Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston MA, MA, 02114, USA.
AMPATH, Moi University, Eldoret, Kenya.
BMC Cancer. 2020 Jan 29;20(1):71. doi: 10.1186/s12885-019-6506-3.
Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa.
We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines.
Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/μl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%).
A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.
卡波氏肉瘤（KS）是撒哈拉以南非洲地区最常见的艾滋病毒相关恶性肿瘤之一。在全球范围内，抗逆转录病毒疗法（ART）的应用提高了 KS 的生存率。在资源丰富的地区，由于广泛应用化疗，生存率也得到了提高。然而，在资源有限的地区，如撒哈拉以南非洲，关于用于治疗艾滋病毒相关 KS 的化疗的使用情况的流行病学知识相对较少。
我们从 2009 年至 2012 年在肯尼亚的大型社区护理网络——AMPATH 诊所网络中确定了所有新诊断为 HIV 相关 KS 的患者。我们确定了诊断时疾病的严重程度、开始化疗的频率以及使用的化疗方案的分布。化疗的指征包括艾滋病临床试验组 T1 期和/或世界卫生组织 KS 治疗指南定义的“严重”疾病。
在 674 名诊断为 KS 的患者中，有 588 名患者的病历可用；61%为男性，中位年龄为 35 岁，KS 诊断时的中位 CD4 为 185 个细胞/μl。在诊断时，58%的患者至少有一个化疗指征，22%的患者有多个指征。对于有化疗指征的患者，以死亡为竞争事件，1 个月时化疗开始的累积发生率为 37%，1 年时为 56%。从诊断到化疗开始的中位时间为 25 天（IQR 1-50 天）。在多变量回归中，与只有一个化疗指征的患者相比，诊断时具有 >3 个化疗指征的患者快速开始化疗（诊断后 30 天内）的风险增加 2.30 倍（95%置信区间 1.46-3.60，p<0.001）。初始方案为博来霉素-长春新碱（78%）、阿霉素-博来霉素-长春新碱（11%）、依托泊苷（7%）和吉西他滨（4%）。
东非的 KS 患者中有相当一部分患者在晚期被诊断出患有该病。对于有化疗指征的患者，近一半的患者在一年内未接受化疗。在资源丰富的地区常用的脂质体蒽环类药物并不是一线药物。这些发现强调了东非癌症治疗所面临的挑战，并强调了需要进一步倡导在该地区获得更高质量的化疗。
