Guidelines aim to reduce treatment disparities for people with HIV diagnosed with cancer

People living with HIV who are diagnosed with cancer should be offered the same treatment as those without HIV; however, considerations should be made for potential interactions and toxicities, according to new practice guidelines from the National Comprehensive Cancer Network.

“The disparity in cancer care is large and significant. For most cancers, people living with HIV are two-to-three times more likely to receive no cancer treatment compared [with] uninfected people,” Gita Suneja, MD, associate professor of radiation oncology and global health at Duke Cancer Institute, said in a press release. “Although we don’t yet know all the reasons for these large differences in cancer treatment, the lack of clinical management guidelines available to clinicians has been shown to be one contributing factor.”

The most common types of cancer occurring among people with HIV include non-Hodgkin lymphoma, Kaposi sarcoma, lung cancer, anal cancer, prostate cancer, liver cancer, colorectal cancer, Hodgkin lymphoma, oral/pharyngeal cancer, female breast cancer and cervical cancer

The NCCN guidelines offered the main takeaway that people with HIV who develop cancer should be offered the same treatment as people who are HIV negative.

“The ultimate goal is to improve cancer survival among people living with HIV,” Suneja said in the release. “With modern antiretroviral therapy, people with HIV are living longer and, therefore, getting more cancers related to both HIV infection and aging. The bottom line is that the cancer burden is growing — in fact, cancer is quickly becoming the leading cause of death in people living with HIV — so we urgently need to improve cancer treatment in this population.”

Treatment considerations

Cancer treatment modifications for people with HIV should not be made based solely on the basis of a patient’s HIV status, according to the recommendations.

The guideline authors further recommended that an HIV specialist be included in the cancer-care team for patients with HIV.

An HIV specialist along with oncology and HIV pharmacists should review proposed cancer therapy to look for possible drug-to-drug interactions or overlapping toxicities.

“One of the most important points we want providers to be aware of surrounds the potential for drug interactions and overlapping toxicities between cancer therapeutics and [antiretroviral therapy],” Erin Reid, MD, clinical professor at UC San Diego Moores Cancer Center, said in the release. “Some antiretroviral-cancer therapeutic combinations have serious risk for increased toxicity, whereas others may reduce levels of either cancer therapeutics or the antiretroviral. The good news is that with the expansion of antiretroviral combinations available, there is opportunity to minimize these risks by modifying antiretroviral therapy during cancer treatment.”

Oncologists should also be aware of potential infection complications for people with HIV.

“The guidelines address infection prophylaxis considerations, including specific recommendations for [people living with HIV] receiving cancer therapy for whom profound immunosuppression/myelosuppression is anticipated,” Reid said.

The guidelines also suggested that people with HIV may have poor performance status after cancer treatment — which could be caused by HIV status, cancer status or other causes — that should be considered when evaluating treatments for this population.

Inclusion in clinical trials

People living with HIV who are diagnosed with cancer are often excluded from clinical trials, making data on their treatment limited.

Per recommendations from ASCO and the Friends of Cancer Research HIV Working Group, people with HIV can and should be included in oncology clinical trials if they meet the criteria. Additionally, doctors who work with people with HIV should encourage participation in clinical trials, to give patients more treatment options and to generate more data about treating patients with HIV who are diagnosed with cancer.

“Treating people living with HIV for cancer is a relatively new concern. It’s both a testament to the successes of HIV treatments in recent years, and a reminder that the quest for healthier outcomes is ongoing,” Robert W. Carlson, MD, CEO of NCCN, said in the release. “That’s why at NCCN, we are always seeking new ways to expand and update the resources that we offer.” – by Cassie Homer

Reference:

NCCN Clinical Practice Guidelines in Oncology. Cancer in people living with HIV. Available at:

www.nccn.org/professionals/physician_gls/pdf/hiv.pdf. Accessed on Feb. 28, 2018.

Disclosures: Reid reports clinical research support from or data and safety monitoring board roles with AbbVie, ADC Therapeutics, AIDS Malignancy Consortium, CALGB/CTSU, Janssen, Millennium, Pharmacyclics and Takeda. Suneja and Carlson report no relevant financial disclosures. Please see the guidelines for a list of all other authors’ relevant financial disclosures.