The National Comprehensive Cancer Network® (NCCN) has released new NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) intended to help make sure people living with human immunodeficiency virus (HIV) who are diagnosed with cancer receive safe, necessary treatment.
According to a report,1 in 2010, an estimated 7,760 patients with HIV in the United States were diagnosed with cancer, representing an approximately 50% higher rate than the general population. However, studies 2,3 have found patients with HIV are treated for cancer at significantly lower rates than HIV-negative people with cancer, despite most treatment courses being safe and effective in this population.
Gita Suneja, MD
“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 to uninfected people,” said Gita Suneja, MD, of the Duke Cancer Institute. Dr. Suneja is Co-Chair of the NCCN Guidelines Panel for Cancer in People Living With HIV. “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.” 4
New Guideline Recommendations
The most common types of cancer occurring in people living with HIV are, in order of incidence, 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 new NCCN Guidelines for Cancer in People Living With HIV include general advice—while highlighting the importance of working in collaboration with an HIV specialist—as well as specific treatment recommendations for non–small cell lung cancer, anal cancer, Hodgkin lymphoma, and cervical cancer. Additional recommendations can be found in the recently released NCCN Guidelines for AIDS-related Kaposi sarcoma, as well as the AIDS-related B-cell lymphomas section of the NCCN Guidelines for B-cell lymphomas.
“The ultimate goal is to improve cancer survival among people living with HIV,” said Dr. Suneja. “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.”
Among the recommendations found in the new NCCN Guidelines:
- Most patients with HIV and cancer should be offered the same cancer therapies as HIV-negative individuals, and modifications to cancer treatment should not be made solely on the basis of HIV status.
- Care for patients diagnosed with HIV should be comanaged with an oncologist and an HIV specialist (visit locator.hiv.gov to find local specialists in the United States).
- Oncologists and HIV clinicians, along with HIV and oncology pharmacists, if available, should review proposed cancer therapy and antiretroviral therapy for possible drug-drug interactions and overlapping toxicity concerns prior to the initiation of therapy.
Erin Reid, MD
“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 therapies,” said Erin Reid, MD, of the University of California, San Diego, Moores Cancer Center. Dr. Reid is Co-Chair of the NCCN Guidelines Panel for Cancer in People Living With HIV and Vice-Chair of the AIDS Malignancy Consortium Lymphoma Working Group. “Some antiretroviral-cancer therapeutic combinations [pose a] serious risk of increased toxicity, while 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.”
Dr. Reid also noted, “Another major area of concern oncology providers have in managing cancers in people living with HIV involves the risk of infectious complications. The guidelines address infection prophylaxis considerations, including specific recommendations for [HIV patients] receiving cancer therapy for whom profound immunosuppression/myelosuppression is anticipated.”
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
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“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,” said Robert W. Carlson, MD, Chief Executive Officer, NCCN. “That’s why at NCCN, we are always seeking new ways to expand and update the resources that we offer.”
The NCCN Guidelines Panel for Cancer in People Living With HIV included oncologists, radiologists, infectious disease specialists, surgical oncologists, pharmacists, and a patient advocate. The panel stressed the importance of increasing the number of patients living with HIV who participate in clinical trials for cancer treatments. Clinicians working with HIV patients who have cancer should use ClinicalTrials.gov to help patients find appropriate trials.
The NCCN Guidelines for Cancer in People Living With HIV are available free of charge for noncommercial use online at NCCN.org. They can also be viewed via the Virtual Library of NCCN Guidelines mobile app for smartphones and tablets. ■
Disclosure: Drs. Suneja and Carlson reported no conflicts of interest. Dr. Reid reported clinical research support and/or participation on a Data Safety Monitoring Board from Abbvie Pharmaceuticals, ADC Therapeutics, AIDS Malignancy Consortium, CALGB/CTSU, Janssen Pharmaceutica Products, LP, Millennium Pharmaceuticals, Inc., Pharmacyclics, and Takeda Pharmaceuticals North America, Inc.
References
1. Robbins HA, Pfeiffer RM, Shields MS, et al: Excess cancers among HIV-infected people in the United States. J Natl Cancer Inst 107:dju503, 2015.
2. Suneja G, Lin CC, Simard EP, et al: Disparities in cancer treatment among patients infected with the human immunodeficiency virus. Cancer 122:2399-2407, 2016.
3. Suneja G, Shiels MS, Angulo R, et al: Cancer treatment disparities in HIV-infected individuals in the United States. J Clin Oncol 32:2344-2350, 2014.
4. Suneja G, Boyer M, Yehia BR, et al: Cancer treatment in patients with HIV infection and non–AIDS-defining cancers: A survey of US oncologists. J Oncol Pract 11:e380-e387, 2015.
