Cervical cancer and human immunodeficiency virus (HIV) infection/acquired immune deficiency syndrome (AIDS) both have a high incidence in South Africa. Cervical cancer treatment of HIV-positive women poses challenges. Treatment-related changes in quality of life (QOL) of such women are important to future treatment protocols.
To examine demographic data of HIV-negative and HIV-positive women at diagnosis of cervical cancer and describe their changes in QOL as a result of treatment.
All newly diagnosed patients with cervical cancer at Tygerberg Hospital were approached to participate in the study. The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) and the Cervix Cancer Module (QLQ-CX24) were used. General QOL was measured with the EORTC QLQ-C30 and cervical-specific QOL with the QLQ-CX24 questionnaire. The patients completed the questionnaire at diagnosis, on completion of treatment and at 3 months’ follow-up.
The study included a total of 221 women of whom 22% were HIV-positive; the latter were younger and of higher educational level than the rest. Mean monthly income and stage distribution was similar between the two groups. HIV-positive patients underwent radiation therapy more commonly than chemoradiation. HIV-positive women showed statistically significantly higher loss to follow-up during the study. HIV-positive women experienced no improvement in insomnia, appetite loss, nausea, vomiting, diarrhoea, social role or any of the sexual domains. In contrast, HIV-negative women experienced statistically significant improvement in all sexual domains other than sexual/vaginal functioning. The QOL improvement of HIV-negative women was statistically significantly greater than their HIV-positive counterparts in the majority of QOL domains. Global health improved in both groups, with HIV-negative women experiencing greater improvement. HIV-positive women experienced an initial decline of peripheral neuropathy (PN) symptoms post treatment with a return to pretreatment values at 3 months’ follow-up. The change in PN was statistically significant between the HIV-negative and HIV-positive women.
Demographic differences exist between the HIV-negative and HIV-positive groups. The differential outcome in the QOL of HIV-positive and HIV-negative women treated for cervical cancer might be related to persistence of AIDS-related symptoms on completion of cervical cancer treatment.
The quality of life (QOL) of human immunodeficiency virus (HIV)-positive women with cervical cancer is the result of both diseases and the impact of their respective treatments. Invasive cervical cancer is an acquired immune deficiency syndrome (AIDS)-defining condition (World Health Organization stage 4).
A limitation of the study by Simonds et al.
Patients referred to the Unit of Gynaecologic Oncology at Tygerberg Hospital who had newly diagnosed cervical cancer were approached to participate in the study. The unit is one of two tertiary referral units for public-sector patients in Western Cape Province. The province has a population of 5.8 million. Most (85%) of the population do not have private medical insurance and are dependent on public facilities provided by two tertiary hospitals (Tygerberg Hospital and Groote Schuur Hospital) for treatment of cervical cancer.
Patients completed the questionnaire in the language of their choice (isiXhosa, English or Afrikaans) after informed consent was obtained.
Descriptive statistics were used to characterise the study sample in terms of the contextual factors of socio-demographic and medical variables. Data presented as medians were analysed using Kruskal–Wallis tests. Post hoc analyses were done with Fisher's least significant difference (LSD) test. Chi-square tests were used for categorical data. A
The study included a total of 221 women (
Comparative demographic data of HIV-negative and HIV-positive women (poverty line as defined by the Western Cape Provincial Government).
Characteristics | HIV-negative |
HIV-positive |
|
---|---|---|---|
51.34 | 43.94 | ||
Mean education level (grade) | 7 | 8 | |
- | - | ||
Mixed race people | 88 | 12 | - |
Black people | 60 | 40 | - |
White people | 100 | 0 | - |
1450 | 1576 | NS | |
Below poverty line of R3500 (%) | 79 | 21 | NS |
- | - | ||
Single | 68 | 32 | - |
Married | 88 | 12 | - |
Widow | 86 | 14 | - |
Divorced | 94 | 6 | - |
- | - | NS | |
- | - | ||
Radiotherapy | 75 | 25 | - |
Chemoradiation therapy | 88 | 12 | - |
- | - | ||
Employed | 77 | 23 | - |
Pensioner | 93 | 7 | - |
Unemployed | 74 | 26 | - |
NS, not significant.
Unemployed women had a statistically significantly higher HIV-positivity rate (26%) than the employed women (23%). The loss to follow-up of HIV-positive women v. HIV-negative women during the post-treatment (56% v. 34%) and 3-month (38% v. 30%) follow-up visits was statistically significantly higher for the HIV-positive women (
Follow-up of HIV-negative versus HIV-positive women over the study period.
