Transplantation and oncogenic risk: the role of viruses

Transplantation and oncogenic risk: the role of viruses VIM 2014, Katoomba Associate Professor Angela Webster angela.webster@sydney.edu.au

What can transplantation help us understand about infection and cancer? Context: transplantation overview and the nature of immunosuppression Epidemiological data on cancer risk How epi relates to cancer causality Similarities to other immunosuppressed states Cessation of immunosuppression

Why is transplantation useful for understanding cancer? The context: Transplantation overview and the nature of immunosuppression

How many transplants are there?

How many transplants are there? Kidney transplants by year, absolute numbers

2012 activity

Transplant recipients require prolonged iatrogenic immunosuppression Combination of agents Calcineurin inhibitor/ anti metabolite/ steroid Tacrolimus/ MMF/ Prednisolone Common for all solid organ transplants Intensity may vary By organ Over time from transplant Withdrawn when organ fails (kidneys)

Rationale for multiple agents: protection from immunological injury with minimal toxicity

What do we know about cancer in the transplanted population? Epidemiological data on cancer risk

Much based on health data linkage Australia is in a fortunate position 1. Longstanding, population-based, high quality Death registries Cancer registries Disease registries, including organ transplant recipients and donors 2. Other administrative databases 3. Data linkage expertise and infrastructure Benefits now recognised, further national capacity building underway (PHRN)

Why health data linkage? Robust (cohort) data High sensitivity and specificity of linkages Internationally accepted Level of evidence second to RCTs Patient outcomes beyond those known to an institution or state/territory health dept Minimises bias Outcomes relative to matched general population Standardised classification systems Community acceptance linkage by independent 3 rd parties. privacy preserving protocols linkage process increasingly automated

Attributing timing of Cancer Diagnosis relative to transplant career not entirely straightforward CKD DIALYSIS TRANSPLANT Reality for some with kidney disease is less clear cut Potential for cycling between dialysis and transplantation Other solid organ transplant recipients have no other life sustaining options past transplantation

Cancer occurs in 80% of kidney transplanted patients by 30 years 100% 80% 60% Any Cancer Skin Non Skin Age-Matched Gen. Pop Australia and NZ 100% 80% 60% 40% 40% 20% 20% 0% 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 0% Years Post Transplant

1 5 10 15 30 50 80 120 200 Increased cancer risk has been comprehensively quantified in kidney transplant recipients female male 95% CI 95% CI Registry data from around the world show consistent increased risk of cancer at most sites 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 Age at cancer diagnosis Webster et al. Am J Transplantation 2007; 7: 2140 2151 Relative risk varies by Age Sex Cancer site

0 Incident cancer rates after kidney transplantation are similar to people 20+ years older in the gen pop rate per 100,000 1000 2000 3000 4000 5000 0 general female population transplant female population 95% confidence intervals general male population transplant male population 95% confidence intervals 10 20 30 40 50 60 70 Age at cancer diagnosis 10 20 30 40 50 60 70 Age at cancer diagnosis Webster et al. Am J Transplantation 2007; 7: 2140 2151

.1.2.3.4.5.1.2.3.4.5 0 0 proportion with at least 1 non-skin cancer proportion with at least 1 non-skin cancer 0 5 10 15 20 time in years.1.2.3.4.5.1.2.3.4.5 0 0 0 5 10 15 20 time in years Cumulative risk of cancer by age transplanted and sex transplanted female general population female <35 years transplanted male general population male transplanted female general population female 35-44 years transplanted male general population male 0 5 10 15 20 time in years transplanted female general population female 45-54 years transplanted male general population male 0 5 10 15 2 time in years transplanted female general population female 55 years and over transplanted male general population male

1000 10000 20000 30000 Impact of cancer: death rate comparisons female Mortality rates by sex male 20 25 30 35 40 45 50 55 60 65 70 20 25 30 35 40 45 50 55 60 65 70 Age transplant with cancer general population with cancer transplant no cancer general population no cancer

Impact of cancer on survival within transplant population ANZDATA 15, 183 recipients Mean follow up 9 years Cox model with time dependent covariates

