Non-Hispanic White 0 3,804 0 HIV positive 3,221 2 0.40 4.97 0.60 to 17.95 Latina 1 6,408 15.6 HIV negative 838 1 0.08 12.57 0.32 to 70.05 Other groups 0 741 0 HAART era Second race comparison (P ϭ .007) (1997-2006) 20,941 11 4.12 2.67 1.33 to 4.78 Non-Hispanic Black 13 14,047 92.5 HIV positive 15,604 10 3.25 3.08 1.47 to 5.66 All others 1 10,953 9.1 HIV negative 5,337 1 0.87 1.15 0.03 to 6.40 Cigarette smoking history Abbreviation: HAART, highly active antiretroviral therapy. Overall (P ϭ .003) Never 0 7,419 0 Former smoker 1 3,889 25.7 Current smoker 13 13,576 95.8 HIV negative (P ϭ .50) significance (Table 3). When stratifying by pack-years, we also found a Never 0 1,770 0 significant dose-response relationship with lung cancer incidence Former smoker 0 749 0 rates. Among HIV-uninfected women, lung cancers were only ob- Current smoker 2 3,626 55.2 served among women with at least 20 pack-years while the majority of HIV positive (P ϭ .007) Never 0 5,648 0 lung cancers in HIV-infected women occurred in those with history of Former smoker 1 3,140 31.8 10 to 20 pack-years of smoking. Current smoker 11 9,951 110.5 The 14 WIHS participants with lung cancer had a median cumu- Lifetime cigarette consumption lative smoking exposure of 18.9 pack-years, significantly higher than among women who reported being current cigarette the 9.7 pack-years among the women who smoked but did not de- smokers at enrollment, velop lung cancer (P ϭ .002). Pack-years of smoking did not differ by ء pack-years HIV status among lung cancer cases. There was no difference between ϭ Overall (P .002) age of onset of smoking for either HIV-infected (17.3 years) or HIV- Ͻ 10 0 6,445 0 10-20 7 3,817 183.4 uninfected current smokers (17.9 years), or for WIHS women with or Ͼ 20 6 3,315 181.0 without incident lung cancer. HIV negative (P ϭ .05) History of previous injection drug use (IDU) was present in both Ͻ 10 0 1,841 0 HIV-uninfected women and three of the 12 HIV-infected women 10-20 0 977 0 with lung cancer, while three additional HIV infected women re- Ͼ 20 2 807 247.8 ported current IDU. The incidence rate for lung cancer among those HIV positive (P ϭ .005) with current or prior history of IDU was 96.5/100,000 PYs, versus Ͻ 10 0 4,604 0 10-20 7 2,840 246.5 36.1/100,000 PYs in those without IDU (incidence rate ratio, 2.67; Ͼ 20 4 2,508 159.5 95% CI, 0.81 to 9.35), and adjustment for age and pack-years did not statistically alter this result. Abbreviations: WIHS, Women’s Interagency HIV Study; PYs, person-years; IR, incidence rate. One incident lung cancer occurred in an HIV positive woman who had Clinical Data Among the WIHS Women Withء stopped smoking prior to being enrolled in the WIHS, and she was excluded from this analysis that was restricted to women who were current smokers Lung Cancer at enrollment. The median age at lung cancer diagnosis in the 12 HIV infected women was 53.3 years (range, 36 to 64). All were non-Hispanic black, with a median of 15.5 pack-years smoking exposure (range, 10.0 to 96.3 pack-years). Median CD4 cells and plasma HIV-1 RNA levels at Risk Factors for Lung Cancer the WIHS visit before lung cancer diagnosis were 376/mm3 (range, 0 Among the characteristics that differed between the age- and to 893/mm3) and 3,400 copies/mL (range, 550 to 310,000 copies/mL). race-adjusted WIHS participants and US female population from Prior AIDS defining conditions were present in eight (67%). At the NHANES III, only smoking history and pack-years of smoking were visit before diagnosis of lung cancer, two patients were taking HAART, significantly associated with lung cancer in WIHS. No lung cancers three were on combination ART, and seven were taking no antiret- occurred among WIHS women who had never smoked, and a dose- roviral therapy. Pathologic types of lung cancer included adenocar- response relationship between pack-years and lung cancer incidence cinoma, poorly differentiated nonsmall cell, and squamous cell rate was clearly observed among both HIV-infected and uninfected carcinoma, all equally distributed. Advanced cancer (stage IIIB or IV) current smokers, though the latter group did not reach statistical was diagnosed in seven of 14 (50%), while stage I or II was present in www.jco.org © 2010 by American Society of Clinical Oncology 1517 Information downloaded from jco.ascopubs.org and provided by UCSF KALAMANOVITZ LIB CKM on March 29, 2010 from 128.218.97.140. Copyright © 2010 by the American Society of Clinical Oncology. All rights reserved. Levine et al two; staging information was unavailable in five. Median survival cancer may be more likely to succumb to the malignancy than their from diagnosis of lung cancer was 14.1 months (range, 3.0 to 62 HIV-uninfected counterparts, still, this study, and that from ALIVE months) with one women remaining alive, at 28 months. actually address different issues. It is also possible that lifestyle factors The two HIV-uninfected WIHS women with incident lung can- related to IDU may have increased the risk of pre-existing pulmonary cer were 46 and 56 years of age, with 25.0 and 30.9 PYs smoking disease, possibly predisposing to lung cancer. In this regard, the inci- history. One was non-Hispanic black while the other was Latina. dence rate for lung cancer among former or current IDUs in the WIHS Survival was 1.6 and 8 months from diagnosis. was more than twice that of participants without history of IDU, although this difference was not statistically significant. Similar to this study, locally extensive or metastatic lung cancer DISCUSSION has been reported at diagnosis in both pre-HAART12 and HAART eras,25 despite improvements in immunity