Clinical Pearls & Morning Reports
In the management of cancer, HIV should be treated as a chronic condition and attention should be paid to potential drug interactions among HIV medications and cancer therapy, as well as to the prevention of opportunistic infections. Read the latest NEJM Review Article here.
Q: How has the burden of HIV-associated cancers changed in the United States in recent decades?
A: As combination antiretroviral therapy (ART) has dramatically improved the survival of patients with HIV infection and AIDS, the number of persons living with AIDS has more than doubled in the United States and the age of this population has increased. The burden of AIDS-defining cancers has remained relatively steady for the past two decades, but the burden of non–AIDS-defining cancers has increased and accounts for an increasing proportion of cancer-related morbidity and mortality in this population.
Q: Kaposi’s sarcoma–associated herpesvirus (KSHV) is associated with what conditions besides Kaposi’s sarcoma?
A: KSHV is the cause of primary effusion lymphoma (a rare lymphoma), KSHV-associated multicentric Castleman’s disease, and a KSHV inflammatory cytokine syndrome (KICS). Two or more of these diseases may develop in a patient, and clinicians should be vigilant for their co-occurrence.
A: The definition of “AIDS-defining lymphoma” generally refers to aggressive B-cell non-Hodgkin’s lymphomas arising in patients who have HIV infection. The presence of HIV also increases the risk of classic Hodgkin’s lymphoma, which is not AIDS-defining. Many HIV-associated lymphomas consist of EBV-infected tumor cells, including AIDS-related primary CNS lymphoma, plasmablastic lymphoma, and Hodgkin’s lymphoma. However, many cases of HIV-associated Burkitt’s lymphoma and diffuse large-B-cell lymphoma are EBV-negative. Lymphoma may be the presenting symptom of HIV infection, and all patients with aggressive B-cell lymphomas or Hodgkin’s lymphoma should be tested for HIV. HIV-infected patients with ring-enhancing central nervous system (CNS) masses should be evaluated for primary CNS lymphoma. Overall survival for patients with HIV-associated lymphoma has increased from less than 20% during the pre-ART era, with dose-reduced regimens, to more than 80% in the current era. Hematopoietic cell transplantation is feasible in patients with HIV, and early studies suggest survival outcomes similar to those in the general population.
A: In persons with HIV, all cancers except Kaposi’s sarcoma, aggressive B-cell lymphoma, and invasive cervical cancer are considered non–AIDS-defining cancers. These include HIV-associated tumors and incidental cancers. The following five cancers make up approximately one half of these tumors among patients with HIV in the United States: lung cancer, anal cancer, hepatocellular cancer, Hodgkin’s lymphoma, and oropharyngeal cancer. In addition, HIV increases the risk of several other cancers, including squamous cell skin cancer, Merkel-cell carcinoma, the myelodysplastic syndrome, polycythemia vera, and (especially in sub-Saharan Africa) squamous-cell carcinoma of the conjunctiva. Early in the AIDS epidemic, patients with AIDS were often too fragile to receive standard cancer therapy. However, this situation has changed with the use of ART; non–AIDS-defining and incidental cancers should be managed according to the standard of care.