Caring for People with HIV and Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers with
00:08 --> 00:10your host doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care by
00:14 --> 00:16welcoming oncologists and specialists
00:16 --> 00:18who are on the forefront of the
00:18 --> 00:20battle to fight cancer. This week,
00:20 --> 00:22it's a conversation about the care
00:22 --> 00:24of patients with both HIV and cancer
00:24 --> 00:26with Doctor Brinda Emu. Doctor Emu is
00:26 --> 00:28an associate professor of internal
00:28 --> 00:30medicine at the Yale School of Medicine,
00:30 --> 00:34where Doctor Chagpar is a professor
00:34 --> 00:36of surgical oncology.
00:36 --> 00:37Brinda, maybe we can start off by you
00:37 --> 00:39telling us a little bit more about
00:39 --> 00:41yourself and what it is you do.
00:41 --> 00:44Sure, so I am an infectious diseases
00:44 --> 00:47physician and a researcher.
00:47 --> 00:50I've been an HIV provider for over
00:50 --> 00:5320 years and my research is also
00:53 --> 00:56focused in this area and it's
00:56 --> 00:59largely to trying to understand the
00:59 --> 01:02long term impact of HIV infection on
01:02 --> 01:04the immune system and what it means
01:04 --> 01:06for individuals and their health.
01:06 --> 01:09Even after viral replication
01:09 --> 01:10has been controlled,
01:10 --> 01:12so I would consider myself
01:12 --> 01:14a viral immunologist.
01:14 --> 01:17I've been working in the field of
01:17 --> 01:19HIV immunology for about 20 years
01:19 --> 01:22and have a lab in the the division
01:22 --> 01:25of infectious diseases here,
01:25 --> 01:28trying to understand the question of
01:28 --> 01:32how long term viral infection impacts
01:32 --> 01:35non viral associated conditions,
01:35 --> 01:36including cancer.
01:37 --> 01:40Yeah, so you know Brenda,
01:40 --> 01:44it really does bring to mind the
01:44 --> 01:47intersection of HIV and cancer now that
01:47 --> 01:50HIV is really become more of a chronic
01:50 --> 01:54disease right that now that we have
01:54 --> 01:57reasonably good antiretroviral therapy.
01:57 --> 02:00People are living with HIV for a
02:00 --> 02:03good long time and we do know that
02:03 --> 02:06HIV is a disease that does affect.
02:06 --> 02:08The immune system and we've talked on
02:08 --> 02:11this show quite a bit about how the
02:11 --> 02:13immune system interplays with cancer.
02:13 --> 02:15So can you kind of give us a lay of
02:15 --> 02:18the land in terms of that intersection?
02:18 --> 02:21Are there certain cancers that are
02:21 --> 02:24more prevalent in people with HIV?
02:24 --> 02:26And conversely,
02:26 --> 02:31does HIV impact how people get and
02:31 --> 02:35respond to other kinds of cancers that
02:35 --> 02:38may not be classically HIV associated?
02:38 --> 02:39Yeah
02:39 --> 02:42yeah. So those are a lot of
02:42 --> 02:44really good questions and and
02:44 --> 02:46really important as you say,
02:46 --> 02:48as the field of cancer care is sort
02:48 --> 02:50of evolving to include therapies
02:50 --> 02:52that target the immune system.
02:52 --> 02:54So just to take a step back,
02:54 --> 02:58you know HIV is a virus that
02:58 --> 02:59directly infects CD4T cells,
02:59 --> 03:01and we've been, you know,
03:01 --> 03:03hearing a lot about the importance
03:03 --> 03:06of T cells in fighting infections.
03:06 --> 03:08You know, as it's relevant
03:08 --> 03:09for many infections.
03:09 --> 03:10Including COVID-19,
03:10 --> 03:14but HIV is unique in that in this virus
03:14 --> 03:18actually infects those cells and kills
03:18 --> 03:21them when when it infects them so.
03:21 --> 03:22T cells, as you know,
03:22 --> 03:26is are a critical defense against infections
03:26 --> 03:30and therefore when when HIV infects,
03:30 --> 03:33people become immunosuppressed and they
03:33 --> 03:35become vulnerable to other infections
03:35 --> 03:38as well as some cancers that rely on
03:38 --> 03:45the immune system in order to in order to.
