The C WORD
Stats on HIV and cancer don’t usually make for uplifting reading
but it’s not all gloom and doom, writes Robert Fieldhouse
Non-Aids-defining
cancers are now more common in people living with HIV than Aids-defining ones,
according to research presented at the 2007 14th Conference on Retroviruses
and Opportunistic Infections (CROI).
By Aids-defining we mean cancers like Kaposi’s sarcoma (KS), non-Hodgkin’s
lymphoma (NHL) and cervical cancer identified in the early 1980s in HIV positive
people as being mainly due to immune deficiency.
Not just about longer lives
Latest research suggests having a low CD4 count on treatment ups our risk
of developing a large number of cancers. This is on top of any cancer risk
associated with us living longer thanks to antiretrovirals. We’ve known
for a while that allowing your CD4 count to drop very low before starting
therapy is risky when it comes to cancer. Having a higher CD4 count on treatment
seemed to offer us some protection.
Recently, the D:A:D study that has followed more than 23,000 people living
with HIV across three continents since 1999 looked at cancer. It found the
four most frequently reported fatal non-Aids defining cancers were lung (20
per cent); gastrointestinal tract such as stomach or liver (13 per cent);
the haematological system, such as Hodgkin’s lymphoma (seven per cent);
and anal cancer (seven per cent).
A quarter of the 1,246 deaths in the D:A:D study were due to cancer; 193 from
non-Aids-defining cancers and 112 from Aids-defining including NHL (82), KS
(28), and cervical cancer. Over 95 per cent of of those who died of cancer
had taken antiretroviral therapy. About two thirds of people with non-Aids-defining
cancers and almost half of those with Aids-defining cancers were on antiretroviral
therapy when they died.
CD4 counts count
These findings tallied with the FIRST study, also presented at CROI. It found
people with lower CD4 counts on HIV therapy remain at an increased risk of
developing non-Aids-defining illnesses including cancer.
On the up side, researchers found the risk of non-Aids-defining illnesses
(including 32 cancers) decreased around 16 per cent for every 100 CD4 cell
count increase. And the risk of Aids-defining cancers fell 43 per cent for
every 100 CD4 cell increase on therapy.
While stats sound pretty bleak, the good news is that, overall, rates of both
Aids-defining and non-Aids-defining cancers have fallen. D:A:D researchers
suggested the improvement might be due to cancer being diagnosed earlier and
being treated more aggressively. D:A:D also revealed that the risk of cancer
increased for each additional five years of age. Smokers were at the greatest
risk, particularly of lung cancer.
Smoking and HPV
Dr Graeme Moyle, of London’s Chelsea and Westminster hospital, told
PN: “Lymphoma has not declined as much in the HAART era as Kaposi’s
sarcoma. Anal cancer is certainly more common in gay men than heterosexual
men and is certainly more common in the HIV setting.
“Liver cancer is related to chronic hepatitis infection. The next most
common is smoking-related lung cancers. There have been a number of reports
of increased prevalence among people with HIV. Smoking has been associated
with cervical cancer, and is likely also to be linked with anal cancer.”
Recent research has shown that gay men with cancer-causing variants of HPV
(human papilloma virus) who smoke have higher HPV levels, which could lead
to faster progression to anal cancer compared with non-smokers.
“At least for cervical cancer there is hope in future of some protection
afforded by Gardasil or Cervarix vaccination although for the current generation
it is really just a case of maintaining quality screening programmes.
“There are risk factors around the number of cancer-associated HPV subtypes
that an individual is infected with being influential over the risk of cancer.
Safer sex messages are relevant for HPV.”
Quit clinics
Many HIV clinics across the country refer patients to smoking cessation courses
in primary care or the voluntary sector. GMFA in London have run a successful
course for years. Dr Moyle’s hospital is talking to funding bodies about
setting up their own HIV specific stop smoking clinic.
“Beyond nicotine patches and Zyban, there’s also a new smoking
cessation drug that Pfizer are developing and there’s an obesity drug
from Sanofi-Aventis that may be useful in smoking cessation,” said Moyle.
“There will be increased focus in years to come to get HIV positive
people to stop smoking. The cocktail of HIV and smoking may be a particularly
deadly one.”
Why more cancers?
People living with HIV are more likely to develop some forms of cancer than
the general population. These include the Aids-defining cancers (see above).
Other cancers are not regarded as Aids-defining since, despite occurring at
a higher rate in people living with HIV, their presence is not solely linked
to immune deficiency. Instead, researchers think the higher rates in people
living with HIV are linked to smoking, sexual activity or the presence of
other viruses like HPV for cervical/anal cancer or HHV8 for KS. This year
(in a non-HIV study) researchers reported that men who had ever had gonorrhoea
were twice as likely to develop bladder cancer.
Non-Aids-defining cancers include Hodgkin’s disease, lung cancer, liver
cancer, anal cancer, squamous cell carcinoma of the eye, skin, or lip, testicular
cancer, multiple myeloma (a type of leukaemia) and leiomyosarcoma, a type
of connective tissue cancer.
