Didactic Series

Cancer and HIV/AIDS

Daniel Lee, MD UCSD Medical Center – Owen Clinic October 12, 2017

1 Learning Objectives

• To identify AIDS defining cancers vs non- AIDS defining cancers • To understand which cancers are at increased risk in HIV/AIDS • To identify cancer screening modalities appropriate for HIV/AIDS

2 Poll Question #1

Do you see increased numbers of malignancies in your HIV+ patients?

A. Yes B. No C. Maybe

3 AIDS Defining Cancers

Development of the following indicates AIDS diagnosis: 1.Kaposi’s sarcoma 2.Cervical cancer 3.Non-Hodgkin’s Lymphoma (CNS Lymphoma, Primary Effusion Lymphoma)

4 Non-AIDS Defining Cancers

• • Breast Cancer • • Prostate Cancer • Hepatocellular Cancer • Lung Cancer • Skin Cancer • Hodgkin’s Lymphoma • Other Cancers 5 Poll Question #2

Are you seeing more AIDS defining cancers (ADC), non-AIDS defining cancers (nADC), or similar numbers of both types of cancers?

A. ADC > nADC B. nADC > ADC C. ADC = nADC

6 Cancers in the Pre- and Post-HAART Era

7 Cancers in the Pre-HAART Era

8 Cancers in the Post-HAART Era

9 Incidence of Non-AIDS Defining Cancers Increasing in HIV+ Patients • Incidence of cancers was increased significantly in ASD/HOPS cohort (HIV+) vs general population (HIV-):

Cancer Type SRR (95% CI)* Anal 42.9 (34.1-53.3) Vaginal 21.0 (11.2-35.9) Hodgkin lymphoma 14.7 (11.6-18.2) Liver 7.7 (5.7-10.1) Lung 3.3 (2.8-3.9) Melanoma 2.6 (1.9-3.6) Oropharyngeal 2.6 (1.9-3.4) Leukemia 2.5 (1.6-3.8) Colorectal 2.3 (1.8-2.9) Renal 1.8 (1.1-2.7) *Standardized ratio rate: observed ASD/HOPS (HIV+) rate to standardized rate (SEER, HIV-). 10

Patel P. Ann Intern Med. 2008;148(10):728-736. HIV and Risk of Non-AIDS Malignancies • Meta-analysis: 444,172 HIV+ persons, 31,977 transplant patients • For 20 / 28 cancers examined there was significantly increased incidence in both groups – strongly suggesting a link with immunodeficiency

Standardized Incidence Ratio HIV/AIDS Transplant Hodgkin lymphoma 11.03 3.89 Liver 5.22 2.13 Stomach 1.9 2.04 Anal 28.75 4.85

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Grulich et al. Lancet. 007;370(9581):59-67. Poll Question #3

Why is there an increased risk of malignancies in HIV?

Please type your answer in the chat pod

12 Increased Risk of Cancer in HIV

• Weakened immune systems with HIV leads to inability to fight cancer • Higher rates of co-infection with HIV and other viruses linked to cancer (HBV,HCV, HPV, HHV-8, EBV) • Prevalence of traditional risk factors are higher in HIV infected (smoking, heavy alcohol use)

13 Incidence of Anal Cancer

http://www.anchorstudy.org/anal-cancer-risk-among-hiv-positive-men-and-women 14 Screening for Anal Dysplasia/Cancer

• Currently no consensus guidelines on screening 1.HIVMA/IDSA HIV Primary Care Guidelines (2014) – Aberg et al. Clin Infect Dis. 2014 Jan;58(1):1-10 2.HIV Clinical Resource – https://www.hivguidelines.org/adult-hiv/preventive- care-screening/anal-dysplasia-cancer/ 3.Refer to HIV Learning Network talk by Dr. Chris Mathews on 4/13/17