03:45 --> 03:49Propagate so in fact that's how HIV and AIDS
03:49 --> 03:53was initially recognized in the early 1980s.
03:53 --> 03:54Is that young.
03:54 --> 03:56Previously healthy people were
03:56 --> 03:58coming in for medical care with
03:58 --> 04:00rare and unusual infections,
04:00 --> 04:03and rare and unusual cancers.
04:03 --> 04:04And so,
04:04 --> 04:05as you alluded to,
04:05 --> 04:09there were certain cancers that were
04:09 --> 04:12specifically associated with HIV infection,
04:12 --> 04:15Kaposi sarcoma non Hodgkin's lymphoma.
04:15 --> 04:17And cervical cancer.
04:17 --> 04:20And we saw those cancers at increasing
04:20 --> 04:23rates back in the 80s and 90s.
04:23 --> 04:25And and for some time afterwards.
04:25 --> 04:27And it was recognized that it was
04:27 --> 04:30because patients with HIV and advanced
04:30 --> 04:33HIV were unable to mount the immune
04:33 --> 04:35response against those cancers.
04:35 --> 04:39The as you as you stated correctly,
04:39 --> 04:41over the next 25 years,
04:41 --> 04:4630 years we have really good therapy to
04:46 --> 04:49treat viral replication and if for the
04:49 --> 04:52most part when patients are taking up
04:52 --> 04:56a a cocktail of antiretroviral therapies,
04:56 --> 04:59we're able to get the HIV viral
04:59 --> 05:00replication under control,
05:00 --> 05:03with usually an increase in
05:03 --> 05:05that CD 4T cell count.
05:05 --> 05:08But what we're starting to see is
05:08 --> 05:10that even though those initial 3
05:10 --> 05:12cancers which redeemed aids defining
05:12 --> 05:15cancers are decreasing in incidence,
05:15 --> 05:16we're seeing increased
05:16 --> 05:18numbers of other cancers,
05:18 --> 05:21and particularly those cancers that
05:21 --> 05:25we are recognizing as relying on the
05:25 --> 05:28immune system to be able to fight them.
05:28 --> 05:33So so so that the the cancer cancers
05:33 --> 05:37that patients are presenting with
05:37 --> 05:39among the HIV population have
05:39 --> 05:42changed over over the last decade.
05:42 --> 05:44Because we're seeing less
05:44 --> 05:46severe immunosuppression,
05:46 --> 05:49but patients with HIV do have residual
05:49 --> 05:51immune dysfunction that may predispose
05:51 --> 05:53them to some of these cancers.
05:54 --> 05:56So tell us a little bit more about that.
05:56 --> 05:58What kinds of cancers?
05:58 --> 06:00Are we now seeing with increased
06:00 --> 06:02frequency in the HIV population?
06:03 --> 06:05Yeah, so I. So what?
06:05 --> 06:08We're starting to see is, well,
06:08 --> 06:12there's a couple of of cancers that that
06:12 --> 06:15are increased in risk in patients with
06:15 --> 06:18HIV compared to the general population.
06:18 --> 06:22And those include still include a those aids
06:22 --> 06:24defining cancers that I mentioned before.
06:24 --> 06:26Non hodgkins, lymphoma,
06:26 --> 06:28KS and cervical cancer.
06:28 --> 06:29But in addition to that,
06:29 --> 06:33we're seeing increased rates of lung cancer,
06:33 --> 06:35Hodgkin's lymphoma, anal cancer.
06:35 --> 06:39Liver cancer had a neck cancer,
06:39 --> 06:42so these cancers are patients with
06:42 --> 06:44HIV infection are at increased risk
06:44 --> 06:47for these particular cancers compared
06:47 --> 06:50to the general population there.
06:50 --> 06:52There are other cancers as well
06:52 --> 06:54that fall into that category,
06:54 --> 06:56but interestingly not all
06:56 --> 06:58cancers are increased in.
06:58 --> 07:01In significant rates in patients with HIV,
07:01 --> 07:02for example,
07:02 --> 07:05we don't see an increased rate of most
07:05 --> 07:07breast cancers or colon cancer or
07:07 --> 07:10prostate cancer in patients with HIV
07:10 --> 07:12compared to the general population,
07:13 --> 07:16and so do we know why there are
07:16 --> 07:17increased risk with certain
07:17 --> 07:20cancers as opposed to others.
