Clinical features
Table 1 summarizes the characteristics of these patients and their tumors. The median patient age was 48 (range, 33 to 69 years). Han population accounted for the majority of study participants (40/47; 85.1%), the minority populations including Dai, Wa, Yi, Bai ethnic groups accounts for 14.9% of these patients. Nearly all (95.7%, 45/47) participants had symptomatic cancer, with only two (4.3%, 2/47) cancers detected through routine screening. Most patients presented with vaginal bleeding (n=45). The time from first symptom to diagnosis varied from 0.5 to 24 months. More than two-thirds patients had parametrial involvement (stage IIB or greater) at the time of diagnosis. 26 (55.3%) participants had started ART before the cervical cancer diagnosis and had received ART for several years (media, 3.5 years; range, 1 to 10 years). In 21 of the 47 patients, HIV was detected at the time of cervical cancer diagnosis. Tumor diameters ranged from 0 to 7 cm, and most (42.6%, 20/47) were cauliflower-like in shape. Co-morbidity status was detected in 11 cases, including Hepatitis B virus (HBV) infection in 5 cases, hepatitis C virus (HCV) infection in 3 cases, tuberculosis (TB) in 3 cases and syphilis in 5 cases. The median CD4 cell count was 243 cells/μl (range, 9 to 806); 14 patients had a CD4 count above 350 cells/μl, 14 patients had a CD4 count below 200 cells/μl and 9 patients had missing data on CD4 count.
Survival outcomes
The median follow-up period for the 47 patient cohort was 33.5 months and the maximum follow-up duration was 54 months. It should be noted that 2 types of follow-up were employed in this study. One group of patients underwent physical examination and/or imaging examination for recurrent disease as scheduled. In contrast, the other group of patients did not come back for examination. These patients did not come back for examination and their survival were confirmed through telephone contact, the exact onset of disease recurrence is unknown. Overall, 21 (44.7%) patients survived with tumor free, 21 (44.7%) died, and 5 (10.6%) patients were withdrawn. All of the deaths were attributed to cancer. 3-year OS rate was 48% and median OS was 33 months. The 3-year OS rates for patients who received surgery with/without chemotherapy and radiatherapy, LCB group, SIB group, PEBRT group and no anti-tumor treatment were 100%, 51.9%, 66.7%, 0%, and 0%, respectively (p<0.001; Fig. 2).
Prognostic factors
To identify potential prognostic factors associated with survival in HIV-infected cervical cancer patients, various clinicopathologic variables were evaluated using univariate analysis. Cox regression analysis revealed that clinical stage, lymphadenopathy, hemoglobin were factors significantly associated with OS in addition to the treatment methods (Table 2). Kaplan-Meier analysis revealed the 3-year OS rates for patient with FIGO IA-IIA and IIB-IV were 83.1% and 33.4%, respectively (p=0.007, Breslow; p=0.005 Log Rank, Fig. 3A). The 3-year OS rates for patients with tumor < 4cm and ≥4cm were 72% and 37.2%, respectively (p=0.043, Breslow; p=0.051, Log Rank; Fig. 3B). The 3-year OS rates for patients with and without lymphadenopathy were 81.4% and 30%, respectively (p=0.002, Breslow; p=0.001, Log Rank, Fig. 3C). The 3-year OS rates for patients hemoglobin>118g/L and ≤118g/L were 70.7% and 24.1%, respectively (p=0.002, Breslow; p=0.002, Log Rank, Fig. 3D). Multivariate analysis revealed that the treatment method was an independent prognostic factor for these HIV- infected patients (p=0.036). Compared with none anti-tumor treatment, EBRT to the pelvis plus LCB (harzard ratio [HR], 0.140; 95% confidence interval [CI], 0.025 to 0.785; p=0.025) or SIB (HR, 0.102; 95% CI, 0.022 to 0.497; p=0.004) to the primary tumor is a significant favorable prognostic factor for OS. These analyses are summarized in Table 3.
Radiotherapy group analyzes
In the radiotherapy group, the median GTV dose, fractions and total treatment time in SIB group were less than those in LCB group, (62.6Gy vs. 66Gy, p=0.003, Mann-Whitney U-test, Fig. 4A; 28 fractions vs. 33 fractions, p<0.001, Mann-Whitney U-test, Fig. 4B; 38.5 days vs. 56 days, p<0.001, Mann-Whitney U-test, Fig. 4C). Of the 9 patients in LCB group, 2 received weekly platinum-based treatment and only 1 complete 4 weekly cycles of cisplatin during radiation therapy (Supplementary Table 2). In SIB group, 6 received concurrent chemotherapy and also only 1 complete 4 cycles cisplatin (Supplementary Table 3).Patients in SIB group had a higher 3-year overall survival than the LCB group (66.7% vs. 51.9%, p=0.994, Fig. 2). There were no casualties related to radiotherapy in both group. Complications related to radiotherapeutic procedures included femoral head necrosis, proctitis, myelosuppression, gastrointestinal tract reaction and hyperpigmentation. Femoral head necrosis occurred in 1 patient in LCB group. Proctitis occurred in 2 patients with 1 from LCB group who also experienced the femoral head necrosis (11.1%, 1/9) and the other from SIB group (6.7%, 1/15). Acute grade 3 leukopenia occurred in 1 from SIB group. Grade1-2 leukopenia, gastrointestinal tract reaction and hyperpigmentation were commen complications in both LCB group and SIB group. No grade 3-4 gastrointestinal tract reaction and hyperpigmentation were recorded in both groups.