The Continuing Tale of HIV and Cancer

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The Newer Face of Cancer in HIV Care
Paul A. VolberdingMarvin Sleisenger Professor of
MedicineUniversity of California San Francisco
From PA Volberding, MD, at 12th Annual Ryan
White HIV/AIDS Program Clinical Conference,
IASUSA.
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Content Outline

• Cancers beyond AIDS defining
• Epidemiology Which one you might expect to see
• Screening Does HIV affect your usual care?
• (Management)
• Prevention

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HIV and CancersOne Approach to Relationships

• Cancers caused by HIV
• Cancers associated with condition/situation that
  lead to HIV infection
• Cancers not related to HIV but occurring in
  HIV-infected

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Cancers Directly Linked to HIV

• Kaposis sarcoma
• Non-Hodgkins lymphoma
• CNS lymphoma
• Typically have a much stronger incidence rise in
  HIV infected population, close connection to CD4
  decline.
• Often linked to second infection

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AIDS-Defining Cancers Have Dramatic Incidence
in HIV
Goedert J. Semin Oncol. 20004390-401.
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Most Cancer in HIV is Infection Related

• True for both AIDS and non-AIDS defining cancers
• HPV (anal, cervical, etc), HBV (liver cancer),
  EBV (Hodgkins lymphoma, etc), H. pylori
  (gastric)
• Much weaker association of HIV with cancers not
  known caused by second infection
• Lung, renal, melanoma, prostate, etc

Kaiser-Permanente Cohort Silverberg et al CROI
2009 30
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Hodgkins Disease

• Association with HIV infection
• Hodgkins disease RR 5 to 30
• Non-Hodgkins disease RR 24 to 165
• Patients with HIV present with
• B symptoms (70 to 96), worse histology,
  higher-stage tumor (74 to 92 are III or IV),
  bone marrow involvement (40 to 50),
  pancytopenia
• Good response to MOPP/ABV
• Complete response 74.5
• 2-year disease-free survival 62
• Early better results with Stanford V and BEACOPP

Gerard L, et al. AIDS. 20031781-87.
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Anogenital Cancers

• Invasive cervical carcinoma
• Considered an AIDS-defining condition
• Anal cancer1
• Not AIDS defining but very common
• HPV involvement1-2
• Both derive from premalignant dysplastic lesions
  due to HPV
• Most oncogenic strains 16, 18, 31, 33, 35, 45
• Repeated infections and infection with multiple
  HPV strains increase the risk of developing
  neoplasia

1Phelps RM, et al. Int J Cancer.
200194753-757. 2Martin F, et al. Sex Transm
Infect. 200177327-331.
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HIV, Aging, and Cancer

• Subject of increasing concern
• As HIV cohort ages, will enter expected period of
  cancer risk
• Also concern that cancer may be increased by
• Chronic poorly characterized immune deficits
• Chronic immune activation and inflammation of HIV
  replication
• Oncogenic potential of long-term ARV exposure

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Cancer ScreeningRecommendations of US Preventive
Services Task Force

• Colorectal cancer
• Breast cancer
• Prostate cancer
• Taken from Primary Care of Veterans with HIV

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Cervical Cancer Screening

• Pap smear or liquid-based cytology in sexually
  active women with a cervix
• Start at age 21 or within 3 years of sexual
  activity
• In HIV-, screen every 3 years
• In HIV, screen at HIV diagnosis and in 6 months
• If neg. and CD4gt200, repaet annually
• If neg. and CD4lt200, repeat every 6 months
• Also screen for anal cancer annually with Pap
  smear

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Anal Cancer Screening

• Anal cancer increased in MSM population
• No firm evidence based recommendation
• Anal pap smears should be considered if available
• No clear guidance on optimal follow-up management

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Prostate Cancer Screening

• Controversial. Some groups do, others dont
  recommend screening
• If screen (ACS, AUA) annual after age 50 years
  with DRE and PSA
• HIV men if anything at lower prostate cancer risk