First NCCN Guidelines for Management of Persons Living with HIV: Don’t Use HIV Status Alone When Making Treatment Decisions

September 2018 Vol 9, No 9

HIV status alone should not be used for cancer treatment decision-making, according to the first guidelines from the National Comprehensive Cancer Network (NCCN) on the management of cancer in persons infected with HIV.

The driving force behind this recommendation is that HIV-infected persons are less likely to receive cancer treatment compared with uninfected patients. In a 2015 survey of 500 oncologists, 20% to 25% indicated that they would not offer standard cancer therapy to an HIV-infected patient, said Gita Suneja, MD, at the NCCN 23rd Annual Conference. In addition, specific guidance in the HIV-infected population was not available, partly because persons living with HIV were previously excluded from cancer clinical trials, creating a knowledge gap.

The guidelines 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, and AIDS-related Kaposi sarcoma, for which there is a separate guideline. These cancers are more prevalent in HIV-infected persons, with contributing factors being co-infection with oncogenic viruses such as human papillomavirus (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 in persons living with HIV. "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," noted Dr Suneja, associate professor, Department of Radiation Oncology and Global Health, Duke University, Durham, NC.

A key driver of cancer treatment decision-making is performance status. If performance status is poor in HIV-infected persons, the reason for the poor performance status is important to consider. "Treating HIV may improve a patient's performance status such that they are eligible for cancer treatment," she said.

Because of the possibility of drug-drug interactions, a consult with both an oncologist and an HIV pharmacist is recommended before initiating cancer therapy.

Kaposi Sarcoma
HHV-8 is the etiologic infection that underlies the development of Kaposi sarcoma. Individual 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 Kaposi sarcoma lesions," said Dr Suneja. ART is the backbone of treatment, according to the guidelines.

"If disease is asymptomatic disease and cosmetically acceptable to the patient, ART alone is really an appropriate treatment paradigm," said Dr Suneja. For patients with symptomatic or cosmetically unacceptable Kaposi sarcoma lesions, additional first-line management options include referral to a clinical trial, topical therapy, systemic therapy, intralesional chemotherapy, radiation therapy, and local excision. If the disease stabilizes, continued ART is recommended. With disease progression, another first-line treatment option can be tried in addition to ART.

For patients with advanced cutaneous, oral, visceral, or nodal disease, check for eligibility for a clinical trial or for systemic therapy combined with ART. For patients not eligible for a clinical trial or for systemic therapy, the guidelines recommend ART plus radiotherapy.

Be aware of immune reconstitution inflammatory syndrome (IRIS), in which Kaposi sarcoma worsens as the immune system is reconstituted. Glucocorticoids should be avoided if possible because iatrogenic immunosuppression can promote the development of Kaposi sarcoma. However, glucocorticoids may be necessary in patients with IRIS.

Cervical Cancer
Persistent HPV infection is more common in people living with HIV, increasing the risk of cervical cancer in this group. Treatment of precancerous cervical lesions may be difficult because endocervical extension of precancerous lesions is more common in people living with HIV. Evaluation for synchronous vulvar or anal cancer is recommended with identification of cervical lesions. The NCCN panel recommends that people living with HIV be treated as per the NCCN guidelines for cervical cancer.

Anal Cancer
In addition to anal cancer, HIV-infected persons are at higher risk for anal squamous epithelial neoplasia, a precursor to invasive anal cancer. HIV-infected persons with anal cancer are recommended to receive the same treatment as those not infected with HIV, but with more frequent surveillance anoscopy (every 3-6 months for 3 years).

Lung Cancer
Lung cancer is the most common non–AIDS-defining cancer in HIV-infected persons. At present, screening should be performed as per NCCN guidelines for lung cancer, but this recommendation could change as evidence becomes available, said Dr Suneja. Treatment per NCCN guidelines for non–small cell lung cancer is recommended.

Hodgkin Lymphoma
The classic histology of Hodgkin lymphoma is associated with HIV; the mixed cellularity subtype is the most common. In the HIV population, almost 90% of cases of Hodgkin lymphoma are associated with Epstein-Barr virus. The presentation of Hodgkin lymphoma is often more advanced in persons living with HIV, including B symptoms and bone marrow involvement. "B symptoms can also represent opportunistic infection, especially if CD4 counts are low," she said.

Adriamycin (doxorubicin), bleomycin, vinblastine, and dacarbazine (ABVD) is the preferred regimen for the treatment of Hodgkin lymphoma in persons living with HIV. Growth factors may also be required with a low CD4+ T-cell count and prolonged severe neutropenia.

PET/CT-guided therapy may be difficult in HIV-infected persons because noncancerous lesions are often found on imaging, but "it still is what we recommend, but there are potential confounders to look for," Dr Suneja said.

Autologous stem cell transplantation is safe and effective for relapsed or recurrent Hodgkin lymphoma in persons with HIV. If the CD4+ T-cell count is <200 cells/µL, prophylactic antibiotics with activity against gram-negative bacteria and Pneumocystis jiroveci pneumonia should be considered.

Supportive Care
Supportive care in HIV-infected persons makes an appearance in the guidelines and is critically important to ensure that treatment toxicity is minimized. Supportive therapies may be needed if patients develop oral mucositis, esophagitis, or colitis. A high index of suspicion and early testing for opportunistic infections are recommended. Vaccine recommendations include avoidance of live virus vaccines with a low CD4+ count and consideration of the new recombinant zoster vaccine in patients 50 years and older.

Last modified: August 10, 2023

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