Personalizing Therapy Central to Treating Patients with HIV and Cancer

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To best treat patients with HIV and cancer and help address known treatment disparities in care, Dr Raghavan suggested “personalized medicine.”
To best treat patients with HIV and cancer and help address known treatment disparities in care, Dr Raghavan suggested “personalized medicine.”

Patients with HIV and cancer often receive less cancer treatment compared with patients who do not have HIV, and cancer outcomes are sometimes worse for these patients.

“Close communication between oncologists and HIV specialists during treatment, to ensure the best cancer and HIV-specific outcomes” is key, Michael J. Silverberg, PhD, MPH, and research scientist at Kaiser Permanente in Oakland, California said in an interview.

Both Dr Silverberg and Derek Raghavan MD, PhD, President of the Levine Cancer Institute at the Carolinas HealthCare System spoke with Infectious Disease Advisor about the many issues that patients with HIV and cancer face.

A study by Silverberg et al that looked at cancer rates and risk in North America in a group of 86620 patients with HIV and 196987 non infected patients from 1996-2009 reported “high cumulative incidences of…Kaposi sarcoma, non-Hodgkin lymphoma, and lung cancer” in patients with HIV when compared with those who did not have HIV. 1

Certain types of cancers have traditionally been seen more commonly in patients with HIV, including, Dr Raghavan explained, anal carcinoma and cervical cancer, both of which are associated with human papillomavirus, along with Kaposi's sarcoma, which is associated with herpes 7, and Hodgkin lymphoma.

Liver cancers, often linked with hepatitis B and C, are also commonly seen in patients with HIV. These cancers are often a result of immune paresis as well as certain risk factors. For example, Dr Raghavan noted, lung cancer has been seen an issue due to higher smoking rates in HIV populations.

Although patients with HIV do not seem to be at any more of an increased risk for breast, colon, or prostate cancer – 3 that are not associated with viral etiology – than the general population, these cancers are also emerging as important causes of morbidity and mortality, surpassing HIV-related events themselves, as more effective treatments for HIV enable patients to live longer, Dr Raghavan explained.

Treating HIV and Cancer –The Treatment Challenges

To best treat patients with HIV and cancer and help address known treatment disparities in care, Dr Raghavan suggested “personalized medicine.”

“Try to look at the best treatment for the specific cancer in an otherwise healthy person,” he said. “Then examine the pattern of side effects in that treatment. The platinum drugs are particularly tough on the kidneys, for example. Anthracyclines are hard on the heart.”  He urged physicians to be mindful of potential drug interactions between antiretrovirals and certain chemotherapy medications.

“Thoroughly discussing side effects with the patient is essential. If the treating physician is not a specialist in treating HIV and cancer together, they should connect with a center of excellence that has a book of patients with HIV and cancer and has experience in the interactions between targeted therapies, chemotherapy, and the drugs for HIV," Dr Raghavan said. 

Dr Raghavan also emphasized the importance of addressing the psychological elements of having both HIV and cancer.

“People who have been through the trauma of HIV and then have a second set of issues relating to the fear, uncertainty, potential toxicity, and life limitation of having cancer” is extremely difficult for patients, Dr Raghavan said.

He added that patients with HIV also may have more than one malignancy due to continuing immunological dysfunction or other risk factors, so this can be traumatizing for patients. Physicians also need to emphasize support for the patient's family, who also are enduring emotional trauma as caregivers.

“Physicians need to be aware of the necessary psychological and fiscal support needed for patients,” Dr Ragahavan stressed. “A lot of HIV patients have lost their jobs or have had to truncate their employment. They are financially challenged before they get sick, and then they have expensive care that may be needed.

Finally, Dr Raghavan said, “It's important that physicians use honesty with HIV patients with cancer and be careful about identifying what they do and do not know about their prognosis. It's also crucially important for physicians to admit if there is something regarding the patient's care that they do not know, and tell the patient they can consult another expert to get that information.”

Reference

1.     Silverberg M, Lau B, Modur S, et al. Cumulative Incidence of Cancer Among Persons With HIV in North America: A Cohort Study. Annals Of Internal Medicine October 6, 2015;163(7):507-518. Accessed February 16, 2016.

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