Patterns of Care and Outcomes of Vulvar Cancer Treatment in Women With or Without HIV Infection in Botswana

Abstract

Vulvar cancer is a rare gynecological malignancy. However, the incidence of human papilloma virus (HPV)-associated vulvar disease is increasing, particularly in low- and middle- income countries. Human immunodeficiency virus (HIV) infection is also associated with an increased risk of vulvar cancer. Patterns of care for vulvar cancer in low resource-limited settings with high rates of HPV and HIV co-infection have not been well described. Women with vulvar cancer who presented to an oncology clinic in Botswana from January 2015 through October 2019 were prospectively enrolled in this observational cohort study. Factors associated with survival including age, HIV status, stage, and treatment were evaluated. Analysis of 128 women with vulvar cancer demonstrated a median age of 42 years. At presentation 53.3% of patients were early stage (stage I/II) and 46.6% were late stage (stage III/IV). The majority of patients were living with well-controlled HIV infection (89%, n = 107) with a median CD4 count of 461 cell/ul (IQR 300.5-684.5) and high level of viral suppression (95% with viral copies & <400). Surgery was performed in 25 (20.8%) patients, 29 (24%) patients received chemotherapy, and 81 (67.5%) received radiation therapy. Adjusted analysis controlling for HIV, age, stage, surgery, chemotherapy and radiation demonstrated no differences in survival at 32 months by HIV status (HR, 0.426; 95% CI, 0.112-1.5976). Advanced stage (stage III and IV) (HR, 2.41; (95% CI, 1.03-5.68) and older age (HR, 1.05; (95% CI, 1.00-1.10) were associated with worse survival while receipt of surgery was associated with improved survival (HR 0.09, 95% CI 0.15-0.74). Women in Botswana with vulvar cancer have a high rate of HIV infection. They present at a young age and just under half of patients present at a late stage. While decreased survival was associated with older age and late stage disease, HIV status did not impact survival outcomes. Efforts to identify patients early with limited disease burden may be necessary to improve outcomes in the future.