US researchers found people living with HIV were at more risk of the following;
a 310-fold risk of KS; a 113-fold risk of NHL; a 36.7-fold risk of blood vessel
cancer; a 7.6-fold risk of Hodgkin’s disease; a 4.5-fold risk of multiple
myeloma; a 3.5-fold risk of brain cancer and a 2.9-fold risk of testicular
cancer.
French researchers reported four times the rate of anal cancer in HIV positive
people since HAART compared with rates in the early 1990s. It’s possible
to screen for early signs of anal cancer using a test similar to a pap smear
used to screen for cervical cancer in women. Screening allows doctors to identify
those most at risk of anal cancer but few HIV clinics offer this test.
Statistics on HIV and cancer don’t make for uplifting reading, but here
two people behind the stats tell inspirational stories.
Rob: recent KS diagnosis
Back in September 2005 I noticed marks on my skin. At the back of my mind
I had an idea what it might be but decided I couldn’t deal with a cancer
and HIV diagnosis before Christmas. So I waited for an HIV test and focused
on having the best Christmas ever, as I thought it would be my last.
I went for a same day test and the doctor told me they were pretty certain
that the lesions were KS. The GU department pulled out all the stops. I had
CD4, viral load and resistance testing and saw a consultant there and then.
They put me straight on septrin to prevent PCP because they suspected I had
a very low CD4 count. Surprisingly, it came back at 220 and my viral load
around 500,000.
Tests confirmed KS. The lesions were also in my lungs and liver. I started
with and remain today on Kaletra and Truvada.
Cancer specialists saw me within a week. I started a course of chemotherapy.
It was tough and I developed cellulitis and ended up on morphine and antibiotics.
After 12 chemo cycles I’m now in remission and my CD4 count has recovered
to 350.
I left it so late to test for HIV because I did not want to face the situation.
Knowing what I know now makes me feel differently. The KS is gone and I’d
recommend anyone in a similar position go for a test.
Leigh: breast cancer shock
I’ve been diagnosed with HIV for 20 years and three years ago was diagnosed
with breast cancer. I had a mastectomy and radiotherapy at the time although
I had very aggressive cancer they thought that chemotherapy might be fatal.
Last year another lump was discovered and the cancer had returned. I have
just been through chemotherapy and this time it was strongly recommended.
Thank God I have finished that. At present I have a year’s herceptin
treatment to follow.
What is cancer?
Human organs and tissues are made up of cells. Cells are constantly dying
off, and new onese replace them. Normally, cell growth and division is orderly
and controlled but if this goes wrong, cells will continue to divide and develop
into a lump or tumour. In benign tumours, cells do not spread to other parts
of the body. Malignant tumours continue to grow and may spread to surrounding
organs. These are cancers.
Cancer is not a single disease; there are more than 200 different kinds, each
with its own name and treatment. One in three of the general population will
develop some form of cancer during their lifetime.
A recent European study found half the 1.4 million cases diagnosed each year
were preventable. The study looked at 11 cancers that can be prevented by
lifestyle changes such as reducing smoking, obesity and alcohol intake as
well as increasing physical activity and eating more fruit and veg.
Five main types of treatment
• Watchful waiting
Some cancers grow slowly and may cause no problems for many years without
treatment. Doctors monitor these closely so if the cancer grows they can be
treated.
• Surgery
If the cancer has not spread too far an operation may be able to remove the
tumour. surgery may be used to remove cancer-affected lymph nodes.
• Radiotherapy
High energy x-rays are carefully targetted at the affected area, killing cancer
cells while causing minimal harm to normal cells. It can cause side effects,
the most common being tiredness.
• Chemotherapy
Toxic drugs that inhibit cells’ ability to reproduce are fed into the
body. They affect all cells but because cancer cells reproduce rapidy they
are affected most. There are more than 50 different chemo drugs, often used
in combination. Side effects depend on which drug (or combination of drugs)
is used, but tiredness and nausea are common.
• Hormonal therapy
Some cancers depend on certain hormones to divide and grow. By altering hormone
levels or by blocking the hormones from attaching to cancer cells, the cancer
can be controlled.
• Other treatments
These include chemicals like interferon and interleukin which stimulate the
body’s immune system to attack the cancer cells. Monoclonal antibodies
are drugs that `locate’ specific cancer cells and attach themselves,
thereby destroying them. They can be used alone, or a radioactive molecule
can be attached which then delivers radiation directly to the cancer cells.
Vaccines may also be able to reduce the chance of a cancer coming back, but
research is in the early stages. Some of these treatments are also being explored
for their ability to work against HIV.
Consider prevention
Many cancers affecting people living with HIV are preventable. By stopping
smoking, taking up exercise and improving our diets we can reduce our cancer
risk. Avoiding exposure to other viruses, sexually transmitted and otherwise,
will reduce the risk further still.
Early diagnosis, monitoring and treatment is key to curing cancer. In recent
years doctors have begun treating cancers in people living with HIV as aggressively
as they would in the HIV negative population. This means you should not accept
a cancer diagnosis as the end. PN readers who contributed to this article
are testament to the possibility of a life following diagnosis with HIV and
cancer.
• Macmillan cancer support and London Friend provide twice monthly peer
emotional support, information and guidance to gay men affected by cancer.
020 7833 1674
• Other cancer support groups are being set up by HIV clinics across
the country
