People living with HIV (PLHIV) are at higher risk of cancer than the general population. An additional risk that has been well described for several decades: from the beginning of the 1990s, three cancers, associated with opportunistic infections by oncogenic viruses (HHV8, EBV and papillomavirus), had already been identified as “classifying AIDS”, i.e. defining the transition to this stage: “Kaposi syndrome, malignant non-Hodgkinin’s lymphoma, and cervical cancer”recalls Professor Sophie Grabar, public health doctor at Inserm and at Saint-Antoine hospital (AP-HP). And a susceptibility to other virus-induced cancers such as Hodgkin’s lymphoma, liver cancer and anal cancer, is well evidenced in this audience. In question: immunosuppression, comorbidities, lifestyle, etc.
An evolving epidemiology
However, the epidemiology of cancers is changing among people infected with HIV. First, the incidence rates of AIDS-classifying cancers and certain virus-induced cancers are falling. A phenomenon undoubtedly attributable, as Professor Grabar suggests, to progress in immune restoration and the early initiation of treatments. As a reminder, people with a LT CD4 rate > 500 /mm3 and an undetectable viral load seem five times less at risk of developing cancers of this type, or even, for certain cancers, such as cervical cancer, have a similar risk to the general population.
More and more non-classifying AIDS cancers
Nevertheless, “the share of non-AIDS-classifying cancers is becoming increasingly significant among PLHIV”reports Professor Grabar. Thus, in the FHDH cohort, between the end of the 2000s and the end of the 2010s a decline in Kaposi’s sarcomas and non-Hodgkin’s lymphomas was observed, with the benefit, in men, of an increase in the incidence of liver and colorectal cancers, and among women, a marked increase in breast cancer and colorectal cancer.
The cause: the aging of the population affected by HIV. « The share of PLHIV over 60 to 70 years old is expected to double between 2018 and 2028″, believes Professor Grabar. In addition, risk factors for HIV cancer remain particularly widespread among PLHIV, like smoking, recalls the public health specialist.
In this context, the recommendations for prevention, screening and treatment of cancers among PLHIV have been reviewed.
Cervical cancer: simplified screening
In terms of screening, significant changes concern the detection of cervical cancer — now simplified in women living with HIV. Indeed, from the age of 30, in the absence of a history of suspicious lesions, screening can now be done in the same way as in the general population, that is, every five years, by means of a smear and research. of high-risk HPV carriage.
Likewise, as in women not infected with HIV, between 25 and 30 years of age, smear screening with cytology is indicated. The only difference with the general population in this age group: the frequency of examinations, which is the same as in the general population (two annual smears, then, in the event of a normal result, every three years up to thirty years) only in young women with a CD4 count > 350/mm3 without history of nadir CD4 < 200/mm3. “In the event of a history of greater immunosuppression, an annual smear by cytology remains indicated every year up to thirty years of age”, underlines Professor Alain Makinson (Montpellier University Hospital).
Anal cancer: expanded targeting
Another important update in screening concerns the detection of anal cancer. While, until now, screening was only indicated among men over 30 who have sex with men (MSM) living with HIV, new populations are now concerned: women living with HIV over 30 years old with a history of precancerous cervical lesion (CIN2+), as well as women living with HIV who have received a solid organ transplant, with a history of vulvar cancer.
In practice, an HPV-16 test is indicated every five years in the event of a negative result.
In addition, the new recommendations specify the possibility of individually offering CT screening for bronchopulmonary cancer to PLHIV aged 50 to 74 reporting significant tobacco consumption. However, such a proposal requires “truly informed information from the doctor”as well as a “ entry into a smoking cessation strategy »specifies Professor Makinson.
Liver, lung cancer
Furthermore, while epidemiological data confirm the increased risk of liver cancer in the event of HIV infection and co-infection with HBV or HCV, in PLHIV, hepatocellular carcinoma must be screened for in the event of fibrosis. F3 or F4 by means of liver Doppler ultrasound every six months. This screening is also recommended in certain HBV subjects at risk, even in the absence of F3 or F4 fibrosis.
The document also recalls screenings in the general population, which equally concern PLHIV: screening for colorectal cancer, breast cancer, etc.
Principle of equity
In terms of cancer treatment, the emphasis is placed on a principle of equity: PLHIV must be able to access treatments as well as multidisciplinary consultation meetings (RCP) such as the OncoVIH RCP. Because while a few years ago, certain oncological therapies were in practice contraindicated in PLHIV, due to concerns about a potential accumulation of immunosuppression, HIV infection is now considered a classic comorbidity. , which should not prevent the treatment of cancers according to oncological standards (including immunotherapies).
Lightened surveillance of opportunistic infections
In addition, virological control and surveillance of opportunistic infections tend to become lighter: monitoring of viral load and CD4+ T lymphocyte levels only every three months, prophylaxis of pneumocystosis and toxoplasmosis only in two situations (deficiency significant immune, increased risk of pneumocystosis linked to the type of cancer), monitoring of CMV viremia only in patients with a CD4+ LT rate < 100/mm3 or in case of allograft, etc.
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