Key points for primary care physicians from a new study: HIV-positive women are vulnerable to invasive cervical cancer. This finding underscores the need for screening per guidelines and to follow-up on abnormal Pap smears.
Primary care physicians are on the frontlines of caring for HIV-infected women. Most primary clinicians offer Pap test screening to their patients in an effort to prevent cervical cancer.1 Hence, the first multicohort prospective study of the relationship between HIV infection and incident invasive cervical cancer in North America, which I focus on here, should be of particular interest to primary care providers.
HIV-infected women are more susceptible to new and persistent human papillomavirus infections. Consequently, HIV-positive women have a higher incidence of precancerous lesions, such as squamous intraepithelial lesions (SIL)-including high-grade SIL (HSIL).2,3 Despite the inclusion of invasive cervical cancer in the 1993 definition of AIDS, data on the risk of invasive cervical cancer in HIV-infected women were mostly obtained from cancer registries retrospectively.
In a study published in the Journal of Acquired Immune Deficiency Syndromes, Abraham and colleagues4 prospectively examined data from 18 cohorts of the North American AIDS Cohort Collaboration on Research and Design (representing more than 60 clinical sites) to define rates of incident invasive cervical cancer. Patients were followed from study entry in January 1996 through invasive cervical cancer, loss to follow-up, or up to December 2010.
The investigators examined a total of 13,690 HIV-infected and 12,021 non–HIV-infected women who contributed 66,249 and 70,815 person-years of observation, respectively. The study demonstrated a significantly higher risk of invasive cervical cancer in HIV-infected patients; there were 17 new cases of invasive cervical cancer in HIV-infected women as opposed to only 4 in non–HIV-infected women. This translates into an incidence rate of 26 and 6 per 100,000 person-years, respectively. The risk of invasive cervical cancer significantly increased, with decreasing CD4 counts indicative of more profound immunosuppression.
It is noteworthy that of the 17 HIV-infected women in whom incident cervical cancer developed, 6 had no documented screening, 5 had screening with low-grade or normal results, and 6 had high-grade results over the 5 years that preceded the diagnosis of cervical cancer. Most of the non–HIV-infected women in this study were followed in a primary care setting, and their low cancer rate may be an indicator of the effectiveness of regular cervical cancer screening for preventing invasive cervical cancer.
The take-home message
It is important for primary care physicians who care for HIV-infected patients to recognize a higher incidence of invasive cervical cancer in this vulnerable patient population, to conduct screening as per guidelines, and to follow up on results of abnormal Pap smears.
1. Yabroff KR, Saraiya M, Meissner HI, et al. Specialty differences in primary care physician reports of papanicolaou test screening practices: a national survey, 2006 to 2007.Ann Intern Med. 2009;151:602-611.
2. Strickler HD, Burk RD, Fazzari M, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus-positive women. J Natl Cancer Inst. 2005;97:577-586.
3. Sun XW, Kuhn L, Ellerbrock TV, et al. Human papillomavirus infection in women infected with the human immunodeficiency virus. N Engl J Med.1997;337:1343-1349.
4. Abraham AG, Strickler HD, Jing Y, et al. Invasive cervical cancer risk among HIV-infected women: a North American multi-cohort collaboration prospective study. J Acquir Immune Defic Syndr. 2013;62:405-413.