Kidney transplant career: (Excl. NMSC, lymphoproliferative, urinary tract and multiple myeloma) Period n observed n expected SIR (95% CI) Chronic kidney disease 689 593.69 1.16 (1.08 1.25) Males 434 379.10 1.15 (1.04 1.26) Females 255 215.59 1.19 (1.05 1.34) During dialysis 870 642.52 1.35 (1.27 1.45) Males 529 419.10 1.26 (1.16 1.37) Females 341 223.42 1.53 (1.37 1.70) After transplantation 1,236 378.06 3.27 (3.09 3.46) Males 751 217.96 3.45 (3.20 3.70) Females 485 160.10 3.03 (2.77 3.31) Vajdic et al, JAMA 2006

Site Results: specific cancers Lip Tongue Mouth Salivary gland Esophagus Stomach Small intestine Colon Rectum Anus Liver Gallbladder Pancreas Larynx Lung Melanoma Mesothelioma Kaposi sarcoma Connective tissue Breast Vulva Cervix uteri Corpus uteri Ovary Penis Prostate Testis Eye Brain Thyroid Hodgkin disease Non-Hodgkin lymphoma Leukemia Unspecified All cancers Prior to RRT During dialysis After transplantation.01.1 1 10 100 1000.01.1 1 10 100 1000.01.1 1 10 100 1000 SIR

What can transplantation tell us about infection and cancer? The context: Transplantation overview and the nature of immunosuppression Epidemiological data on cancer risk How epi relates cancer causality Similarities to other immunosuppressed states Cessation of immunosuppression

IARC causality review (up to 2008) Viral agent IARC: Evidence of causality Sufficient Limited Inconclusive Hepatitis B Hepatitis C HTLV-1 HHV8 Liver Liver Adult T-cell lymphoma Kaposi sarcoma Primary effusion lymphoma Epstein-Barr Nasopharynx Salivary gland Hodgkin disease Stomach Non-Hodgkin lymphoma* Lung Human papilloma virus Cervix Anus Vulva Vagina Penis Tongue Tonsil Mouth Oropharynx Nonmelanoma skin Periungal skin Larynx Eye Nasal cavity Colon Lung Breast Ovary Prostate Bladder www.iarc.fr

IARC review Agency of WHO February 2009 36 scientists, 16 countries Reassess evidence of carcinogenicity Epidemiological and molecular mechanistic evidence Weight of evidence for specific cancers Majority vote Evolving Preliminary report Bouvard et al. Lancet Oncology 2009;10:321-322 100 th Monograph

IARC classification system Scientific judgement Group 1 Group 2A Group 2B Definition The agent (mixture) is carcinogenic to humans. This category is used when there is sufficient evidence of carcinogenicity in humans. The agent (mixture) is probably carcinogenic to humans. This category is used when there is limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals. The agent (mixture) is possibly carcinogenic to humans. This category is used for agents, mixtures and exposure circumstances for which there is limited evidence of carcinogenicity in humans and less than sufficient evidence of carcinogenicity in experimental animals. Strong and weak carcinogens... There is no perfect way to classify a continuum of carcinogenic potential. Schiffman et al 2009

Cancer after organ transplantation Meta-analysis Cancer risk for all solid organ transplants 97% kidney transplants Grulich et al, Lancet 2007 n= 31,977 Cancer site/type Kaposi s sarcoma Non-Hodgkin s lymphoma Hodgkin disease Liver Stomach Vulva and vagina Penis Anus Oral cavity and pharynx Cervix uteri Lip Non-melanoma skin Eye Oesophagus Larynx Kidney Thyroid Multiple myeloma Bladder Leukemia Melanoma Trachea, bronchus, and lung Colon and rectum Testis Ovary Breast Prostate Brain HHV8 EBV HBV/HCV H. pylori HPV Possible HPV.1 1 10 100 1000 SIR