associated with HAART. We found a substantially increased risk of lung cancer among Delays in initial diagnosis of lung cancer among HIV-infected persons both HIV-infected and at-risk uninfected women compared with may explain the disseminated nature of disease.25 Alternatively, fac- population-based expectations. A possible explanation is the high rate tors related to HIV itself, or to the abnormal immunologic milieu of cigarette smoking in WIHS women, reported by approximately associated with HIV may be operative. two thirds, including all women diagnosed with incident lung Several studies have reported that adenocarcinomas occur more cancer. Several prior reports have also documented a strong history commonly than expected in HIV-infected individuals,4,12,26-29 while of tobacco exposure in their HIV-infected patients who developed 6,13,30 6,8,9,11-13 others have not. Our data demonstrate an equivalent distribu- lung cancer. 25 As previously noted,23 we found that WIHS women were almost tion of pathologic types. Brock and colleagues noted a change in the twice as likely to smoke as age- and race-matched women, studied as pathologic spectrum of lung cancer among 92 HIV-infected patients, part of NHANES III.17-19 While multiple other behavioral and demo- when comparing pre-HAART and HAART eras, with 48% of all graphic differences between WIHS and NHANES III women were cancers diagnosed as adenocarcinoma in both time periods, while found, only smoking was significantly associated with incident lung squamous cell carcinoma increased from 10% to 21%. cancer. Thus, when compared to population-based controls, any in- The WIHS study followed a large cohort prospectively for up to crease in the incidence of lung cancer among HIV-infected women 12 years, and all cancer diagnoses were confirmed. However, details of could be explained by differences in history of tobacco exposure. treatment or response were not available. Furthermore, despite our When comparing lung cancer incidence rates between HIV- large database of more than 3,500 women and 25,000 PYs of follow- infected women in the WIHS and the internal group of HIV- up, the small number of incident lung cancers limited the statistical uninfected women, no differences were apparent. Of importance, all power. Nonetheless, a prospective comparison between HIV-infected women with lung cancer had strong histories of tobacco exposure, women, and HIV-uninfected women with similar lifestyles was possi- thus serving to explain the equivalent increase in lung cancer among ble, augmenting the study design. Further, the careful documentation both HIV-infected and uninfected women, when compared with of tobacco exposure, and the ability to compare our data with behav- population-based expectations. Of note, both HIV-infected and ioral data from age- and race-matched US women (NHANES III) -uninfected WIHS participants were statistically more likely to smoke allowed evaluation of the potential role of cigarette smoking as a cause than the NHANES III/US female population. Nonetheless, HIV- for the increase in lung cancer among WIHS women. uninfected women with lung cancer had smoked for 25 and 30 PYs, We have demonstrated that WIHS participants, whether HIV- while those infected with HIV had 10 to 20 PY smoking history. It is infected or at-risk but uninfected, have a significantly increased risk of possible that HIV may accelerate the development of lung cancer. lung cancer when compared with the rates expected in the general Several studies have shown a significant increase in lung cancer population, while no difference in lung cancer rates among HIV- among HIV-infected patients after the introduction of HAART.6,8,9 infected versus uninfected women was seen. Of importance, both The remarkable prolongation in survival due to HAART may have HIV-infected and -uninfected WIHS participants were significantly allowed these individuals to live long enough to develop lung cancer. more likely to have smoked than the NHANES III/US female popula- However, we found no difference in the incidence of lung cancer tion. All WIHS women with lung cancer had history of smoking, and among HIV-infected women in the pre-HAART versus HAART eras. A recent study of 54,780 HIV-infected patients also failed to demon- the risk of cancer increased with increasing smoking exposure. The strate an increase in lung cancer incidence in the HAART era,24 sug- development of lung cancer among HIV-infected women appears gesting that the excess risk of lung cancer is not related to use of very strongly correlated with tobacco exposure. As such, the develop- antiretroviral therapy per se, but rather to other factors, such as pack- ment and implementation of smoking cessation programs aimed at years of smoking, in an aging population. HIV-infected persons will be of increasing importance. The precise A significant increase in the risk of death due to lung cancer was role of HIV infection, per se, in terms of the development or progres- reported among HIV-infected IDUs,8 studied as part of the AIDS Link sion of lung cancer awaits further clarification. to the Intravenous Experience Study (ALIVE); 26 of 27 patients had history of smoking. After adjusting for smoking status and other variables, HIV infection was found to be independently associated AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS with an increased risk of lung cancer death. Our data indicate that OF INTEREST HIV, per se, was not a risk factor for initial development of lung cancer. While it is plausible that HIV-infected patients with lung The author(s) indicated no potential conflicts of interest.

