Determining Why Patients With HIV Infection and Non–AIDS-Defining Cancers Are Less Likely to Receive Cancer Treatment

Get Permission

A survey sent to medical and radiation oncologists to identify factors contributing to observed disparities in cancer treatment between patients infected with HIV and those not infected “found that a substantial proportion of physicians (21%) would alter their treatment recommendations based on HIV status,” Gita Suneja, MD, of the University of Salt Lake City, Utah, and colleagues reported in the Journal of Oncology Practice. “The likelihood of offering standard treatment was associated with concerns about toxicity, efficacy, and comfort level with discussing cancer treatment adverse effects and prognosis,” the investigators stated.

Before the advent of highly active antiretroviral therapy improved survival in HIV-infected individuals, “cancers in HIV-infected individuals were largely AIDS-defining cancers related to severe immunosuppression, such as Kaposi sarcoma,” the researchers wrote. With improved survival in HIV-infected individuals, cancers considered non–AIDS-defining cancers, “such as lung, colorectal, and anal cancers, have become an increasingly important cause of mortality in the HIV-infected population. Despite improvements in the management of HIV, HIV-infected patients with cancer have worse survival compared with uninfected counterparts,” the authors stated. This lower survival, they noted, could be due in part to a disparity in receiving cancer treatment, as seen in recent population-based studies.

The survey was mailed to 500 medical and radiation oncologists randomly selected from the American Medical Association Physician Masterfile, with greater sampling in areas of highest HIV prevalence. Recipients had the option of responding by mail or online.

Among 273 physicians who responded, 79% indicated they would provide standard cancer treatment to HIV-infected patients, but 69% disagreed with the statement, “Sufficient guidelines are available to aid in treatment decision-making for HIV-infected patients with non–AIDS-defining malignancies.” In addition, 45% never or rarely discussed their cancer management plan with an HIV specialist; 20% were not comfortable discussing cancer treatment adverse effects with their HIV-infected patients with cancer, and 15% were uncomfortable discussing prognosis.

Multivariable Analysis

“In multivariable analysis, physicians comfortable discussing adverse effects and prognosis were more likely to provide standard cancer treatment (adjusted odds ratio, 1.52; 95% CI, 1.12–2.07). Physicians with concerns about toxicity and efficacy of treatment were significantly less likely to provide standard cancer treatment (adjusted odds ratio, 0.67; 95% CI, 0.53–0.85),” the investigators stated.

Among medical oncologists, 77% scored as providing standard therapy to HIV-infected patients. This was assessed by responses to three specialty-specific management questions, with 18% indicating they would not use standard chemotherapy agents, 48% indicating that they would use lower doses and fewer cycles, and 51% indicating that they would discontinue therapy if adverse effects occurred when treating HIV-infected patients with cancer.

Among radiation oncologists, 80% scored as providing standard therapy to HIV-infected patients. Responses to three specialty-specific management questions showed that 20% would use lower radiation doses, 27% would treat with smaller fields, and 31% would discontinue therapy if adverse effects occurred when treating HIV-infected patients with cancer.

The authors noted that concerns cited regarding safety and efficacy of cancer treatment in HIV-infected patients “are not surprising, given the dearth of high-quality data and resulting lack of evidence-based guidelines specific to HIV-infected patients with non–AIDS-defining cancers. Clinical trial data are available to inform the management of HIV-infected patients with non-Hodgkin lymphoma and anal cancer but not most other non–AIDS-defining cancers. This is because HIV-infected patients have historically been excluded from clinical trials, so randomized trial data regarding treatment outcomes are largely unavailable.” The authors added that the National Cancer Institute and other organizations have initiated steps to address this issue.

“Inclusion of HIV-infected patients in cancer clinical trials, development of cancer treatment guidelines specific to HIV-infected patients, and enhanced care coordination between oncologists and HIV specialists may reduce cancer treatment disparities for HIV-infected patients with cancer,” the investigators concluded. ■

Suneja G, et al: J Oncol Pract 11:e380-e387, 2015.