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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.
Kaposi sarcoma
While the risk of KS has declined by 90% with better HIV management, patients with HIV are still at elevated risk for this cancer. It is important to understand that Individual lesions may be distinct clones that arise from persistent immunosuppression and human herpesvirus 8 infection, so treating existing disease may not prevent future lesions.

In AIDS-related KS, in patients who are asymptomatic and find their condition cosmetically acceptable, “sometimes we don’t need to do any cancer-related therapy … ART is really the backbone of treatment for KS," Suneja said.

Patients who are symptomatic or find their condition cosmetically unacceptable should receive ART with topical drugs, systemic therapy, radiation therapy, intralesional chemotherapy, local excision, or a clinical trial. Patients with advanced disease should receive ART together with treatment in a clinical trial if eligible.

Because reconstitution of immune function is important for the control of KS, the clinician should be aware of immune reconstitution inflammatory syndrome, during which glucocorticoids may become necessary (though they should be generally avoided, as they may promote KS). Potential lymphedema should also be closely monitored.

Cervical and anal cancers
NCCN recommends that patients who have cervical cancer or anal cancer be treated in line with existing NCCN guidelines for these conditions. In the case of anal cancer, patients should receive more frequent surveillance, with anoscopy every 3 to 6 months for 3 years.

Lung cancer
The most common non–AIDS-defining cancer in people with HIV is lung cancer. Even after controlling for increased levels of smoking in the HIV population, people with HIV still have an increased risk for this disease. NCCN says that patients with HIV should receive treatment per NCCN’s guidelines for non–small cell lung cancer, and smoking cessation support should be offered.

Hodgkin lymphoma
Ninety percent of cases of Hodgkin lymphoma in people with HIV are related to Epstein-Barr virus, and many patients with HIV present with more advanced disease. The preferred treatment regimen in this population is doxorubicin hydrochloride, bleomycin, vinblastine, and dacarbazine, but dose reductions may be required in cases of prolonged neutropenia; growth factors, which are generally avoided in this population, may be required. Autologous stem cell transplant has also been shown to be safe and effective for patients with HIV who have recurrent or relapsing Hodgkin lymphoma.

Supportive Care
In general, steroids should be avoided because of the risk of opportunistic infections, and a high index of suspicion—together with early testing for opportunistic infection—is appropriate. Live vaccines should be avoided if CD4+ count is under 200 cells/uL, but patients over age 50 may receive the new recombinant zoster vaccine.

Coordinated care
All patients with cancer should be screened for HIV. “Point of care testing [for HIV] is really in our domain” as oncologists, said Suneja, and together with an HIV specialist, the oncologist should undertake more frequent CD4+ T-cell count and viral load testing.

Drug-to-drug interactions should be reviewed by both specialists and a pharmacist; of greatest concern are pharmacologic boosters like ritonavir and cobicistat, as well as protease inhibitors. Overlapping toxicities may be present; both cancer drugs and HIV therapies may cause neuropathy and neutropenia, for example. If there is the potential for drug-to-drug interactions or overlapping toxicities, the oncologist may substitute ART, choose a different cancer therapy, or temporarily discontinue ART if cancer treatment is curative or palliative in nature.

In the future, said Suneja, NCCN plans to expand the number of cancers that it addresses in its guidelines, adapt guidelines for low-resource settings, generate an evidence base for the management of HIV-associated cancers, and increase clinical trial accrual.

Reference
CDC. Pneumocystis pneumonia—Los Angeles. MMWR Morb Mortal Wkly Rep. 1981;30(21):250-2.

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