AIDS-Defining Cancers
Incidence rates of Kaposi sarcoma have declined in veterans with HIV during the ART era. High risk factors include high cumulative HIV viremia and low recent CD4 counts. The investigators in the largest study of Kaposi sarcoma among HIV patients concluded that quickly controlling HIV replication upon diagnosis was important in preventing Kaposi sarcoma, but use of ART was not independently associated with reduced incidence. Another study among veterans, however, determined that one type of ART, boosted protease inhibitor-based regimens, did reduce risk.
The incidence rates for non-Hodgkin lymphoma have declined for veterans with HIV but remain significantly higher than in veterans without the virus. As with Kaposi sarcoma, risk for NHL increases with recent low CD4 count, extended low CD4 levels, and prolonged HIV viremia. The degree of increased risk varies across the types of NHL.
Lung cancer is the leading cancer death among individuals with HIV Several factors—most notably, smoking and older age—sharply increase risk of lung cancer among veterans. Veterans generally have higher rates of smoking than non-veterans and people with HIV have two to three times the rate of smoking compared to non-infected individuals, according to the U.S. Department of Health and Human Services. Most veterans with HIV are in an age group with a rising risk of lung cancer.
HIV status alone also elevates the risk lung cancer, with a large study in veterans finding that HIV infection increased lung cancer risk 60%, after adjusting for smoking and other potential confounders. A VACS study determined that recurrent bacterial pneumonia and a low CD4/CD8 ratio, indicative of chronic immune activation, also increased risk.
The VA follows lung cancer screening guidelines established by the U.S. Centers for Disease Control and Prevention. Those recommend low-dose computed tomography (CT) scans for patients with a history of heavy smoking who are currently smoke or quit within the last 15 years and are between 55 and 80 years of age. Studies among veterans with HIV found that HIV status does not increase the risk of false positives and subsequent invasive evaluation from the recommended screening, the review authors noted.
Anal cancer also occurs at much higher rates in people with HIV than in other individuals, a pattern also observed in veterans with HIV who have an incidence rate ratio of 14.9. As with other types of cancer, low CD4 counts increased risk for anal cancer in veterans. Veterans with low CD4 levels also had worse outcomes from chemoradiotherapy as well as greater hematologic toxicity, elevated risk of recurrence, and reduced cancer-specific survival. On the plus side, high levels of HIV viral suppression reduced the odds of anal cancer by 45% in one analysis of VA data.
Given the increased risk of anal cancer in veterans with HIV, researchers at a Florida VA center studied the utility of anal cancer screening. They found high rates of positive tests and concluded that screening would be well accepted and feasible within the VA HIV care model, the review authors said.
“There are some cancers that are more common in people with HIV such as anal cancer; some groups therefore advocate for anal cancer screening, particularly in people at higher risk of exposure to [the human papilloma] virus,” Sigel said. “Lung cancer is also more common in people with HIV although it is not clear if screening should be more aggressive in this group.”
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