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NCCN Annual Conference

NCCN's New Guidelines Promote Better Cancer Care for People With HIV

Kelly Davio
“HIV status alone should not be used for cancer treatment decision making,” said Gita Suneja, MD, Duke Cancer Institute.
At the 23rd National Comprehensive Cancer Network (NCCN) Annual Conference, held March 22-24 in Orlando, Florida, Gita Suneja, MD, Duke Cancer Institute, presented NCCN’s new guidelines on treating cancer in people living with HIV.

“The story of HIV in America began in June of 1981,” said Suneja, with the CDC's Morbidity and Mortality Weekly Report that described 5 young men with biopsy-confirmed Pneumocystis carinii pneumonia. While the CDC would not name AIDS-defining cancers (Kaposi sarcoma [KS], non-Hodgkin lymphoma, and cervical cancer) until 1993, Suneja said that “Cancer was a part of the story from the very beginning.” As early as July 1981, KS was described together with pneumonia among homosexual men.

Today, Suneja said, we understand that people with HIV have a higher incidence of many cancers—not only AIDS-defining cancers—compared with the general population. Some factors involved are coinfection with oncogenic viruses and a higher incidence of smoking within this population. Aging, too, is playing a role; antiretroviral therapy (ART) has increased survival of people living with HIV, and “HIV has really been converted over to a chronic disease … not only is the US HIV population growing over time, they’re also aging.”

While the incidence of AIDS-defining cancers is on the decline due to patients’ improved immune function with ART, the incidence of non–AIDS-defining cancer is rising among people with HIV. Some potential explanations include complications with AIDS, advanced cancer stage at diagnosis, decreased immune surveillance, and more biologically aggressive disease.

Concerningly, people living with HIV are also significantly less likely to receive cancer treatment compared with patients without HIV. Suneja pointed to a 2015 survey that she and her colleagues conducted among 500 US oncologists. Among the respondents, 20% to 25% said that they would not offer standard cancer therapy to a patient who had HIV, 70% said that sufficient guidelines for treating these patients were not available, and 45% said that they rarely or never discussed a management plan together with an HIV specialist.

Further compounding the problem is the fact that patients with HIV are routinely excluded from clinical trials, so there is a knowledge gap about how best to treat these patients. Suneja likens such a practice to excluding people with cardiovascular disease—something that wouldn't really be done.

“HIV status alone should not be used for cancer treatment decision-making,” said Suneja. Instead, clinicians should bear in mind unique considerations for patients who have HIV.

Cancer work-up
Because imaging may reveal lymphadenopathy with non-malignant etiology, clinicians should consider a lower threshold to perform a nodal biopsy to determine whether cancer is involved; lesions of the brain, bone, lung, spleen, liver, or gastrointestinal tract may be non-cancerous in nature, especially if a patient’s CD4+ T-cell count is low.

General management
Poor performance status could be from HIV, cancer, or other causes, and drug-to-drug interactions among oncology and HIV therapies are possible. It is key to consult an HIV specialist and a pharmacist, said Suneja, before initiating therapy, and co-management between the oncologist and HIV specialist is critical.

While publications from the pre-ART era showed increased toxicity from cancer therapies in patients with HIV, modern data do not demonstrate the same results in patients who have CD4+ T-cell counts more than 200 cells/uL. Conformal radiotherapy techniques can be used to reduce the dose to bone marrow, skin, and mucosa, and there is no difference in clinical outcomes or complications for patients with HIV who undergo surgery compared with patients without HIV.

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