Módulo 2 – Curso pós-graduado – VIH e Envelhecimento

Non-AIDS Defining Cancers Among HIV Infected People

Clinical Management of non-AIDS defining cancers

Autor: Prof. Doutor Vicente Estrada, MD PhD (Hospital Clínico San Carlos, Madrid, Spain)

Lung cancer

Lung cancer is currently the most prevalent NADC. The incidence of lung cancer is two-four times higher in HIV-infected persons than in the general population, and it probably reflects the synergistic effect of HIV and tobacco smoking in the development of this neoplasia. Furthermore, the risk is higher for women, for younger individuals, and patients who injected drugs.

Regarding diagnosis and tumor staging, when lung cancer is diagnosed, it’s usually with a locally advanced or metastatic disease. Tumor type, stage of cancer, and functional status must be determined for proper management. Stage evaluation should include computed tomography (CT scan) of chest and abdomen (including adrenal glands), bone scan, and, for operable patients, mediastinoscopy. On the other hand, positron emission tomography (PET scans) may be more difficult to assess in HIV-infected patients who often have underlying lung pathology and, so, are not so sensitive for the diagnosis of metastasis. Although a less frequent lung cancer type, the evaluation of small-cell lung cancer staging should also include either a magnetic resonance imaging (MRI) or CT with contrast of the brain.

When considering the treatment of lung cancer, there is a lack of information about the efficacy and toxicity of chemo- therapy and radiation therapy in HIV-infected patients, especially regarding the newer targeted therapies. The manage- ment of non-small-cell lung cancer is dictated by stage, while treatment of small-cell lung cancer should be the same as for HIV-negative patients. Drug-drug interactions are a critical point, and drugs that have no or less interactions are recom- mended, namely, the integrase inhibitors dolutegravir (DTG) and raltegravir (RAL)2.

Lung cancer has a poor prognosis, with a clinical course of- ten rapidly progressive with short survival. Overall survival seems to be similar between HIV-infected and HIV-negative lung cancer patients3. Another study also observed that patients with higher CD4+ count (=<200 cells/mm3) had an over- all survival more similar to the one of HIV-negative patients, while HIV-infected patients with more severe immunosuppression (<200 cells/mm3) presented a statistically significant worse prognosis (p<0.001)4. Hence, immune situation might affect the survival of these patients.

The role of lung cancer screening is under discussion. In the general population, the screening of heavy smokers has shown an effect on mortality. Regarding HIV-infected patients, screening might be cost-effective in patients at high risk for lung cancer, namely patients aged 55-75 years, with a heavy story of smoking (smokers at least 40 years, >20 pack-years) and low immunity, i.e., CD4-lymphocyte nadir count below 350 cells/µL. A study of a French Group evaluated feasibility and efficacy of early lung cancer diagnosis with chest CT scan in HIV-infected smokers5. They have screened 443 patients with this history of heavy smoking, low nadir CD4+, more than 55 years, and they found eight patients with lung cancer. From screened patients, 20% presented one lung lesion who could be suspicious of neoplasia, and approximately 2% of the patients presented one lung cancer definitively proved.

Nevertheless, the implications of these screening programs on daily practice remains difficult to ascertain, namely in face of health resources’ constraints and the difficult access to timely CT scans. On the other hand, annual X-ray has not shown any effect on mortality. Supporting patients to quit smoking may turn out to be more cost-effective.

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