15 Screening for Anal Cancer

MSM

Females - anal receptive sex or abnormal cervical pap

Heterosexual Males – anal receptive sex Pap Anal Anal/Genital Warts

16 Anal Cancer Screening

HPV vaccine all females 9-26y, males 9- Annual Anal Pap 21y(consider 22-26y if not vaccinated)

ASCUS LSIL HSIL

High Resolution Anoscopy/Biopsy

17 Poll Question #4

25 y F newly diagnosed with HIV, CD4 186, VL 10,500 comes for her initial visit. She tells you she has had recurrent genital warts. What cancer screening do you recommend on her initial visit? A. Anal pap and cervical colposcopy B. Cervical pap only C. Anal pap and cervical pap D. Anal pap only

18 Cervical Cancer Incidence

• HIV infected women have increased risk of high grade HPV types and CIN • More likely to have persistent HPV due to immunosuppression • In HIV + women who received routine cervical cancer screening the incidence of cervical cancer is not higher than general population http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice- Bulletins-Gynecology/Gynecologic-Care-for-Women-With-Human-Immunodeficiency-Virus 19 Cervical Dysplasia/Cancer Screening • Guidelines: www.acog.com • https://www.hivguidelines.org/adult- hiv/preventive-care-screening/cervical- dysplasia-cancer/

20 Cervical Cancer Screening

Initial Visit 6 months Annual Cervical pap Cervical

21 Cervical Dysplasia/Cancer

• Age 9 to 26 vaccinate Cervical Pap with Gardasil

ASCUS • Repeat pap q3-6months until 2 LSIL successive normal paps then annual HSIL

• All cervical GYN referral HSIL also Colposcopy referred for HRA

22 of Liver • Increase risk in HIV due to coinfection with HCV, HBV, and alcohol use • Screening in HBV carriers or past infection, HCV coinfection, cirrhotics • Imaging (U/S in noncirrhotics, CT/MRI in cirrhotics) every 6 months • AFP no longer recommended (lacks sensitivity/specificity for surveillance)

23 www.aasld.org • Matched cohort study comparing HIV infected to uninfected enrollees • Risk of Colon Cancer is not increased in HIV infected patients compared with general population • Decreased colorectal cancer screening despite increased frequency of PCP visits

24 25 Colorectal Cancer Screening

Annual Fecal Immunochemical Colonoscopy every Test for occult blood 10 years Screening at Flex Sigmoidoscopy Age 50 every 5-10 years

CT Colonography every 5 years

Guidelines: www.uspreventiveservicestaskforce.org/ www.gi.org

26 • Prostate cancer incidence especially for higher grade cancers was less in HIV-infected men vs HIV negative men • More frequent screening especially with testosterone therapy • Hypogonadism with lower testosterone levels may contribute to lower risk of prostate cancer 27 Screening for Prostate Cancer

• Controversial guidelines • USPSTF and CDC does not recommend PSA testing • ACS and AUA recommend PSA and DRE • Guidelines differ for those men on testosterone therapy • No separate guidelines for HIV-infected men

28 Prostate Cancer Screening (ACS)

Discuss risk vs benefits of screening

Screening Age 50 for asymptomatic men Age 45 for 1st degree relative w/prostate CA Age 40 for multiple relatives w/prostate CA No screening for men < 10 y life expectancy

PSA w/wo Digital Rectal Exam (DRE) PSA < 2.5mg/ml repeat every 2 years PSA > 2.5mg/ml repeat annually

29 Cancer Prevention in Persons Living with HIV • Smoking cessation • prevention and treatment • Virologic control of HIV with HAART • Screening: follow current guidelines in HIV- infected persons

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Aberg J, et al. Clin Infect Dis. 2009;49:651-681. Summary

• While we may see less AIDS defining cancers due to better control of HIV, we continue to see non-AIDS defining cancers as our patients live longer • Some cancers, such as anal cancer (but not all), are at increased risk in HIV/AIDS • Remember to screen HIV+ patients for malignancies, just as you do for HIV- patients

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