Living with HIV and other LGBTQ Issues!!: Cancers

Thursday, September 8, 2016

Cancers

Submitted on Jun 27, 2016

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What Is Cancer?

Cancer refers to the abnormal and uncontrolled growth of certain cells that can get in the way of normal body functions. Cancer can spread (metastasize) from where it starts growing to other organs and parts of the body. Cancer can destroy healthy cells and cause illness and death.
A healthy immunesystem helps to prevent cancer. Because those living with HIV (HIV+) have weakened immune systems, it is easier for people living with HIV to be infected with viruses that can lead to cancer. These viruses include:

Human papilloma virus (HPV): there are several types of HPV; certain types can cause cervical and anal cancer, as well as vaginal, vulvar, penile, and head and neck cancers

Epstein Barr Virus (EBV): EBV can cause both non-Hodgkin's and Hodgkin's lymphomas

Hepatitis B and Hepatitis C viruses: these can cause liver cancer

Human herpesvirus 8 (HHV-8), which can cause Kaposi's sarcoma

The following types of cancer lead to an AIDSdiagnosis: Kaposi's sarcoma, certain types of lymphoma, and cervical cancer. Other non-AIDS defining cancers for which people living with HIV are at increased risk include anal, liver, and lung cancer. All of these are explained in detail below.

Kaposi's Sarcoma (KS)

KS was one of the most common opportunisticinfections (OIs) in the early days of the AIDS epidemic.

HHV-8 is the virus that causes KS. It is transmitted through sexual contact or blood products. KS has always been less common in women than in men, but is less common in all people with HIV since the use of newer, more effective HIV drug combinations.

A recent study found that some people living with HIV who have KS find that their KS gets worse after starting HIV drugs. This is most likely due to IRIS (immunereconstitution inflammation syndrome), which happens when your immune system acts so strongly and so quickly that it causes lots of inflammation that can actually make your symptoms worse. KS-IRIS usually happens more often in people living with HIV who have higher HIV viral loads, higher KS viral loads, and more advanced KS disease.

KS on the skin is not life threatening. However, if KS spreads to other parts of the body, especially the lungs, it can cause serious problems. An oncologist (a doctor who specializes in cancer) usually suggests treatment options based on factors such as the size, number, and location of KS tumors. However, the first treatment for KS is to begin HIV drugs. Your HIV provider and other specialists (e.g., radiation oncologist, dermatologist) may be involved as well.

Symptoms (by location)

Skin (most common site of KS):

Flat or raised, and usually painless lesions that do not itch or drain

Lesions may be pink, red, purple, or brown – or resemble "blood blisters"

There may be swelling, especially in the legs (lymphedema)

Oral cavity (inside the mouth):

Lesions as described above

Trouble eating and swallowing

Gastrointestinal tract tumors:

Diarrhea (loose or frequent stools)

Cramping

Bleeding

Lung tumors:

Breathing problems

Bad cough

Diagnosis

Usually made by biopsy (sample of tissue taken and examined under microscope)

Treatment

HIV drug therapy alone may make lesions or tumors shrink or disappear (go into remission)

Depending on the location of the KS, cancer specialists will recommend some combination of chemotherapy and radiation therapy

Lymphoma
Lymphoma involves the uncontrolled growth of lymph cells that may spread to other organs, including bone marrow, the brain or spinal cord (central nervous system, or CNS lymphoma), and the gastrointestinal tract (GI lymphoma). The lymph system is a key part of the immune system and is part of the circulatory system as well. The Epstein-Barr virus (EBV) may play a role in the development of lymphomas.

The two major types are:

Non-Hodgkin's lymphoma (NHL)

Hodgkin's lymphoma (also called Hodgkin's disease)

Lymphomas can be more advanced and harder to treat in people living with HIV, especially CNS lymphoma.

Symptoms

Swollen lymph nodes

Fever, chills, sweats

Weight loss

Belly pain or swelling; nausea; gassy or bloated stomach (GI lymphoma)

Headache; changes in vision, alertness, or personality; confusion; problems with balance (CNS lymphoma)

Diagnosis

Biopsy of affected part of the body (e.g., lymph node, lung, intestine, etc.)

