Cancer refers to the abnormal and uncontrolled growth of certain cells that can interfere with normal body functions. Cancer can spread (metastasize) from where it originates to other organs and parts of the body. Cancer can destroy healthy cells and cause illness and death.

A normally-functioning immune system plays a role in limiting the occurrence of cancer. Due to immune suppression, HIV+ people are more vulnerable to several kinds of cancer, three of which lead to an AIDS diagnosis: Kaposi’s sarcoma, certain types of lymphoma, and cervical cancer.

KS was one of the most common opportunistic infections (OIs) in the early days of the AIDS epidemic. KS is actually caused by a virus called Kaposi’s sarcoma herpes virus (KSHV) or HHV-8. But KS behaves and is treated like a cancerous tumor.

HHV-8 is transmitted through sexual contact or blood products. KS has always been less common in women, but is less common in all groups since the introduction of potent HIV drug combinations.

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. Treatment decisions are usually made by an oncologist (cancer specialist) based on the severity or stage of the condition. Your HIV doctor and other specialists (e.g. radiation oncologist, dermatologist) may be involved as well.

Skin (most common site of KS):

• Lesions are usually flat, painless, and do not itch or drain
• Lesions are often pink, red, or purple and do not turn white when pressure is applied to them (unlike bruises)
• May resemble “blood blisters” (lesion involves growth of blood vessels)
• May be swelling around lesion (lymphedema)

Oral cavity (inside of mouth):

• Trouble eating and swallowing

Gastrointestinal tract:

• Diarrhea
• Cramping
• Bleeding

Lungs:

• Breathing problems
• Bad cough

• Biopsy (sample of tissue taken and examined under microscope)
• “Good prognosis” KS:
  - No internal organ involvement
  - CD4 count greater than 200 cells
  - No history of opportunistic infections (or AIDS diagnosis)
• “Poor prognosis” KS:
  - Tumor in organs, or very bulky (ulcerated)
  - CD4 count less than 200
  - Other HIV-related illness

HIV drug therapy alone may make tumor shrink or disappear (remission)

• Local treatment with cryotherapy or Panretin (alitretinoin gel) if there are only a few isolated lesions
• Radiation therapy, especially if tumor is bulky and ulcerated
• Recombinant interferon-alpha
• Chemotherapy – used for more extensive and/or internal KS:
  - Doxil (Liposomal doxorubicin) or DaunoXome (Liposomal daunorubicin) - Liposomal form minimizes side effects (liposomal means that the drug is encased in small fat bubbles)
  - ABV (adriamycin, bleomycin, and vinblastine)
  - Taxol (paclitaxel)
  - Vepesid (etoposide, VP16)

Lymphoma involves the unchecked growth of lymph node cells that may spread to other organs (especially to the bone marrow). Lymphoma that spreads to the brain or spinal chord it is called central nervous system (CNS) lymphoma. 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 difficult to treat in HIV+ people, especially CNS lymphoma.

• Swollen lymph nodes
• Fever, chills, sweats
• Weight loss

• Biopsy of affected lymph node
• More sophisticated techniques (e.g. brain biopsy, gastrointestinal or lung biopsy)

• NHL: Chemotherapy
• CNS lymphoma: Combination of radiation and chemotherapy

Cervical cancer is strongly linked to human papillomavirus (HPV). HPV is the most common sexually-transmitted infection in the U.S. Different strains of HPV cause warts or abnormal cell growth (dysplasia) near the anus or cervix.

Dysplasia 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- women. Untreated dysplasia can lead to cervical cancer, which can be life threatening. HPV may also cause cancer in the vagina, vulva, and anus. When dysplasia is detected and treated early, cervical cancer can be prevented.

• Many women do not experience symptoms
• Bleeding between periods is one of the only signs of advanced cervical dysplasia

Pap smears

• A Pap smear is a screening test your doctor does to check for changes in the cervix
• An abnormal Pap smear can indicate inflammation, infection, dysplasia, or cancer
• If you have an abnormal Pap, you may need a colposcopy (an exam of your cervix using a microscope to look at the tissue more closely)
• HIV+ women are 10 times more likely to have abnormal Pap smears than HIV- women
• The Centers for Disease Control (CDC) recommend that:
  - HIV+ women have a complete gynecological examination, including a Pap smear, when they are first diagnosed or when they first seek prenatal care
  - HIV+ women have another Pap six months later
  - If both tests are negative, yearly screening is recommended
  - Women who have symptomatic HIV infection or who have had dysplasia in the past should receive a Pap smear every six months

A new HPV test is starting to be used in conjunction with Pap smears to detect cancerous and precancerous conditions.

• Electro-cauterization
• Laser therapy
• Cold-knife cone biopsy
• Loop electric excision procedure (LEEP)
• Cryotherapy (may mask future problems)

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 doctor to perform these tests on a regular basis. Treatments for anal dysplasia are the same as for cervical dysplasia.

Cancers can be very serious for HIV+ people. On-going medical care allows for early diagnosis and treatment, or even prevention, in the case of cervical and anal cancers.

Seeing your doctor on a regular basis and taking HIV drugs when necessary can help keep your immune system strong and your CD4 cell counts from falling too low. This also helps fight off cancers.

1		Chin-Hong, P.V. & Palefsky, J.M. (2002). Natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus. Clinical Infectious Diseases, 35. 1127-1134.
2		Powderly, W.G. (2001). Manual of HIV Therapeutics, Second Edition. Philadelphia: Lippincott, Williams & Wilkins.
3		Scadden D.T. (2003). AIDS-related malignancies. Annual Review of Medicine 54:285.
4		United States Public Health Service & Infectious Diseases Society of America. (2001). Guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: Retrieved July 2003 from http://aidsinfo.nih.gov/guidelines/op_infections/OI_112801.html.