Site Broad-ranging role of viruses Lip Tongue Mouth Salivary gland Esophagus Stomach Small intestine Colon Rectum Anus Liver Gallbladder Pancreas Larynx Lung Melanoma Mesothelioma Kaposi sarcoma Connective tissue Breast Vulva Cervix uteri Corpus uteri Ovary Penis Prostate Testis Eye Brain Thyroid Hodgkin disease Non-Hodgkin lymphoma Leukemia Unspecified All cancers Prior to RRT During dialysis After transplantation.01.1 1 10 100 1000.01.1 1 10 100 1000.01.1 1 10 100 1000 SIR Sufficient evidence Limited evidence Inconclusive evidence

What can transplantation tell us about infection and cancer? The context: Transplantation overview and the nature of immunosuppression Epidemiological data on cancer risk How epi relates cancer causality Similarities to other immunosuppressed states? HIV/ AIDS Cessation of immunosuppression

Meta analysis: Incidence of cancers in people with HIV/AIDS and transplant recipients Population-based cancer ascertainment only 7 HIV studies o n>444,000 5 solid organ transplant studies o n~32,000 o 95% kidney Compare patterns of site-specific cancer incidence Grulich et al. Lancet 2007;370:59-67

Grulich et al, Lancet 2007 Infection-related cancers Cohort Meta-analysis SIR (95% CI) Number Observed number of studies of cases Heterogeneity p-value EBV related cancers Hodgkin lymphoma HIV / AIDS Transplant 11.03 (8.43-14.44) 3.89 (2.42-6.26) 7 4 802 21 0.00 0.65 Non-Hodgkin lymphoma HIV / AIDS* Transplant 76.67 (39.37-149.29) 8.07 (6.40-10.17) 6 4 5295 333 0.00 0.02 HHV-8 related cancer Kaposi sarcoma HIV / AIDS* Transplant 3640 (3326-3976) 208.0 (113.7-349.0) 1 1 494 14 - - HBV/HCV related cancer Liver HIV / AIDS 5.22 (3.32-8.20) 7 133 0.01 Transplant 2.13 (1.16-3.91) 3 19 0.25 Helicobacter pylori related cancer Stomach HIV / AIDS 1.90 (1.53-2.36) 7 89 0.49 Transplant 2.04 (1.49-2.79) 3 44 0.85 1 10 100 1000 SIR Figure 2: Standardised incidence ratios for cancers related to infection with Epstein-Barr virus, human herpesvirus 8, hepatitis B and C virus, and Helicobacter pylori in people with HIV/AIDS and in transplant recipients EBV=Epstein-Barr virus. HBV=hepatitis B virus. HCV=hepatitis C virus. HHV8=human herpesvirus8. *For AIDS-defining cancers, data from cohorts defined by an AIDS diagnosis included only those individuals who did not have that type of cancer at the time of AIDS.

HPV-related cancers Cohort Meta-analysis SIR (95% CI) Number Observed number of studies of cases Heterogeneity p-value HPV related cancers Cervix uteri HIV / AIDS* Transplant 5.82 (2.98 11.3) 2.13 (1.37 3.30) 6 3 104 22 0.00 0.67 Vulva and vagina HIV / AIDS Transplant 6.45 (4.07 10.2) 22.76 (15.79 32.70) 2 2 21 33 0.55 0.85 Penis HIV / AIDS Transplant 4.42 (2.77 7.07) 15.79 (5.79 34.37) 3 1 21 6 0.52 - Anus HIV / AIDS Transplant 28.75 (21.60 38.27) 4.85 (1.36 17.29) 6 2 303 18 0.03 0.04 Oral cavity and Pharynx HIV / AIDS Transplant 2.32 (1.65 3.25) 3.23 (2.40 4.35) 4 3 238 49 0.07 0.37 Possibly HPV related cancers Non-melanoma HIV / AIDS Skin Transplant 4.11 (1.08 16.62) 28.62 (9.39 87.20) 4 3 121 448 0.00 0.00 Lip HIV / AIDS Transplant 2.80 (1.91 4.11) 30.00 (16.27 55.30) 2 5 30 506 0.45 0.00 Oesophagus HIV / AIDS Transplant 1.62 (1.20 2.19) 3.05 (1.87 4.98) 4 3 48 28 0.53 0.28 Larynx HIV / AIDS Transplant 2.72 (2.29 3.22) 1.99 (1.23 3.23) 5 3 142 20 0.55 0.88 Eye HIV / AIDS Transplant 1.98 (1.03 3.81) 6.94 (3.49 13.81) 2 2 11 10 0.92 0.35.1 1 10 100 1000 SIR Figure 3: Standardised incidence ratios for cancers related to, or possibly related to, human papillomavirus infection, in people with HIV/AIDS and in transplant recipients HPV=human papillomavirus. *For the AIDS-defining cancer (cervical cancer), data from cohorts defined by an AIDS diagnosis included only those individuals who did not have cervical cancer at the time of AIDS. Excluding lip and nasopharynx. Any measure of non-melanoma skin.