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Collection and assembly of data: Alexandra M. Levine, Nancy A. Hessol, AUTHOR CONTRIBUTIONS Mardge H. Cohen, Howard Minkoff Data analysis and interpretation: Alexandra M. Levine, Eric C. Seaberg, Conception and design: Alexandra M. Levine, Eric C. Seaberg, Nancy A. Nancy A. Hessol, Susan Preston-Martin, Sylvia Silver, Mardge H. Cohen, Hessol, Susan Preston-Martin, Sylvia Silver, Kathryn Anastos, Kathryn Anastos, D. Heather Watts Jan Orenstein Manuscript writing: Alexandra M. Levine, Eric C. Seaberg, Nancy A. Financial support: Alexandra M. Levine, Mardge H. Cohen, Kathryn Hessol, Susan Preston-Martin, Sylvia Silver, Mardge H. Cohen, Anastos, Howard Minkoff, Geraldina Dominguez, D. Heather Watts Kathryn Anastos, Howard Minkoff, Geraldina Dominguez, Administrative support: Alexandra M. Levine D. Heather Watts Provision of study materials or patients: Alexandra M. Levine, Nancy A. Final approval of manuscript: Alexandra M. Levine, Eric C. Seaberg, Hessol, Susan Preston-Martin, Mardge H. Cohen, Kathryn Anastos, Nancy A. Hessol, Sylvia Silver, Mardge H. Cohen, Kathryn Anastos, Howard Minkoff Howard Minkoff, Jan Orenstein, D. Heather Watts

12. Tirelli U, Spina M, Sandri S, et al: Lung carci- National Technical Information Service (NTIS), REFERENCES noma in 36 patients with human immunodeficiency Springfield, VA virus infection: The Italian Cooperative Group on 20. Inskip H: Standardization methods, in Gail 1. Palella FJ Jr, Delaney KM, Moorman AC, et al: AIDS and Tumors. Cancer 88:563-569, 2000 MH, Benichou J (eds): Encyclopedia of Epidemio- Declining morbidity and mortality among patients 13. Spano J-P, Massiani M-A, Bentata M, et al: logic Methods. New York, NY, Wiley, 2000, pp with advanced human immunodeficiency virus in- Lung cancer in patients with HIV infection and 871-884 fection. N Engl J Med 338:853-860, 1998 review of the literature. Med Oncol 21:109-115, 21. Newman SC: Biostatistical Methods in Epide- 2. International Collaboration on HIV and Cancer: 2004 miology. New York, NY, Wiley, 2001 Highly active antiretroviral therapy and incidence of 14. Barkan SE, Melnick S, Preston-Martin S, et al: 22. Longnecker JC, Coresh J, Powe NR, et al: cancer in human immunodeficiency virus infected The Women’s Interagency HIV Study. Epidemiology Traditional cardiovascular disease risk factors in adults. J Natl Cancer Inst 92:1823-1830, 2000 9:117-125, 1998 dialysis patients compared with the general pop- 3. Hessol NA, Seaberg EC, Preston-Martin S, et 15. Bacon MC, von WylV, Alden C, et al: The ulation the CHOICE study. J Am Soc Nephrol 13: al: Cancer risk among participants in the Women’s Women’s Interagency HIV Study: An observational 1918-1927, 2002 Interagency HIV Study (WIHS). J Acquir Immune cohort brings clinical sciences to the bench. Clin 23. Saves M, Chene G, Ducimetiere P, et al: Risk Defic Syndr 36:978-985, 2004 Diagn Lab Immunol 12:1013-1019, 2005 factors for coronary heart disease in patients treated 4. Engels EA, Brock MV, Chen J, et al: Elevated 16. Surveillance, Epidemiology, and End Results for human immunodeficiency virus infection com- incidence of lung cancer among HIV infected indi- (SEER) Program (www.seer.cancer.gov) Public-Use pared with the general population. Clin Infect Dis viduals. J Clin Oncol 24:1383-1388, 2006 Data (1973-2002), National Cancer Institute, DCCPS, 37:292-298, 2003 5. Mbulaiteye SM, Biggar RJ, Goedert