HIV & Cancer Risk: Expert Interview
The risk for cancer-related mortality in PLWHIV is a public health issue, as well as a medical education issue.
Infectious Disease Advisor: What are additional recommendations for clinicians?
Dr Volberding: One thing to keep in mind is that we are dealing with an aging population — many of these patients have been infected since the 1980s and 1990s and are now aged 60 to 70 years. Aging increases the risk for cancer in any population. We also think that HIV — even in cases of a well-managed infection — may increase cancer risk.
As HIV has gotten easier to treat, I think our attention has slipped a bit from the range of issues of PLWHIV, especially as they get older. Doctors need to make sure they pay attention to the need for screening in these patients. Cancer screening is recommended for all patients, especially for the common cancers that aren't necessarily HIV-related, such as those of the prostate, breast, or colon cancers.
In addition, the rate of smoking is significantly higher in PLWHIV compared with other populations, for reasons we don't quite understand. Urging providers who treat HIV infection to address smoking cessation would be really important as well.
Dr Malvestutto: As the population of PLWHIV ages — more than 50% of PLWHIV in the United States will be older than 50 years within the next few years — the problem of cancer will continue to be a leading cause of death in PLWHIV.5 There is much that can be done to mitigate the increased risk for certain types of cancers.
Screening for viral hepatitis should be done [according to] guideline recommendations. Patients with HCV should be offered treatment as soon as possible. Cervical and anal Pap smears should also be done [according to] guidelines recommendations, and all age-appropriate cancer screenings should be offered to all patients. Further, rapid initiation of ART and viral suppression maintenance is extremely important in all PLWHIV, not only in terms of control of viremia and immune reconstitution, but it appears that by reducing chronic inflammation and immune activation in PLWHIV [by means of] ART, we are able to reduce the incidence of multiple malignancies. One key finding of the START trial was that immediate initiation of ART led to a 64% reduction in cancer and included reductions in infection-related cancers and infection-unrelated cancers.6
Another factor that greatly contributes to the increased incidence of multiple cancers in PLWHIV is smoking. For many populations of PLWHIV, the prevalence of smoking is much higher than in similar populations of individuals who do not have HIV. Smoking cessation should be strongly encouraged and nicotine replacement therapy and other effective medical smoking cessation aids should be offered to all PLWH who smoke
Infectious Disease Advisor: What should be the focus of future efforts in this area, in terms of research or otherwise?
Dr Volberding: There isn't much research being conducted on this particular topic; the current emphasis is more on implementation of screening and vaccination and why rates are different in different subpopulations in HIV. There is a growing awareness that health disparities are a problem in patients with HIV in general — for example, among young African American gay men. More attention to these disparities and how we can reduce them will also be part of the solution to cancer prevention in PLWHIV as well.
This is a public health issue as well as a medical education issue. There is a need for education programs aimed at healthcare providers so that they will advocate for cancer screening. I think the Centers for Disease Control and Prevention can play a role, and the American Society for Liver Disease has been very involved with HBV and HCV.
Dr Malvestutto: We expect that as HPV and HBV vaccination rates will improve in the general population and the incidence of HPV-related malignancies will decrease for all, including PLWHIV. We await the results of the ANCHOR trial to determine appropriate management of HPV-associated high-grade anal lesions.
As HBV vaccination rates and treatment of HCV is offered to all patients with chronic HCV, the incidence of HCC is expected to decrease. Research is finally starting to gain traction in the development of new therapies to cure HBV, and we hope that these efforts will lead to cure regimens as effective as the ones currently available for HCV.
We also need to continue to improve HIV screening programs to identify new HIV cases early and initiate ART immediately to limit individuals' future risk for cancer.
- Valanikas E, Dinas K, Tziomalos K. Cancer prevention in patients with human immunodeficiency virus infection. World J Clin Oncol. 2018;9(5):71-73.
- Coghill AE, Shiels MS, Suneja G, Engels EA. Elevated cancer-specific mortality among HIV-infected patients in the United States. J Clin Oncol. 2015;33(21):2376-2383.
- Hernández-Ramírez RU, Shiels MS, Dubrow R, Engels EA. Spectrum of cancer risk among HIV-infected people in the United States during the modern antiretroviral therapy era: a population-based registry linkage study. Lancet HIV. 2017; 4(11):e495-e504.
- Wilkin TJ, Chen H, Cespedes MS, et al. A randomized, placebo-controlled trial of the quadrivalent human papillomavirus vaccine in human immunodeficiency virus-infected adults aged 27 years or older: AIDS Clinical Trials Group Protocol A5298. Clin Infect Dis. 2018;67(9):1339-1346.
- Brooks JT, Buchacz K, Gebo KA, Mermin J. HIV infection and older Americans: the public health perspective. Am J Public Health. 2012;102(8):1516-1526.
- The INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373(9):795-807.