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Vulvar cancer in Botswana in women with and without HIV infection: patterns of treatment and survival outcomes
  1. Emily MacDuffie1,
  2. Sruthi Sakamuri2,
  3. Rebecca Luckett3,4,5,6,
  4. Qiao Wang7,
  5. Memory Bvochara-Nsingo8,
  6. Barati Monare9,
  7. Lisa Bazzett-Matabele5,6,10,
  8. Thabo Moloi6,
  9. Tlotlo Ralefala6,
  10. Doreen Ramogola-Masire2,5,
  11. Sanghyuk S Shin7,
  12. Nicola M Zetola1,9 and
  13. Surbhi Grover1,6,9,11
  1. 1 Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2 Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3 Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
  4. 4 Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  5. 5 Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
  6. 6 Princess Marina Hospital, Gaborone, Botswana
  7. 7 Sue and Bill Gross School of Nursing, University of California, Irvine, California, USA
  8. 8 Department of Oncology, Gaborone Private Hospital, Gabarone, Botswana
  9. 9 Botswana-UPenn Partnership, Gaborone, Botswana
  10. 10 Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut, USA
  11. 11 Department of Medicine, University of Botswana, Gaborone, Botswana
  1. Correspondence to Dr Surbhi Grover, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA; surbhi.grover{at}


Objectives Vulvar cancer is a rare gynecological malignancy. However, the incidence of human papillomavirus (HPV)-associated vulvar disease is increasing, particularly in low- and middle-income countries. HIV infection is associated with an increased risk of HPV-associated vulvar cancer. We evaluated treatment patterns and survival outcomes in a cohort of vulvar cancer patients in Botswana. The primary objective of this study was to determine overall survival and the impact of treatment modality, stage, and HIV status on overall survival.

Methods Women with vulvar cancer who presented to oncology care in Botswana from January 2015 through August 2019 were prospectively enrolled in this observational cohort study. Demographics, clinical characteristics, treatment, and survival data were collected. Factors associated with survival including age, HIV status, stage, and treatment were evaluated.

Results Our cohort included 120 women with vulvar cancer. Median age was 42 (IQR 38–47) years. The majority of patients were living with HIV (89%, n=107) that was well-controlled on antiretroviral treatment. Among women with HIV, 54.2% (n=58) were early stage (FIGO stage I/II). In those without HIV, 46.2% (n=6) were early stage (stage I/II). Of the 95 (79%) patients who received treatment, 20.8% (n=25) received surgery, 67.5% (n=81) received radiation therapy, and 24.2% (n=29) received chemotherapy, either alone or in combination. Median follow-up time of all patients was 24.7 (IQR 14.2–39.1) months and 2- year overall survival for all patients was 74%. Multivariate analysis demonstrated improved survival for those who received surgery (HR 0.26; 95% CI 0.08 to 0.86) and poor survival was associated with advanced stage (HR 2.56; 95% CI 1.30 to 5.02). Survival was not associated with HIV status.

Conclusions The majority of women with vulvar cancer in Botswana are young and living with HIV infection. Just under half of patients present with advanced stage, which was associated with worse survival. Improved survival was seen for those who received surgery.

  • vulvar neoplasms

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • EM and SS are joint first authors.

  • EM and SS contributed equally.

  • Contributors Study conception and design: SG, NMZ. Acquisition of data: SS, BM, LB-M, TM, TR, BM, SG. Analysis and interpretation of data: QW, SSS, EM, SS, SG, NMZ. Drafting of manuscript: EM, SS. Critical revision: RL, DRM, NMZ, SG. All authors approved the manuscript before submission.

  • Funding Mentored Patient Oriented Career Research Development Award (1-K08CA230170-01A1).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.