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ORLANDO – "HIV status alone should not be used for cancer treatment decision-making."

That's the most important takeaway message of the first guidelines issued by the National Comprehensive Cancer Network (NCCN) for the treatment of cancer in patients living with human immunodeficiency virus (HIV), said Gita Suneja, MD, of Duke University in Durham, North Carolina, and co-chair of the NCCN committee that wrote the guidelines.

The bottom line for the new treatment algorithm:

"HIV status alone should not be used for cancer treatment decision-making," Suneja repeated.

With better treatments for HIV developed over the past 20 years, AIDS-related cancers have decreased in this population to the point that the rate of non–AIDS-related cancers is now higher in the HIV population.

"Cancer is now the leading cause of death of people living with HIV," she said. "Co-management by an oncologist and an HIV specialist is essential for these patients because modifications to antiretroviral therapy, supportive drugs or cancer therapy may be needed."

The new guidelines were prompted by recent surveys in which 20% to 25% of practicing oncologists said they would not treat a patient living with HIV for cancer, Suneja said, with 70% of those doctors saying that guidelines on the treatment of these patients were insufficient; 45% of the doctors said they rarely discussed management of these patients with an HIV specialist.

Five cancers related to patients with HIV infection are specifically referred to in the new guidelines: Kaposi's sarcoma, Hodgkin lymphoma, and cervical, anal and lung cancers.

She cautioned that when doing imaging as part of the workup for patients living with HIV who are suspected of having a malignancy, clinicians should realize that some lesions of the brain, bone, lung, spleen, liver or gastrointestinal tract may be infections caused by HIV and not metastases.

Kaposi's sarcoma was one of the first cancers associated with HIV development, Suneja said. The incidence of the invasive skin disease has decrease more than 90% among HIV patients who have controlled their disease with antiretroviral combination therapy, but she said that the disease occurs 250 times more often in people living with HIV than in the non-infected population.

In treating Kaposi's sarcoma, Suneja said that if the lesion is asymptomatic and cosmetically acceptable, antiretroviral therapy and observation are recommended. If the lesion becomes symptomatic, patients should be treated with antiretrovirals and should be recommended for a clinical trial. Other acceptable treatments include topical remedies, systemic therapy, intralesional chemotherapy, radiation therapy or local excision.

If the patient is stable or there is a response to the treatment, then antiretroviral therapy should be continued and observation is recommended until there is disease progression.

As with all NCCN guidelines, treatment in a well-designed clinical trial is always an acceptable option, she said.

Suneja said the guidelines for the other cancers suggest using the algorithms already suggested for treatment among persons without HIV infection, with some considerations:

• Hodgkin's lymphoma patients who also have HIV are likely to have more aggressive disease, including B symptoms and bone marrow involvement
• Women with cervical cancer should also be evaluated for vulvar or anal cancer since these cancers are linked to human papillomavirus (HPV) infection as well -- more-persistent HPV infection occurs in patients with HIV, and endocervical extension of precancerous lesions is more common
• For patients with anal cancer, which is seen 15- to 19-times more frequently in those with HIV infection, the post-treatment surveillance should be performed more often than in non–HIV-infected patients -- the guidelines suggest every 3 to 6 months for 3 years
• Because people living with HIV have higher smoking rates, the guidelines for lung cancer include a message to promote smoking cessation -- people living with HIV should undergo lung screening as recommended by NCCN guidelines

The new set of guidelines also offers detailed treatment support recommendations, Suneja said, with details on how to treat various opportunistic infections that may emerge during therapy as well as prophylactic treatment for preventing fungal infections.

The NCCN guideline writing committee included 26 doctors, pharmacists and patient advocates, representing most of the 27-member institution. NCCN guidelines are used worldwide as a guide for treating scores of cancer and cancer-related conditions.

Commenting on the guidelines from the audience, Samuel Silver, MD, of the University of Michigan in Ann Arbor, said, "These are great guidelines, but I want more -- especially non-Hodgkin's lymphoma."

Suneja stated that the next round of guidelines will include recommendations for other cancers.

Silver said he routinely screens his patients for their HIV status, noting that he has never had a patient question why he was doing so. Suneja said she thinks that more clinicians should be testing for HIV in patients with lymphoma and other malignancies related to HIV.

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