Differences in utilization, complications, and mortality after cancer surgery by HIV status among Medicaid beneficiaries from 2001-2021.

Background: People with HIV (PWH) experience higher cancer-specific mortality and may have worse surgical outcomes than people without HIV (PWoH), though the limited prior evidence largely predates the treat-all antiretroviral therapy (ART) era. We examined postoperative outcomes among PWH and PWoH enrolled in Medicaid in 26 states and Washington, D.C. from 2001-2021. Methods: We identified the first inpatient/outpatient surgery for anal, bladder, breast, colorectal, female genitourinary, gastroesophageal, head and neck, kidney, liver, lung, ovarian, or pancreatic cancer among adults with continuous enrollment for at least 6 months pre- and 3 months post-surgery. Outcomes included length of stay (LOS), 7- and 30-day readmissions (overall and unplanned), emergency department (ED) use, surgical site infection (SSI), and mortality (30-day, 90-day, 1-year, 5-year). Linear, logistic, and Cox proportional hazards models were adjusted for demographics, comorbidities, cancer type, surgical setting and risk, metastasis, and preoperative treatment (radiation/chemotherapy). Results: Among 198,535 beneficiaries undergoing cancer surgery, 4,199 (2.1%) were PWH. PWH were more likely to have inpatient procedures (72.6% vs. 56.4%). Compared to PWoH, PWH had more utilization with longer LOS (7.0 vs. 4.3 days; adjusted mean difference [aMD] = 0.79, 95% CI = 0.60-0.99), extended hospital stays (13.8 vs. 7.4 days; aMD=2.76, 95% CI= 2.42-3.10), and more ED visits (0.82 vs. 0.55 per 90 days; aMD = 0.19, 95% CI = 0.15-0.23). There were no significant differences in readmission, SSI, or 30-day mortality. PWH had higher 90-day mortality (3.2% vs. 1.8%; adjusted odds ratio [aOR] = 1.31, 95% CI = 1.08-1.57), though this was attenuated in the treat-all ART era (2012 - 2021). Results were similar for inpatient surgeries and most common cancer types. PWH had an elevated hazard of 1-year and 5-year mortality post-surgery with an adjusted hazard ratio [aHR] of 1.31 (95% CI = 1.17-1.46) and 1.22 (95% CI= 1.14-1.31), respectively, especially for colorectal cancer (1-year aHR= 1.53, 95% CI=1.24-1.88; 5-year aHR=1.32, 95% CI= 1.14-1.52). Conclusions: PWH had higher post-cancer surgery utilization but similar short-term complications, which supports current guidelines to provide standard cancer care for PWH. More work is needed to elucidate the factors contributing to higher long-term mortality among PWH.