Incidence and Risk Factors of Keratinocyte Carcinomas in the HIV Atlanta Veterans Affairs Cohort Study Open Access

Yeung, Howa (Spring 2019)

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Keratinocyte carcinomas (KC) – also known as nonmelanoma skin cancers and including basal cell carcinomas and squamous cell carcinomas – represent the most common non-AIDS defining malignancies in the United States in persons living with HIV. There is limited research on KC epidemiology and treatment in persons living with HIV in the United States since KCs are not reportable to cancer registries. This study aimed to 1) estimate the positive predictive value of diagnostic codes in identifying incident cases of KC in VA administrative data, and 2) estimate the associations between incident KC and the immune status, HIV viremia, and duration of HIV diagnosis in persons diagnosed with HIV. Using data from the HIV Atlanta Veterans Affairs (VA) Cohort Study and the VA HIV Clinical Case Registry from 1982 to 2017, we demonstrated modest positive predictive values of ICD-9 and -10 diagnostic codes in ascertaining incident KC cases upon manual electronic medical record review. Among 3,353 veterans with HIV followed for a mean of 8.5 years (median 7.2 years), 227 cases of incident biopsy-confirmed KC cases were identified. 223 cases of KC cases occurred in 680 non-Hispanic White male veterans, with an incidence rate estimated at 29.0 cases per 1,000 person-years. In a multivariable negative binomial model, KC incidence in non-Hispanic White male veterans was associated with older age (incidence rate ratio [IRR] 6.19 for 65 or older versus 18-44, 95% confidence interval [CI]: 0.87-43.98; P = 0.009), active follow up status by the end of the study period (IRR 0.22 for inactive versus active follow up; P = 0.002), and nadir CD4 lymphocyte count between 50-149 cells/mm3 (IRR 5.40, 95% CI: 1.55-18.78) or 150-249 cells/mm3 (IRR 6.12, 95% CI 1.52-24.67; P = 0.002]. We demonstrated KC incidence rates greater than 4-fold higher in non-Hispanic White male veterans diagnosed with HIV as compared with previous studies in non-veterans. Early HIV diagnosis and sustained HIV treatment, reduction of ultraviolet radiation exposure, and improved secondary prevention of keratinocyte carcinomas will be required to reduce the high burden of keratinocyte carcinomas in non-Hispanic White male veterans.

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