Date Published: March 11, 2012
Publisher: Hindawi Publishing Corporation
Author(s): H. Francis, M. J. Bates, L. Kalilani.
Background. Human-Immunodeficiency-Virus- (HIV-) related Kaposi’s sarcoma (KS) has a high prevalence in Africa; however, there is minimal published data on treatment and outcomes in this population. Objective and Design. This was a prospective study of 50 patients, aiming to assess the impact of vincristine therapy on tumour response and survival and to assess palliative care outcomes in patients with HIV-related KS. Methods. 50 consecutive patients were recruited during 2008. Vincristine therapy and highly active antiretroviral therapy (HAART) were given. Tumour response, survival, and chemotherapy-related toxicities were documented. Palliative care outcomes were assessed using the African Palliative Care Association (APCA) Palliative Outcome Scale (POS). Results. The majority of patients were male, and the median age was 33 years. At baseline assessment, the median CD4 T-cell count was 263, and 50% patients had evidence of peripheral neuropathy. The overall response rate was 64% at 6 weeks, and median progression-free survival was 30 weeks. Treatment was generally well tolerated, with peripheral neuropathy the main dose-limiting toxicity. Conclusion. The combination of vincristine and HAART is feasible and effective in a low resource setting, although peripheral neuropathy is a dose-limiting factor. This patient group carries a high mortality and as such adequate access to palliative care is crucial.
Kaposi’s sarcoma (KS) is the most common human-immunodeficiency virus- (HIV-) related malignancy, and the most common malignancy in Malawi, explaining at 54% of cancer diagnoses in males, and 27% in females from 1994–1998 . Although widespread access to highly active antiretroviral therapy (HAART) has resulted in the reduction in prevalence of KS in the developed world [2, 3], there is minimal data regarding the impact of increased access to HAART in Sub-Saharan Africa. KS accounted for 5–10% of new registrations for HAART in Malawi in 2005 and was associated with a poorer outcome than for other patients on HAART . Since antiretroviral therapy became available to patients in Malawi from 2004, a fixed dose combination of nevirapine, stavudine, and lamivudine has been utilized as first line therapy for HIV.
This was a prospective study to assess the impact of vincristine therapy on tumour response and survival and to assess the feasibility of utilizing the APCA POS in patients with HIV-related KS. Chemotherapy related toxicities were documented.
Fifty patients being treated at the Tiyanjane Clinic were recruited from April 2008 to December 2008. All patients referred to the clinic that satisfied inclusion criteria were offered enrollment in the study and none declined. Informed consent was obtained from all patients at the time of enrollment, with thumbprints taken from those unable to write. Ethics approval was obtained from the College of Medicine Research Ethics Committee, College of Medicine, University of Malawi.
Baseline demographic data are recorded in Table 1. Most patients were male and aged between 28 and 41. Baseline median Karnofsky performance status (KPS)  was 70 (range 50–80), indicating that most patients were self-caring however somewhat limited in their ability to perform active work. 50% patients had a preexisting peripheral neuropathy, which was predominantly sensory and grade 1. Three patients had grade 2 neuropathy at baseline.
This study is one of the few looking at patient outcomes in HIV-associated KS, in the era of widespread antiretroviral therapy in the developing world. We found that the combination of HAART and vincristine therapy is associated with an impressive response rate, although there were no reports of complete response in our study. Liposomal doxorubicin is considered the standard of care in the developed world on the basis of two large randomized clinical trials [14, 15]; however, it is not only expensive, but can be associated with myelosuppression and gastrointestinal side effects which would be difficult to manage currently in our setting. Northfelt et al. reported 1 complete response and 60 partial responses out of 133 patients who received liposomal doxorubicin, for an overall response rate of 45.9% in their study . Median time to response was 39 days. The highly favourable response rate in our series is likely explained by a combination effect of vincristine, along with immune reconstitution associated with HAART.
HIV-related KS is a common problem in Malawi. The combination of vincristine and ART is a feasible option for the treatment of patients with moderate-advanced disease in a low resource setting and is associated with good response rates; however, peripheral neuropathy is a dose-limiting factor. Given the poor prognosis in this patient group, adequate palliative care remains of upmost importance. Optimal utilization of a palliative care assessment tool remains a challenge in our setting.