Treatment

Depending on the size, type, and location of the lymphoma, cancer specialists will recommend some combination of chemotherapy, radiation therapy, and surgery

Cervical Cancer
Cervical cancer is strongly linked to the humanpapilloma virus (HPV). HPV is the most common sexuallytransmitted infection in the US. Different strains of HPV cause warts or abnormal cell growth (dysplasia) near the anus or cervix (entrance to the womb).

Abnormal cell growth is more common in women with advanced HIV disease and low CD4 cell counts. It is often more severe and difficult to treat than in HIV-negative women. Untreated dysplasia can lead to cervical cancer, which can be life threatening. HPV may also cause cancer in the vagina, vulva, and anus.

The good news is, when dysplasia is found and treated early, cervical cancer can be prevented. Cervical screening tests are used to look for changes in the cervix, including dysplasia and cervical cancer. Cervical cancer usually takes years to develop, and it does not usually have symptoms until it is quite advanced. This is why getting screened for cervical cancer on a regular basis is important; screening can catch potential problems before they get worse. For more information on getting a gynecologic exam, see our article on Caringfor a Woman's Body.

Prevention

The other good news is that there are three widely used HPV vaccines: Gardasil (made by Merck; also known as Silgard), Gardasil-9 (also made by Merck), and Cervarix (made by GlaxoSmithKline). These vaccines protect against the types of HPV that cause the most cervical cancers and genital warts. Pregnant women should not receive the vaccine, although it is safe to get the vaccine while breastfeeding.

All three HPV vaccines have been approved by the US Food and Drug Administration (FDA), Health Canada, and the European Medicines Agency (EMA). Gardasil-9 is still awaiting approval in the UK. In the US, Gardasil products are approved for females and males ages 9 to 26, while Cervarix is approved for females ages 10 to 25. There are now demonstration projects that are bringing HPV vaccines to girls and women in low-income countries as well.

It is best if young people get all doses of the vaccine before their first sexual contact. This helps them develop an immune response before they are exposed to HPV. People who are infected with some types of HPV may still benefit from the vaccine's effects against other types of HPV. The US Centers for Disease Control and Prevention (CDC) recommends HPV vaccines for all girls and young women ages 11 through 26 and all boys and young men ages 11 through 21 (even if they have already become sexually active).

In Canada, the National Advisory Committee on Immunization (NACI) recommends Gardasil vaccination for females and males ages nine through 26, or vaccination with Cervarix for girls and young women ages nine through 26. In the UK, vaccination with Gardasil is offered to girls ages 12 and 13 through the National Health Service.

Symptoms

Many women do not experience symptoms

Bleeding between periods and bleeding after sexual intercourse are two signs of advanced cervical dysplasia

Diagnosis

Screening for dysplasia and cervical cancer is essential to find and treat early pre-cancerous changes and to prevent cervical cancer. Traditionally, the Papanicolaou test (Pap test or Pap smear) has been done. This test uses a small brush to collect a few cells to check for changes in the cervix. Now, liquid based systems to screen samples of cervical cells are much more common and are effective for finding abnormal cells.

Treatment for cervical cancer

Treatment depends on the type of cervical cancer and how far it has spread. Often, more than one kind of treatment is used.

LEEP (loop electrosurgical excision procedure): Using a thin wire loop with an electrical current to cut away abnormal tissue

Cryotherapy: Freezing the cells with liquid nitrogen

Laser therapy: Using an intense light to destroy the cells

Cold-knife cone biopsy (conization): Cutting the cells out

In cases of mild dysplasia, your health care provider may just monitor the cervix by repeat Pap or HPV test

Surgery: Hysterectomy (removal of the uterus, including the cervix)

Chemotherapy: Drugs (pills and/or intravenous medications) are used to shrink or kill the cancer

Radiation: High-energy rays (similar to X-rays) are used to kill the cancer cells

Anal Cancer
Anal cancer is on the rise, in men as well as women. It is also tied to specific strains of HPV. An anal Pap smear and physical examination are the best ways to detect anal dysplasia. It is important to ask your health care provider to perform these tests on a regular basis. Because some of the same strains of HPV that cause cervical cancer can cause anal cancer, getting vaccinated with one of the three FDA-approved HPV vaccines can help to prevent anal cancer, too.

Symptoms

Anal bleeding or discharge

Itching, pain, or pressure in the anal area

A lump or swelling in the anal area

Changes in bowel movements, including changes in the diameter of stool

Diagnosis

Anal pap smear

Anal pap smears check for changes to the anus; some experts recommend that people living with HIV receive regular anal pap smears

Your provider may also perform a digital rectal exam (DRE). During this test, the provider inserts a gloved and lubricated finger into the anus to feel for lumps or abnormalities.

