Colorectal cancer screening in patients with HIV

Momplaisir F, Brady K, Badolato G, Long JA. Colorectal cancer screening in patients with HIV. Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ.

BACKGROUND: As HIV positive patients live longer, they become susceptible to the development of chronic diseases and cancers. Since the introduction of antiretroviral therapy (ART) in 1995, the incidence of AIDS-defining malignancies (ADMs) has declined tremendously, whereas the frequency of non-ADMs has risen disproportionately compared to the general population. Currently, there are only two published studies describing the use of CRC screening in HIV positive patients. In both, CRC screening was found to be significantly lower in HIV positive patients compared to HIV negative patients. These studies; however, did not evaluate in detail factors associated with CRC screening. There is strong evidence that quality measures for HIV care are better met when, compared to non-expert general practitioners, patients are seen by infectious disease (ID) specialists or expert generalists. There are very few studies; however, looking at quality of primary care in these patients. Whether having a primary care physician (PCP) improves non-ADM screening in HIV positive patients is unknown. In this study we evaluate whether having a PCP is associated with higher CRC screening rates in a population of HIV positive patients. METHODS: Study sample. Patients included in this study were selected from a larger study called the Medical Monitoring Project (MMP) led by the Pennsylvania Department of Public Health and the Center for Disease Control (CDC). MMP participants were selected based on a three-stage sampling design described elsewhere and consists of HIV patients seeking care from a diverse pool of providers in Philadelphia. Patients were included in our study if they were MMP participants aged 50 or older. Data source. The data was collected by means of chart abstraction. We used the National Health And Nutrition Examination Survey (NHANES) template to determine if CRC screening had been performed. Outcomes. The primary outcome of interest was CRC screening defined as having a documented colonoscopy, sigmoidoscopy, barium enema, or Fecal Occult Blood Test after the age of 50. Independent variables. Patient and provider related factors were collected. Patient factors of interest included age, gender, race, lowest and most recent CD4 counts, lowest and most recent HIV viral loads, presence of co-morbid conditions, insurance status, and history of substance abuse or alcohol use. Provider factors of interest included provider specialty (ID or Generalist) and practice type (primary care practice, single versus multispecialty care practice).Statistical analysis. Standard descriptive statistics were used to describe all potential factors associated with ever having at least one CRC screening. All variables were dichotomized. Statistical differences for CRC screening (yes/no) based on clinical and demographic factors were assessed using the 2 test. A multivariable logistic regression model was created to assess the relative strength of the various associations. All variables associated with CRC screening at p RESULTS: Out of 123 chart abstractions performed, 115 had a complete clinical record from MMP to be fully analyzed. The majority of the population was male (71.3%), non-white (73.8%) and between the age of 50 and 59 (71.3%). Most patients had a recent CD4 count greater than 350 (69.6%), an undetectable viral load (75.6%), and no history of opportunistic infections (69.5%). 45.2% did not have a PCP. In accordance with other studies, we found that the rate of CRC screening among patients with HIV was low (49%) compared to the national rate of 62.9%. Having a documented PCP was the only variable strongly associated with CRC screening. Rates of screening were 66.7% among those with a PCP versus 28.5% among those without a PCP ( 2 p < 0.001). After adjusting for race, substance use, and alcohol use, the odds of getting CRC screening in those without a PCP was 0.2 (95% CI 0.09-0.51, p < 0.001). CONCLUSION: Patients with HIV who lack a PCP are significantly less likely to receive CRC screening. Given the improved survival among patients with HIV and the increased risk of dying of non-ADMs, it is imperative that all persons be managed with standard preventive practices regardless of HIV status. Having PCPs working in collaboration with ID specialists might help improve CRC screening rates in this population.