07:20 --> 07:22I mean, just thinking about
07:22 --> 07:24some of the mechanisms by which
07:24 --> 07:27HIV is transmitted and some of
07:27 --> 07:29the cancers that you mentioned.
07:29 --> 07:32It seems to me that there may be
07:32 --> 07:35a correlation between HIV and HPV.
07:35 --> 07:37The human papilloma virus is that
07:37 --> 07:39one of the reasons why we see the
07:39 --> 07:41increased frequency in some of
07:41 --> 07:43the cancers that you mentioned.
07:43 --> 07:43I
07:43 --> 07:45think that's that's correct,
07:45 --> 07:48and in fact some individuals have
07:48 --> 07:51actually broken down the cancers that
07:51 --> 07:53patients with HIV are at increased
07:53 --> 07:56risk for into those that are virally
07:56 --> 07:59associated and non virally associated.
07:59 --> 08:02So HPV is human.
08:02 --> 08:05Papilloma virus is a causative
08:05 --> 08:07agent for cervical cancer.
08:07 --> 08:10For anal cancer, some skin cancers,
08:10 --> 08:13and some head and neck cancers.
08:13 --> 08:16Similarly, other viruses like
08:16 --> 08:20hepatitis B&amp;C can cause liver cancer,
08:20 --> 08:24and the infection EV can cause lymphomas.
08:24 --> 08:27So I I think that coinfection
08:27 --> 08:29with these other viruses.
08:29 --> 08:32That we know cause cancer do seem
08:32 --> 08:35to be increased among patients
08:35 --> 08:38that also have HIV infection.
08:38 --> 08:39But as an immunologist,
08:39 --> 08:42it is interesting to me that there
08:42 --> 08:44are also some cancers that are not
08:44 --> 08:46associated with viruses that are
08:46 --> 08:48increased in risk among patients with HIV,
08:48 --> 08:51and that includes lung cancers,
08:51 --> 08:55some leukemias, renal cell cancer,
08:55 --> 08:57and head and neck cancer that's
08:57 --> 08:59not associated with HPV.
08:59 --> 09:00So I think that.
09:00 --> 09:03The the immune system and the
09:03 --> 09:06immune system responds to cancer
09:06 --> 09:08to viruses that cause cancer.
09:08 --> 09:10It certainly puts patients at increased risk,
09:10 --> 09:12but I think the immune systems
09:12 --> 09:14response to non virally associated
09:14 --> 09:17cancer is also something that
09:17 --> 09:18deserves closer scrutiny because
09:18 --> 09:21not all of the cancers that are at
09:21 --> 09:23increased risk are due to viruses.
09:24 --> 09:26Certainly we know that the
09:26 --> 09:28immune system plays a role in
09:28 --> 09:30fighting some of these cancers,
09:30 --> 09:32and and certainly some cancers have
09:32 --> 09:36developed a kind of what I I I like
09:36 --> 09:38to call the invisibility cloak,
09:38 --> 09:41where we're very much like a Harry Potter.
09:41 --> 09:43They they can kind of evade
09:43 --> 09:45the immune system.
09:45 --> 09:46That can't really fight,
09:46 --> 09:48fight the cancers off.
09:48 --> 09:50And that's where immunotherapy
09:50 --> 09:52kind of comes in.
09:52 --> 09:54Kind of taking away that that.
09:54 --> 09:56Poke if you will.
09:56 --> 09:58So when we think about that,
09:58 --> 10:02you know there are particular cancers
10:02 --> 10:09that have expression of PD 1 PDL 1.
10:09 --> 10:11Do we know whether those cancers
10:11 --> 10:14are more likely to occur
10:14 --> 10:16in HIV infected patients?
10:16 --> 10:18And is there a difference in
10:18 --> 10:20terms of how these patients,
10:20 --> 10:22if they do have one of these cancers,
10:22 --> 10:24how they respond to immunotherapy?
10:26 --> 10:29Yeah, that that's a great question and
10:29 --> 10:31actually is is the hypothesis that
10:31 --> 10:33our lab was sort of operating under?
