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Certain cancers increase in pts on long-term ART
Focus should be on screening
HIV clinicians are seeing increasing numbers of patients who are developing cancers associated with infectious agents, particularly in the areas of the oropharynx and genitals, researchers say.
A chief culprit is the human papillomavirus (HPV). Squamous cell carcinomas (SCC) are associated with HPV at specific sites.1
"We've found HPV in tissues of young African American men who have sex with men (MSM)," says Minh Nguyen, MD, an assistant professor of medicine at Emory University in Atlanta, GA.
"We have found that the incidence of SCC is higher among people with HIV in our clinic than among the general population in the metro-Atlanta area in Georgia," Nguyen says.
"This suggests that it's really important to emphasize screening for that cancer," says Kira Harvey, MPH candidate and research assistant in global epidemiology at Emory University.
For female HIV patients, a cervical pap smear twice a year when they first are seen at a clinic is common practice, Nguyen says.
"If there are any abnormal cells then they get a more detailed examination of the cervix," Nguyen says.
MSM also need to be screened for HPV infection in the mouth or rectal-anal areas.
"Rates for cervical cancer are lower than for rectal-anal cancer, and cervical cancer screening is emphasized a lot," Harvey says. "Also, it's important to look at seeing whether an HPV vaccine could in the future lower these rates."
Some studies have shown that it's acceptable to use the HPV vaccine on HIV-positive individuals, Harvey notes.
A three-pronged approach to preventing squamous cell carcinomas in an HIV population involves encouraging HIV patients to be vaccinated against HPV, educating them about practicing safe sex with condoms and dental dams, and doing more screenings and diagnoses, Nguyen says.
However, rectal-anal screening for HPV in men remains a controversial issue, Nguyen notes.
"The cervix doesn't connect to the bowels so you can keep on burning it and destroy normal tissue without affecting other tissue," he explains. "But with the rectum if you burn it a person can become incontinent, so the approach is different than how you would approach the cervix in women."
The New York Department of Health does not recommend screening that would remove tissue for testing in the rectal area because it's more subject to scarring than the cervical area, he says.
"So the New York Department of Health is recommending providers do a digital rectal exam once a year, feeling for any kind of mass," Nguyen says.
Other experts have recommended an anal pap smear, but high resolution endoscopy would be a better screening approach, he adds.
"We're now recommending high resolution endoscopy," Nguyen says.
Annual dental exam a must
Each year, HIV patients should be given a dental exam in which the clinician looks for bumps under the neck area, tongue area, and inside the mouth. These could be a marker for HPV infection in the mouth, Nguyen says.
HIV clinicians also should encourage their patients to get the HPV vaccine and practice safe sex with condoms and dental dams, he adds.
"In our clinic we recommend safe sex for everybody," he says.
Harvey, Nguyen, and co-investigators became interested in learning more about the types of cancers impacting patients of an urban AIDS clinic in the era of successful antiretroviral therapy (ART).
"We compared cancers between 2000 and 2007 with the general population and with the metro-Atlanta population," Harvey says.
"We looked at age distribution and risks, and what we found was that for almost all of the squamous cell carcinoma there was a significantly higher incidence in clinic patients than in the general population," she says. "We looked at patients enrolled in the clinic and studied cancers in the head, neck, rectal, lungs, and genital areas."
For the bronchial and lungs areas, there were not any conclusive or significant findings, Harvey says.
For cervical cancer there was a significantly lower one-year survival time among HIV patients. Also, for cervical, head and neck, and anal-rectal cancers, there was a significantly lower survival time for the clinic population, she adds.
"We could not find results for the bronchial area because nobody survives for five years with that cancer," Harvey says. "Basically, for most of these cancers, people who have them in the clinic survived less."
Investigators tried to control for smoking, but were unable to do so because of a lack of accurate data, she notes.
"Some studies have found a link between lung cancer and HIV beyond increased smoking, but this study looked at one kind of lung cancer and not at lung cancer in general," Harvey says.
They did find that the majority of cancers occurred among clinic patients who were in the 30 years to 50 years age group, while most of the cancers among the general population occurred in people over age 50, she adds.
"But that also reflects the demographics of this clinic which has a younger population," Harvey says.
"In the future we want to look at other risk factors and whether people are on treatment when they're diagnosed, but we didn't have the medical records to do that for this study," she adds.