JJ, et al: Surveillance Research Program, Cancer Statistics 24. Patel P, Hanson DL, Sullivan PS, et al: Inci- Immune deficiency and risk for malignancy among Branch, released April 2005, based on the Novem- dence of types of cancer among HIV-infected per- persons with AIDS. J Acquir Immune Defic Syndr ber 2004 submission sons compared with the general population in the 32:527-533, 2003 17. U.S. Department of Health and Human Ser- United States, 1992-2003. Ann Intern Med 148:728- 6. Bower M, Powles T, Nelson M, et al: HIV vices (DHHS): National Center for Health Statistics: 736, 2008 related lung cancer in the era of highly active anti- Third National Health and Nutrition Examination Sur- 25. Brock MV, Hooker CM, Engels EA, et al: retroviral therapy. AIDS 17:371-375, 2003 vey, 1988-1994, NHANES III Examination Data File Delayed diagnosis and elevated mortality in an urban 7. Frisch M, Biggar RK, Engels EA, et al: Asso- (CD-ROM). Public Use Data File Documentation ciation of cancer with AIDS related immunosuppres- Number 76200. Hyattsville, MD, Centers for Dis- population with HIV and lung cancer: Implications sion in adults. JAMA 285:1736-1745, 2001 ease Control and Prevention, 1996. Available from for patient care. J Acquir Immune Defic Syndr 8. Kirk GD, Merlo C, O’Driscoll P, et al: HIV National Technical Information Service (NTIS), 43:47-55, 2006 infection is associated with an increased risk for Springfield, VA 26. Bazot M, Cadranel J, Khalil A, et al: Computed lung cancer, independent of smoking. Clin Infect Dis 18. U.S. Department of Health and Human Ser- tomographic diagnosis of bronchogenic carcinoma in 45:103-110, 2007 vices (DHHS): National Center for Health Statistics: HIV infected patients. Lung Cancer 28:203-209, 2000 9. Herida M, Mary-Krause M, Kaplan R, et al: Third National Health and Nutrition Examination Sur- 27. Karp J, Profeta G, Marantz PR, et al: Lung Incidence of non-AIDS defining cancers before and vey, 1988-1994, NHANES III Youth Data File (CD- cancer in patients with acquired immunodeficiency during the highly active antiretroviral therapy era in a ROM). Public Use Data File Documentation Number syndrome. Chest 103:410-413, 1993 cohort of human immunodeficiency virus-infected 77550. Hyattsville, MD, Centers for Disease Control 28. Vyzula R, Remickj SC: Lung cancer in patients patients. J Clin Oncol 21:3447-3453, 2003 and Prevention, 1996 with HIV infection. Lung Cancer 15:325-339, 1996 10. Grulich AE, Li Y, McDonald A, et al: Rates of 19. U.S. Department of Health and Human Ser- 29. Alshafie MT, Donaldson B, Oluwole SF: Hu- non-AIDS defining cancers in people with HIV infec- vices (DHHS): National Center for Health Statistics: man immunodeficiency virus and lung cancer. Br J tion before and after AIDS diagnosis. AIDS 16:1155- Third National Health and Nutrition Examination Sur- Surg 84:1068-1071, 1997 1161, 2002 vey, 1988-1994, NHANES III Household Adult Data 30. Powles T, Thirwell C, Newsom Davis T, et al: 11. Phelps RM, Smith DK, Heilig CM, et al: Can- File (CD-ROM): Public Use Data File Documentation Does HIV adversely influence the outcome in ad- cer incidence in women with or at risk for HIV. Int J Number 77560. Hyattsville, MD, Centers for Dis- vanced non–small-cell lung cancer in the era of Cancer 94:753-757, 2001 ease Control and Prevention, 1996. Available from HAART? Br J Cancer 89:457-459, 2003

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