10:33 --> 10:37Because if you think back to the list
10:37 --> 10:40of cancers that I stated were increased
10:40 --> 10:42at risk among patients with HIV,
10:42 --> 10:46including lung cancer and liver cancer,
10:46 --> 10:48head and neck cancer,
10:48 --> 10:51many of those cancers are the same
10:51 --> 10:54cancers in which that immunotherapy
10:54 --> 10:56is effective in suggesting.
10:56 --> 10:57That in fact,
10:57 --> 11:00it is because patients with HIV
11:00 --> 11:03infection have an impaired immune
11:03 --> 11:06response that these are the same cancers
11:06 --> 11:08that respond to immunotherapy and
11:08 --> 11:10also the same cancers that patients
11:10 --> 11:12with HIV see it increase risk because
11:12 --> 11:14they have impaired immune function.
11:14 --> 11:17So that raises a really the excellent
11:17 --> 11:20and and really critical question is,
11:20 --> 11:24will immunotherapy work as well in
11:24 --> 11:27patients with HIV as those without?
11:27 --> 11:30And you mentioned the the the PD 1
11:30 --> 11:33PDL 1 pathway and drugs that target
11:33 --> 11:37that pathway as well as the CTA for
11:37 --> 11:40pathway are commonly known as immune
11:40 --> 11:43checkpoint inhibitors and they're
11:43 --> 11:45designed to reinvigorate exhausted
11:45 --> 11:48T cells in order to fight cancer.
11:48 --> 11:50Having worked in infectious disease,
11:50 --> 11:53these same pathways that PD one PD
11:53 --> 11:56L1 pathway for example are also
11:56 --> 11:57extremely relevant.
11:57 --> 12:02In chronic viral infection and the PD 1 PDL,
12:02 --> 12:041 pathways upregulated in the setting
12:04 --> 12:07of HIV as it is in other chronic
12:07 --> 12:11viral infections and so so whether
12:11 --> 12:13treatment with inhibitors to this
12:13 --> 12:16pathway will work better or worse
12:16 --> 12:20in patients with HIV is a bit of
12:20 --> 12:22an of an unanswered question.
12:23 --> 12:25But a really, really important one,
12:25 --> 12:27and I say it's unanswered.
12:27 --> 12:31Because patients with HIV have
12:31 --> 12:33not been regularly studied in the
12:33 --> 12:37clinical trials that looked at immune
12:37 --> 12:38checkpoint inhibitors because of
12:38 --> 12:41initial concerns about potential toxicity,
12:41 --> 12:44and therefore we don't have clinical
12:44 --> 12:46trial data that tell us for sure
12:46 --> 12:49that patients with HIV do as well
12:49 --> 12:50as the general population.
12:50 --> 12:53So these studies are now being
12:53 --> 12:55conducted retrospectively to see
12:55 --> 12:58whether patients with HIV are in fact.
12:58 --> 13:01Getting getting responses at the same level,
13:01 --> 13:03but this is something that is really
13:03 --> 13:05understudied and really important,
13:05 --> 13:07particularly for our patients
13:07 --> 13:09that have immune dysfunction.
13:09 --> 13:10To know the answer to
13:11 --> 13:12so important. Well,
13:12 --> 13:14we're going to take a short
13:14 --> 13:15break for a medical minute,
13:15 --> 13:17but please stay tuned to learn
13:17 --> 13:19more about HIV and cancer with
13:19 --> 13:21my guest doctor Brenda Emu.
13:21 --> 13:23Funding for Yale Cancer answers
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13:30 --> 13:32Learn more at Yale Cancer Center dot org.
13:35 --> 13:37The American Cancer Society
13:37 --> 13:39estimates that nearly 150,000 people
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13:42 --> 13:44colorectal cancer this year alone.
13:44 --> 13:46When detected, early colorectal cancer
13:46 --> 13:49is easily treated and highly curable,
13:49 --> 13:51and men and women over the age of
13:51 --> 13:5345 should have regular colonoscopies
13:53 --> 13:55to screen for the disease.
13:55 --> 13:56Patients with colorectal cancer
13:56 --> 13:58have more hope than ever before,
13:58 --> 14:01thanks to increased access to advanced
14:01 --> 14:03therapies and specialized care.
14:03 --> 14:05Clinical trials are currently underway.