Anoscopy

If you have an abnormal anal Pap, you may need an anoscopy (an exam of your anus using a microscope to look at the tissue more closely)

During the anoscopy, your health care provider may remove a tissue sample (biopsy) for laboratory examination to determine if the abnormal cells are cancerous

Treatment

Infrared coagulation (IFC): Using short bursts of infrared light to cut off the blood supply to the affected area

Laser therapy: Using an intense light to destroy the cells

Electrocautery: Burning off the cells with an electrical current

Trichloracetic acid: Burning off the cells with acid

Surgery

Chemotherapy with radiation

Liver Cancer
The increased risk for liver cancer among people living with HIV is strongly linked to infection with the hepatitis B and/or hepatitisC viruses (HBV and HCV, respectively). Researchers have also shown a direct link between having a low CD4 cell count and having an increased risk for liver cancer. Other factors involved in damaging the liver include opportunisticinfections (e.g., Mycobacterium avium complex, tuberculosis, cytomegalovirus, and cryptosporidium), excessive alcohol and recreational drug use, and even some HIV drugs.

Symptoms

Many people have no symptoms until the disease is very advanced

Weight loss

Nausea and vomiting

Upper belly pain

Loss of appetite

White, chalky stool

Swelling of the belly

Jaundice (yellowing of the eyes and/or skin)

Diagnosis

Blood tests to check liver function

Imaging tests (e.g., CT scan, ultrasound, MRI) to look for masses

Biopsy: removing a tissue sample by inserting a needle through the skin and into the liver

Treatment
Depending on the size, type, and location of the liver cancer, your provider will suggest treatment, which may include:

Chemotherapy

Radiation

Surgery to remove a part of the liver

Liver transplant surgery to remove the liver and replace it with healthy liver from a donor

Radiofrequency ablation: Using electrical current to heat and kill cancer cells

Lung Cancer
Although lung cancer is not an AIDS-defining cancer, people living with HIV have a greater chance of developing lung cancer than HIV-negative people. This difference is likely due to the weakened immune systems of those living with HIV. Unfortunately, lung cancer is one of the deadliest cancers. In the US, it is the leading cause of cancer-related deaths among both women and men.

An increased risk of developing lung cancer is also strongly tied to smoking. Both the duration (how long) and amount (how much or how many per day) of smoking contribute to the risk for lung cancer. Second-hand smoke exposure (breathing smoke in the environment) also contributes to an increased risk for lung cancer.

Researchers recently reported that smoking is the single biggest risk factor for non-AIDS defining cancers among people living with HIV in the US. Smoking has more of an effect on the risk of a person with HIV getting cancer than having a low CD4 count, a non-suppressed viral load, hepatitis C, or an AIDS diagnosis.

The best way to prevent lung cancer is to avoid or stop smoking. For more information, see our article on Smokingand Tobacco Use.

Symptoms

Cough, with or without phlegm or mucus

Coughing up blood

Shortness of breath

Chest pain

Fatigue

Loss of appetite

Diagnosis

Sputum sample for microscopic examination, which shows if abnormal cells are present in the lungs. Sometimes a person can cough up the sputum (mucus or phlegm). If not, a procedure known as bronchoalveolar lavage (BAL) can be done. In this procedure, sputum is obtained by placing a small tube down the windpipe.

Bronchoscopy: insertion of a thin, flexible tube with a light on the end into the windpipe to look inside the lungs and possibly take a sputum or tissue sample for examination under a microscope

Biopsy: removal of a tissue sample for examination under a microscope

Imaging tests: chest x-ray, CT scan, PET scan, or MRI

Treatment
Depending on the size, type, and location of the lung cancer, cancer specialists will recommend some combination of chemotherapy, radiation therapy, and surgery.

Conclusion
Cancers can be very serious for people living with HIV. On-going medical care allows for early diagnosis and treatment, or even prevention, in the case of cervical and anal cancers.
Seeing your health care provider on a regular basis and taking your HIV drugs regularly can help keep your immune system strong and your CD4 cell counts up. This also helps fight off cancers.

Additional Resources

Select the links below for additional material related to cancers.