Common epithelial cancers Cohort Meta-analysis SIR (95% CI) Number Observed number of studies of cases Heterogeneity p-value Breast HIV / AIDS Transplant 1.03 (0.89 1.20) 1.15 (0.98 1.36) 6 5 194 156 0.60 0.66 Prostate HIV / AIDS Transplant 0.70 (0.55 0.89) 0.97 (0.78 1.19) 6 3 202 98 0.22 0.82 Colon and rectum HIV / AIDS Transplant 0.92 (0.78 1.08) 1.69 (1.34 2.13) 5 3 224 185 0.34 0.11 Ovary HIV / AIDS Transplant 1.63 (0.95 2.80) 1.55 (0.99 2.43) 5 3 30 23 0.34 0.61 Trachea, bronchus, and lung HIV / AIDS Transplant 2.72 (1.91 3.87) 2.18 (1.85 2.57) 7 3 1016 234 0.00 0.25.1 1 10 100 1000 SIR Figure 4: Standardised incidence ratios for common epithelial cancers in people with HIV/AIDS and in transplant recipients Grulich et al, Lancet 2007

Other cancers, no known infectious cause Cohort Meta-analysis SIR (95% CI) Number Observed number of studies of cases Heterogeneity p-value Increased in both Kidney HIV / AIDS Transplant 1.50 (1.23 1.83) 6.78 (5.69 8.08) 6 5 93 197 0.79 0.27 Multiple myeloma HIV / AIDS Transplant 2.71 (2.13 3.44) 3.12 (2.13 4.57) 6 3 76 31 0.78 0.67 Leukemia HIV / AIDS Transplant 3.20 (2.51 4.09) 2.38 (1.77 3.79) 7 4 235 51 0.19 1.00 Melanoma HIV / AIDS Transplant 1.24 (1.04 1.48) 2.34 (1.98 2.77) 6 4 200 148 0.37 0.41 Increased in Transplant only Bladder HIV / AIDS Transplant 0.75 (0.43 1.32) 2.46 (1.82 3.34) 5 4 52 91 0.20 0.17 Thyroid HIV / AIDS Transplant 0.84 (0.51 1.40) 5.91 (4.41 7.90) 5 5 43 72 0.31 0.30 Increased in HIV/AIDS only Brain HIV / AIDS Transplant 2.18 (1.29 3.68) 1.02 (0.64 1.63) 7 4 192 22 0.00 0.68 Testis HIV / AIDS Transplant 1.35 (1.01 1.79) 1.61 (0.69 3.79) 7 2 216 7 0.16 0.49.1 1 10 100 1000 SIR Figure 5: Standardised incidence ratios for other cancers occurring at increased rates in one or both population Grulich et al, Lancet 2007

Meta-analysis conclusions Despite marked differences in cancer risk factors, the incidence pattern was very similar for HIV and patient groups A wide range of cancers is associated with immunosuppression Most, but not all, of these cancers are infection related and HPV plays a prominent role

Oncogenic virus: KSHV / HHV8 Agent Sufficient evidence of carcinogenesis in humans (Group 1) Limited evidence of carcinogenesis in humans (Group 2A) Established mechanistic events Kaposi sarcoma herpes virus or Human herpes virus-8 Kaposi sarcoma (100%) Primary effusion lymphoma (~97%) Multicentric Castleman s disease (50%) Cell proliferation Inhibition of apoptosis Genomic instability Cell migration No newly identified carcinogenic links Bouvard et al. Lancet 2009;10:321-322