14:05 --> 14:06Federally designated comprehensive
14:06 --> 14:09cancer centers such as Yale Cancer
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14:13 --> 14:15treatments for colorectal cancer.
14:15 --> 14:18Tumor gene analysis has helped
14:18 --> 14:19improve management of colorectal
14:19 --> 14:22cancer by identifying the patients
14:22 --> 14:24most likely to benefit from
14:24 --> 14:26chemotherapy and newer targeted agents,
14:26 --> 14:29resulting in more patient specific treatment.
14:29 --> 14:32More information is available at
14:32 --> 14:33yalecancercenter.org. You're listening
14:33 --> 14:35to Connecticut Public Radio.
14:36 --> 14:38Welcome back to Yale Cancer Answers.
14:38 --> 14:41This is Doctor Anees Chagpar and I'm joined
14:41 --> 14:43tonight by my guest doctor Brinda Emu.
14:43 --> 14:45We're learning about the care of
14:45 --> 14:47patients with HIV and cancer and
14:47 --> 14:49right before the break, Brinda,
14:49 --> 14:53you had mentioned that patients with HIV,
14:53 --> 14:55you know, really weren't enrolled
14:55 --> 14:57in the early clinical trials.
14:57 --> 14:59Looking at immunotherapy.
14:59 --> 15:02And yet, you know that intersection
15:02 --> 15:04between HIV and immunotherapy
15:04 --> 15:07in the treatment of cancer.
15:07 --> 15:12Is so important and and and so
15:12 --> 15:14something that we really don't
15:14 --> 15:16understand and you had mentioned
15:16 --> 15:19that one of the reasons why patients
15:19 --> 15:21with HIV were not included in
15:21 --> 15:23those initial clinical trials.
15:23 --> 15:27Was for fear of toxicity now that
15:27 --> 15:29patients with HIV are starting to
15:29 --> 15:31be enrolled in clinical trials.
15:31 --> 15:34Looking at immunotherapy for cancer.
15:34 --> 15:36Can you talk a little bit about
15:36 --> 15:38whether they do experience more
15:38 --> 15:41toxicity and whether that initial
15:41 --> 15:43fear was was justified?
15:45 --> 15:51So so I I I feel like the initial fear
15:51 --> 15:54you know came out of the the biology
15:54 --> 15:58that the PD one pathway that we had
15:58 --> 16:00mentioned is so critical at the level
16:00 --> 16:03of the tumor for the general population.
16:03 --> 16:06But in the setting of a global viral
16:06 --> 16:08infection that pathways upregulated
16:08 --> 16:11on cells throughout the body.
16:11 --> 16:14So so I think the concern was.
16:14 --> 16:17When you sort of unleash those cells that
16:17 --> 16:20patients with chronic viral infections
16:20 --> 16:24like HIV and hepatitis C might have
16:24 --> 16:26worse immune related side effects
16:26 --> 16:29compared to the general population.
16:29 --> 16:32Now that we have more experience
16:32 --> 16:34with using these medications,
16:34 --> 16:37we know that that is not the case.
16:37 --> 16:41We there's been two clinical trials
16:41 --> 16:43specifically focused on patients
16:43 --> 16:46with HIV in advanced malignancies.
16:46 --> 16:47That have studied immune
16:47 --> 16:48checkpoint inhibitors,
16:48 --> 16:51and though they were not
16:51 --> 16:53powered to test efficacy,
16:53 --> 16:55they were able to report that
16:55 --> 16:58there does not appear to be any
16:58 --> 17:00increased toxicity from immune
17:00 --> 17:02checkpoint inhibitors in patients
17:02 --> 17:05with HIV compared to those without,
17:05 --> 17:07so that is very reassuring and
17:07 --> 17:09allows us to move forward both with
17:09 --> 17:12treatment but also importantly and
17:12 --> 17:14hopefully more studies to really
17:14 --> 17:16understand the efficacy of these drugs.
17:16 --> 17:18In our patients,
17:18 --> 17:18for
17:18 --> 17:21patients who have HIV who may
17:21 --> 17:24get very much to your point,
17:24 --> 17:27immune related toxicity to immunotherapy.
17:27 --> 17:29Are there special considerations that
17:29 --> 17:32need to be taken in terms of how you
17:32 --> 17:35manipulate the therapy in these patients?
