World AIDS Day: Professor Mark Bower on HIV-related cancers

World AIDS Day

To mark World AIDS Day 2017, we have published a series of blog posts to highlight the important and varied research that takes places at Imperial. Three experts from Faculty of Medicine share their interest in HIV/AIDS which spans from the elusive vaccine to the economics of the epidemic.

World AIDS Day takes place annually on 1 December as an opportunity for people worldwide to unite in the fight against HIV and to show support for people living with HIV/AIDS.

Oncologist turned HIV expert

As a medical oncologist at Chelsea and Westminster Hospital, I specialise in the treatment of HIV-related cancers at the National Centre for HIV Malignancy – Europe’s largest research and treatment institute for these cancers. Over the last 25 years, I have seen an astonishing improvement in the outcomes of people diagnosed with both HIV and cancer, so that patients under my care with most HIV associated cancers now have the same overall survival as HIV negative patients.

The population of people living with HIV is ageing

One less welcome finding in recent years is the rising number of non-AIDS defining cancers – cancers not previously associated with severe immunosuppression and AIDS – amongst people living with HIV. Overall, the risk of cancer rises with age, although the age-related risk of individual types of cancers varies. In the UK half of all cancers are diagnosed in people over the age of 70 years old. The combination of increasing age of people living with HIV and the rising rates of cancer with age, is reflected in the changing epidemiology of non-AIDS defining cancers amongst people living with HIV. This was first described in the US by Shiels in 2011 who reported a three-fold rise in the rates of non-AIDS defining cancers between 1991 and 2005, and by 2005, 60% of these cancers occurred in people over 50 years old. We have since described the same phenomenon at the National Centre for HIV Malignancy, Chelsea and Westminster Hospital and in a pan-European cohort.

The challenges of treating cancer in people living with HIV

The clinical care of cancer in people living with HIV requires careful attention and thoughtful medicine and this is even more important in an ageing population. Most treatments for cancer impair the immune system and predispose to infections. This is particularly problematic in people living with HIV who often already have compromised defences. Similarly, people living with HIV are prescribed long-term antiretroviral medication, and in addition, the elderly are frequently on additional medicines for co-morbidities. The addition of systemic anticancer therapies leads to polypharmacy and needs careful attention to the potential interactions between each of these many medicines. Nevertheless, an elderly patient with few co-morbidities and good functional status should receive the same treatment intent as a younger patient and there is nothing to suggest that this should not also be the case for people living with HIV. Conversely, a frail patient with multiple co-morbidities is often better managed with palliation of symptoms and enhancement of quality of life.

Increase awareness, fight prejudice and improve education

In conclusion, it is our responsibility, as HIV experts, to raise awareness among all health professionals of HIV infection in the ageing population and to highlight the serious morbidity and mortality risks of cancer treatment in the setting of unknown HIV serostatus. Unsurprisingly, the barriers to HIV testing in this older population appear to be physician-led, as confirmed by a Swiss study. We urgently need to overcome prejudice and ignorance and encourage HIV testing of all patients with a cancer diagnosis.

Professor Mark Bower (@profbower) is a medical oncologist at Chelsea and Westminster Hospital and Honorary Clinical Senior Lecturer at Imperial.

Read our other World AIDS Day posts:

Dr Katharina Hauck on the health economics of fighting HIV
Professor Robin Shattock on the elusive HIV vaccine

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