Kaposi Sarcoma risk in HIV or transplantation Prior to RRT During dialysis After transplantation Lip Australian Tongue HIV/AIDS registries (n=20,232) linked to Mouth Salivary cancer gland registry Esophagus Stomach Small intestine Colon Rectum Kaposi sarcoma 100000 Anus Liver Gallbladder 10000 Pancreas Larynx Lung 1000Melanoma Prior to RRT During dialysis After transplantation Mesothelioma Lip Kaposi sarcoma Tongue Connective 100 Mouth tissue Salivary Breast gland Esophagus Vulva 10 Cervix Stomach uteri Small Corpus intestine uteri 1 Ovary Colon Rectum Penis Prostate Anus Pre-HAART Early-HAART Late-HAART Testis Liver Period Gallbladder Eye Pancreas Brain Thyroid Larynx Hodgkin disease Lung Non-Hodgkin lymphoma Melanoma Mesothelioma Leukemia Prior to RRT During dialysis After transplantation Kaposi Unspecified sarcoma Lip Connective All cancers Tongue tissue van Leeuwen Breast Mouth et al. AIDS in press 2009 Vulva gland.01.1 1 10 100 1000.01 Cervix Esophagus SIR uteri.1 1 10 100 1000.01.1 1 10 100 1000 Corpus Stomach uteri Small intestine Ovary Clifford et al. JNCI 2005;97:425-32

Oncogenic virus: EBV Agent Sufficient evidence (Group 1) Limited evidence (Group 2A) Established mechanistic events Epstein-Barr virus Nasopharyngeal carcinoma (98%) Gastric carcinoma (5-10%) Cell proliferation Burkitt s lymphoma (82%) Immune-suppression related non-hodgkin lymphoma (PTLD) (?%) Lymphoepithelioma-like carcinoma (?%) Inhibition of apoptosis Genomic instability Extranodal NK/T-cell lymphoma (nasal type)* (87%) Cell migration Hodgkin lymphoma (46%) Newly identified carcinogenic link known as angiocentric T-cell lymphoma Bouvard et al. Lancet 2009;10:321-322 *Previously

SIR (95% CI) SIR (95% CI) Lymphoma risk in HIV Key: %EBV +ve tumors in people with HIV. Schulz TF IJC 2009 1000 NHL 100 Hodgkin lymphoma 80-100% EBV 100 10 10 1 1.1.1.01 Pre-HAART Early-HAART Late-HAART Period.01 Pre-HAART Early-HAART Late-HAART Period 1000 Diffuse large B-cell lymphoma ~100% EBV 1000 Burkitt lymphoma 30-60% EBV 100 100 10 10 1 1.1.1.01 Pre-HAART Early-HAART Late-HAART Period.01 Pre-HAART Early-HAART Late-HAART Period

NHL (PTLD: post transplant lymphoproliferative disease) risk in kidney transplant recipients Data linkage, ANZDATA registry (n=8,164) and cancer registry Incidence relative to general population (SIR) 1000 NHL 100 immunosuppression immunosuppression 10 1.1.01 D1 T1 D2+ T2+ Period van Leeuwen et al. Blood 2009;114:630-7

NHL risk in kidney transplant recipients Early Late

*Adj. for age, sex, EBV status, duration transplantation, receipt of immunosuppressive agents and antibodies; P- values reported for test of homogeneity in nominal covariates Multivariate Results: Early NHL (n=27) n Adjusted IRR (95% CI)* P-value EBV IgG status at transplantation Positive/unknown Negative 17 10 1.00 4.66 (2.12-10.36) <0.001 Receipt of antiproliferative No Yes 6 21 1.00 0.50 (0.17-1.23) 0.120 Receipt of calcineurin inhibitor No Yes 2 25 1.00 1.36 (0.31-5.96) 0.682 Receipt of T cell depleting antibody No Yes 17 10 1.00 2.39 (1.08-5.30) 0.031