The domains of dyspnoea, financial difficulties, lymphoedema and menopausal symptoms remained unchanged during the study period. HIV-positive women experienced no improvement in insomnia, appetite loss, nausea and vomiting, diarrhoea, social role or any of the sexual domains over the study period. In contrast, HIV-negative women experienced statistically significant improvement in all sexual domains other than sexual/vaginal function. The improvement in QOL of HIV-negative women was statistically significantly more than their HIV-positive counterparts in all domains, with the exception of role function, insomnia, constipation, sexual worry and sexual activity (
Change in quality of life during study period.
Quality of life domain | HIV- |
HIV+ |
HIV- versus HIV+ |
---|---|---|---|
Physical function | |||
Role function | NS | ||
Dyspnoea | NS | NS | NS |
Pain | |||
Fatigue | |||
Insomnia | NS | NS | |
Appetite loss | NS | ||
Nausea and vomiting | NS | ||
Constipation | NS | ||
Diarrhoea | NS | NS | |
Cognitive function | |||
Emotional role | |||
Social role | NS | ||
Financial difficulties | NS | NS | NS |
Global health status | |||
Symptom experience | |||
Lymphoedema | NS | NS | NS |
Peripheral neuropathy | NS | ||
Menopausal symptoms | NS | NS | NS |
Body image | |||
Sexual worry | NS | NS | |
Sexual activity | NS | NS | |
Sexual/vaginal functioning | NS | NS | |
Sexual enjoyment | NS |
NS, not significant.
†, Improved; ‡, decreased; §, HIV+ >HIV-.
All other
The results of the study show significant demographic differences between HIV-positive and HIV-negative women with a diagnosis of cervical cancer. The former group is statistically younger, and has a higher educational level and higher unemployment rate than the latter. Black women have a statistically higher HIV-positivity rate than mixed race and white women. Single women had the highest HIV-positivity rate. Monthly income is similar in both groups. RT was more frequently used than CR in HIV-positive patients. The 22% HIV-positive rate in the current study is higher than previously reported rates. This change is the result of a general change in HIV-positive rates in the total population over time.
The majority of QOL domains in HIV-negative women improved with treatment with prolonged effect up to 3 months’ follow-up. Improvement of QOL domains in HIV-positive women was statistically less than in HIV-negative women. PN domain did not change in HIV-negative women. In HIV-positive women, initial improvement occurred in PN with relapse to pretreatment level at 3 months. Appetite loss in HIV-positive women initially improved after treatment and returned to pretreatment levels at 3 months’ follow-up. HIV-negative women showed an improvement in appetite loss up to 3 months’ follow-up. The QOL of HIV-negative women significantly improved in the majority of domains. HIV-positive women had fewer domains improved by treatment, and the magnitude of improvement was less than that amongst HIV-negative women. Temporary improvement of pain, fatigue and appetite loss after treatment in HIV-positive women reverted to pretreatment levels at 3 months’ follow-up. Pain and fatigue are AIDS-related conditions that are prevalent in AIDS patients, despite adequate treatment. Depression is associated with these symptoms, and the difference in emotional functioning in the current study underlines the element of depression in the HIV-positive women.
In the present study, higher rates of loss to follow-up occurred in HIV-positive women. A meta-analysis of sub-Saharan low- and middle-income countries’ antiretroviral treatment programmes reports on causes of loss to follow-up. Self-transferring care to other facilities (18.6%), unreported death (38.8%) and stopping treatment were identified as the major reasons for loss to follow-up.
Limitations of the present study include a short follow-up subsequent to completion of therapy. The short follow-up limits the conclusion to long-term effects of treatment. Prolonged follow-up may reveal an increased incidence of PN. The higher loss to follow-up rate of HIV-positive women during the study period precludes sub-analysis of smaller groups, for example treatment-related PN in those women undergoing CR.
In conclusion, the study documents the demographic difference in HIV-negative and HIV-positive women with cervical cancer with regard to a younger age in the latter group. The 5-year survival benefit of CR in comparison with RT in HIV-negative women with stage III to IVA is a statistically non-significant 3%.
The research forms part of a PhD thesis (GCDT) with promotor Prof. T.F. Kruger, Department of Obstetrics and Gynaecology, Stellenbosch University. The members of the Unit of Gynaecological Oncology, Tygerberg Hospital and the head of the unit, Prof. M.H. Botha, are acknowledged for their assistance.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
G.d.T. (Stellenbosch University) was the project leader and designed the study, wrote the protocol, collected the data and wrote the paper. M.K. (Stellenbosch University) performed the statistical analysis and contributed to discussions. Both authors read and approved the manuscript.