Módulo 2 – Curso pós-graduado – VIH e Envelhecimento

Non-AIDS Defining Cancers Among HIV Infected People

Risk factors for non-AIDS defining malignancies

Autor: Prof. Doutor Mark Bower, MD PhD (National Centre for HIV malignancy Chelsea & Westminster Hospital, London, UK)

Cancer screening programs

People living with HIV should not be excluded from national screening programs, such as cervical and mammographic screening for women, or colorectal screening11. Of note, regarding prostate cancer screening amongst people living with HIV, there is a much higher false positive rate of prostate-specific antigen (PSA), which has actually detracted many investigators and clinicians from using PSA screening.

The value of screening for anal cancer by anal cytology and anoscopy is recommended by some advocates for MSM vwho are HIV positive. The support for this approach comes from the fact that anal cytology enables the identification of low or high grade atypical squamous intraepithelial lesions. If these abnormalities are detected, a high resolution anoscopy (HRA) should be conducted. Treatment of high grade anal intra-epithelial neoplasia (AIN 2/3) may reduce the risk of subsequent invasive anal cancer12. The treatments available for high grade AIN are infrared coagulation, topical trichloroacetic acid, imiquimod or, occasionally, surgical anal mucosectomy. However, there is a high relapse rate following treatment.

A pilot study of the HRA screening with 368 asymptomatic HIV- positive MSM with a median follow-up of 4.2 years (maximum 13 years), showed that, at the first HRA, 24% patients had AIN2 or AIN3, even though they were asymptomatic. Despite HRA screening and intervention with treatment of AIN 2/3, five patients (1.4%) developed invasive anal cancer. However, the tumours that occurred in screened patients were small, localized, and the outcomes were favourable. Progression to cancer was associated with: older age (p-value=0.049) and AIN3 (p-val- ue=0.024)(13). In the absence of a control group, the value and cost-effectiveness of the HRA screening cannot be accurately stated. One hypothesis is that, instead of it being a cancer prevention strategy, it is more an early detection strategy, so that patients are diagnosed at a more treatable stage.

Other pertinent possibility and better way of preventing anal cancer is through HPV vaccination. More than 90% of all cervical cancers, more than 80% of anal cancers, 50% of penile cancers and a significant proportion (20-80%) of head and neck cancers, particularly, tonsil ones are caused by HPV. And 94% of the HIV positive MSM have acquired HPV in the anal canal, with a third (36%) having the high risk HPV-16. Similarly, a quarter (24%) of these patients have oral HPV and 5% HPV-16. In the UK, although the license for Gardasil® is only up to the age of 26 years in men, some advocate routine vaccinations for MSM up to the age of 40 years14.

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