Multivariate Results: Late NHL (n=79) n Adjusted IRR (95% CI)* P-value Age (years) 79 1.02 (1.01-1.04) 0.005 EBV IgG status at transplantation Positive/unknown Negative 74 5 1.00 0.92 (0.37-2.28) 0.849 Time since transplantation 2-4.99 5-9.99 10 Receipt of antiproliferative No Yes Receipt of calcineurin inhibitor No Yes Receipt of T cell depleting antibody No Yes 12 43 24 14 65 10 69 59 20 1.00 3.63 (1.91-6.89) 4.68 (2.29-9.55) <0.001^ 1.00 1.14 (0.63-2.06) 0.647 1.00 3.04 (1.52-6.07) 0.002 1.00 1.21 (0.73-2.03) 0.456

Oncogenic virus: HPV-16 Agent Sufficient evidence (Group 1) Limited evidence (Group 2A) Established mechanistic events Human papillomavirus type 16 Carcinoma of the: Cervix (100%) Anus (90%) Vagina (40%) Vulva (40%) Penis (40%) Oropharynx (35%) Larynx cancer (3-47%) Immortalisation Genomic instability Inhibition of DNA damage response Anti-apoptotic activity Oral cavity (24%) Tonsil (50%) No newly identified carcinogenic links %s for any HPV infection Bouvard et al. Lancet 2009;10:321-322

Other oncogenic HPV types Agent Sufficient evidence (Group 1) Probably carcinogenic (Group 2a) Possibly carcinogenic (Group 2b) HPV 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 Cervical cancer HPV 68 Cervical cancer HPV 26, 53, 66, 67,70, 73, 82 Cervical cancer HPV 30, 34, 69, 85, 97 Cervical cancer HPV 5, 8 Skin cancer in patients with epidermodysplasia verruciformis Newly identified carcinogenic link Bouvard et al. Lancet 2009;10:321-322

Is increased cancer risk reversed upon cessation of immunosuppression? Probabilistic data linkage Australia and New Zealand Dialysis and Transplant Registry Dates of change in RRT National Cancer Statistics Clearing House 8,173 patients first transplanted in Australia 1982-2003 1,820 returned to dialysis, 668 re-transplanted, 66 received 3 or more transplants SIRs for periods of transplant function and dialysis after transplant failure Incidence rate ratios (IRRs) adjusted for current age, sex and duration of transplantation

Immunosuppression currency and risk The effect of immunosuppression on cancer risk is rapidly reversible for some, but not all, cancer types Risk reversal was mostly, although not exclusively, observed for cancers with a confirmed infectious cause Risk of other cancers, especially those related to ESKD, remains significantly elevated after reduction of immunosuppression This finding offers insight into the role of current functional immunity in cancer prevention and may help inform the management of cancer risk in other immunosuppressed populations

SIR (95% CI) Intriguing cancers showing reversibility of risk 1000 Lip cancer 1000 Melanoma 100 100 10 10 1 1.1.1.01 D1 T1 D2+ T2+.01 D1 T1 D2+ T2+ Period Period van Leeuwen et al. CEBP 2009;18:561-9 Vajdic et al. CEBP 2009;18:2297-2303

CTS Opelz

SIR (95% CI) SIR (95% CI) Cancers showing no change in risk 1000 Colon 1000 Breast 100 100 10 10 1 1.1.1.01 D1 T1 D2+ T2+ Period.01 D1 T1 D2+ T2+ Period 1000 Lung cancer 1000 Prostate 100 100 10 10 1 1.1.1.01 D1 T1 D2+ T2+ Period.01 D1 T1 D2+ T2+ Period

So, final words Transplantation is associated with increased cancer risk across a number of organ sites Most, but not all, are cancers with a known or suspected viral cause Most cancers increase in risk markedly after transplantation Cessation of immunosuppression decreases risk for cancers with known or suspected viral cause Important interaction between common viral infections and the immune system in the etiology of a large number of cancers

Claire Vajdic, UNSW Acknowledgements Andrew Grulich, Marina van Leeuwin Jeremy Chapman Colleagues at Sydney Uni Patrick Kelly Custodians and contributors to ANZDATA and other organ transplant registries

Questions? angela.webster@sydney.edu.au