Gita Suneja, MD
The HIV status of a patient who is living with the infection and has been diagnosed with cancer may be a component of a diagnostic workup but should not be the sole determining factor in making decisions about treatment, according to the first set of National Comprehensive Cancer Network (NCCN) guidelines for this population.1
The recommendations reflect that there are worse overall and cancer-specific survival outcomes seen in the HIV-infected population compared with the general population, in part because people living with HIV are less likely to receive cancer treatment compared with uninfected patients, said Gita Suneja, MD, during a presentation at the 2018 NCCN Annual Conference in March.2
Specific guidance in the HIV-infected population was not previously available, partly because persons living with HIV were previously excluded from cancer clinical trials, creating a knowledge gap.
Suneja, associate professor, Department of Radiation Oncology and Global Health, Duke University School of Medicine, noted that there is an urgent need for these guidelines. In a survey of 500 oncologists, 20% to 25% said that they would not offer standard cancer therapy to a person living with HIV, but most physicians would be more likely to offer therapy if they had an understanding of the adverse effects and prognosis.
The guidelines (version 1.2018) cover the management of 5 specific AIDS-defining and non–AIDS-defining cancers in persons with HIV: cervical cancer, anal cancer, lung cancer, Hodgkin lymphoma (HL), and AIDS-related Kaposi sarcoma (KS), for which there are separate guidelines. Each of these cancers is more prevalent in persons with HIV than in the general population, noted Suneja.
Factors that contribute to increased cancer risk in HIV-infected persons is co-infection with oncogenic viruses, such as human papilloma virus (HPV) and human herpes virus (HHV)-8, a higher prevalence of smoking in the HIV population, and aging, owing to effective antiretroviral therapy (ART) that has increased life expectancy of the HIV-infected population. “The number of AIDS-defining cancers is actually declining, and that’s due to better immune function with modern antiretroviral therapy, and the number of non– AIDS-defining cancers is rising,” Suneja said.
A unique consideration in HIV-infected patients is that in the cancer workup, imaging may reveal lymphadenopathy with a non-malignant etiology. In such a circumstance, a nodal biopsy should be considered to confirm cancer involvement, said Suneja. Similarly, lesions of the brain, bone, lung, spleen, liver, or gastrointestinal tract can be noncancerous, especially if the patient has a low CD4-positive T-cell count or a high viral load. Differential diagnoses can include progressive multifocal leukoencephalopathy; other malignancies, such as non-Hodgkin lymphoma in the case of brain lesions; infection or tenofavirrelated bone lesions; and opportunistic infection with lung lesions.
Performance is a key driver of cancer treatment decision-making. In HIV-infected persons, poor performance status may be from the HIV itself, cancer, or other causes. “It’s important to consider the reason for the poor performance status, and whether or not it’s reversible with appropriate treatment,” she said. “Treating HIV may improve a patient’s performance status such that they are eligible for cancer treatment.”
A consult with both an oncologist and an HIV pharmacist before initiating cancer therapy is recommended because of the possibility of drug– drug interactions, and co-management is critical. Suneja also noted that testing for CD4 T-cell count and viral load should be done more frequently to prevent potential interactions that could make ART less effective.
Although the risk of AIDS-related KS has declined dramatically with ART, the risk is still increased by more than 250 times in people living with HIV. HHV-8 is the etiologic infection that underlies the development of KS. Individual KS lesions may be distinct clones that arise from persistent immunosuppression and HHV-8 infection. “That means that treating existing disease doesn’t necessarily prevent future KS lesions,” Suneja said.
In the guideline, management of KS is divided into limited cutaneous and advanced cutaneous disease. ART is the backbone of treatment in either case, according to the guideline, as reconstitution of immune function is very important for control of KS.
If disease is asymptomatic and cosmetically acceptable to the patient, ART alone is an appropriate treatment paradigm, said Suneja. If the lesion is symptomatic or cosmetically unacceptable, additional first-line management options include referral to a clinical trial, topical therapy, systemic therapy, intralesional chemotherapy, radiation therapy, and local excision. Continued ART is recommended if the disease stabilizes; with disease progression, another first-line treatment option can be tried.