Healthcare utilization and outcomes in HIV versus non-HIV patients with anal cancer: A nationwide analysis

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Background: Anal cancer (AC) is the most common HPV-associated cancer in men with HIV. Nearly one third of men with anal cancer have HIV with HPV accounting for 88% of cases. Studies have reported mixed outcomes in HIV-Anal Cancer (HIV-AC) compared to non-HIV-AC patients with most studies being small and retrospective. There were no clear explanations for the differences in the outcomes in both groups. We studied HIV-AC patients from a national database and compared the outcomes and healthcare utilization with non-HIV AC cohort. Methods: We identified all adult patients with AC, with and without HIV, between 2016-2018 from the Healthcare Cost Utilization Project (HCUP) National Inpatient Sample (NIS) database. The groups were compared for socio-demographic differences, inpatient mortality, length of stay (LOS) and total hospital charges (THC). Secondary outcomes studied were rate of acute kidney injury (AKI), tumor lysis syndrome (TLS), lower GI Bleed (LGIB), anemia, tumor lysis (TLS), sepsis, septic shock (SS), neutropenia and protein energy malnutrition (PEM). Statistics was performed using the t-test, univariate and multivariate logistic regression using Stata software. Results: A total of 1235 inpatient admissions with HIV-AC and 10,415 with non-HIV-AC were identified. HIV-AC patients were significantly younger (mean age 50.2 vs 63 years, p < 0.0001) with few over 65 years (8% vs 44.2%, p < 0.0001), more men (82.6% vs 30.8%, p < 0.001), more likely African Americans (AA) (47.8% VS 11.2%, p < 0.0001) and significantly more likely to be treated at a teaching hospital (90.7% vs 9.3%, p < 0.0001) compared to non-HIV-AC cohort. HIV-AC patients had significantly lower odds of inpatient mortality (aOR= 0.26, CI = 0.093 – 0.705, p = 0.008) but higher LOS (7.4 vs 6.5 days, p = 0.02) and higher THC ($74,131 vs $60,864, p = 0.005). Rates of sepsis were higher in HIV-AC (OR = 2.11, CI = 1.465 - 3.028, p < 0.0001) compared to non-HIV-AC, but odds of AKI, TLS, LGIB, SS, anemia, neutropenia and PEM were similar. Conclusions: HIV-AC patients are more likely to be younger, AA, men and have significantly lower inpatient mortality compared to non-HIV-AC, despite higher rates of sepsis. HIV-AC patients being younger and overwhelmingly (90%) treated at teaching hospitals may be contributing to the observed lower mortality. However, the HIV-AC cohort was also a high inpatient healthcare utilizer with significantly increased hospital charges amounting to over $16 million over 3 years. The reversal of sex incidence likely reflects the different exposure to HPV in HIV and non-HIV cohorts. Prospective studies are needed to further evaluate outcomes in HIV-AC patients and identify underlying contributors of higher utilization.

Cutaneous Metastasis of Prostate Adenocarcinoma: A Rare Presentation of a Common Disease

Prostate cancer is the most common cancer affecting men in the United States and the second greatest cause of cancer-related death. Metastases usually occur to bone followed by distant lymph nodes and then viscera. Cutaneous metastases are extremely rare. Their presence indicates advanced disease and a poor prognosis. As they are highly variable in appearance and may mimic a more benign process, biopsy is essential for identification. Serine proteases, particularly human tissue kallikreins, may play an important role in promoting metastasis and facilitate infiltration of the skin. Individual cancer genetics may predispose to more aggressive cancer and thus earlier and more distant metastases. In this article, we report our case of a 67-year-old man with a 4-year history of castrate-resistant prostate cancer with cutaneous metastases confirmed by histology. Despite multiple lines of systemic therapy, the patient suffered progressive disease with worsening performance status and was enrolled in hospice.