17:35 --> 17:36Because, as you say,
17:36 --> 17:39that pathways so critical to every cell,
17:39 --> 17:42so you know 11 might think that it it's
17:42 --> 17:45a little bit difficult to kind of say.
17:45 --> 17:46OK, well, we'll we'll just.
17:46 --> 17:47Stop the immunotherapy.
17:47 --> 17:50Or we'll we'll kind of reduce the dose.
17:50 --> 17:52Are there other other considerations
17:52 --> 17:55in that population when treating them
17:55 --> 17:57with immunotherapy that patients and
17:57 --> 17:59their doctors need to be aware of?
17:59 --> 18:00The most
18:00 --> 18:01important thing, I think,
18:01 --> 18:05is that there are HIV be well controlled.
18:05 --> 18:11I think that the pathway the the
18:11 --> 18:14immune checkpoint pathways are really
18:14 --> 18:17sort of very highly upregulated.
18:17 --> 18:19In the setting of ongoing viral replication,
18:19 --> 18:23so I think that it would be very
18:23 --> 18:26important for every patient with with
18:26 --> 18:29HIV to be on effective antiretroviral
18:29 --> 18:33therapy at the time of of receiving
18:33 --> 18:35immune checkpoint inhibitor therapy.
18:35 --> 18:38But as I mentioned before and and I think
18:38 --> 18:41this is important for patients and providers,
18:41 --> 18:44and all of the retrospective studies and the
18:44 --> 18:46clinical trials that have looked at safety.
18:46 --> 18:48That initial fear that patients
18:48 --> 18:51with HIV were going to have worse
18:51 --> 18:53immunologic outcomes, in fact,
18:53 --> 18:56is is it does not appear to be the case.
18:56 --> 18:58So I think that is that is very reassuring.
18:58 --> 19:00Every study that has looked looked at
19:00 --> 19:04that has has shown that those classic.
19:04 --> 19:06Immune related adverse events
19:06 --> 19:08are not increased in incidence.
19:09 --> 19:12Yeah, but to your point in terms of making
19:12 --> 19:14sure that your HIV is well controlled,
19:14 --> 19:16one would think you know we talk
19:16 --> 19:20on this show a lot about this
19:20 --> 19:21multidisciplinary cancer management
19:21 --> 19:24and you know many medical oncologists
19:24 --> 19:27may not be as comfortable in managing
19:27 --> 19:32HIV because they are so focused on
19:32 --> 19:35managing cancer in in patients who.
19:35 --> 19:38Have HIV, can you talk a little bit
19:38 --> 19:41about how critical it is to make sure
19:41 --> 19:44that your your HIV doctor is part of
19:44 --> 19:46that multidisciplinary team and the
19:46 --> 19:48crosstalk that that individual would
19:48 --> 19:51have with oncology in terms of the
19:51 --> 19:54management of the overall patient?
19:55 --> 19:59Yeah, and so I think this is is so so
19:59 --> 20:03important and I think that you know medical
20:03 --> 20:07care and subspecialty care is is that it's
20:07 --> 20:10it's very specialized and our patients
20:10 --> 20:13with HIV have unique comorbidities.
20:13 --> 20:16They have, you know,
20:16 --> 20:18generally multiple medications that
20:18 --> 20:21have drug drug interactions.
20:21 --> 20:23And as we've been talking about
20:23 --> 20:25quite a bit have very unique.
20:25 --> 20:28Considerations for their immunologic health,
20:28 --> 20:31so I think the key here is that the
20:31 --> 20:34oncology treatment team and the
20:34 --> 20:36infectious disease provider really
20:36 --> 20:39be coordinated and have an integrated
20:39 --> 20:43approach for the care of these patients.
20:44 --> 20:47And certainly you know having HIV
20:47 --> 20:50adds a whole other level of complexity
20:50 --> 20:53to quote routine cancer management.
20:53 --> 20:56You know one of the things.
20:56 --> 20:59When you think about patients who are on.
20:59 --> 21:02Antiretroviral therapy and you know,
21:02 --> 21:05already we're we're controlling
21:05 --> 21:07their immune system.
21:07 --> 21:11Regardless, is is the issue
21:11 --> 21:14between how patients with HIV,
21:14 --> 21:17whether or not they are
21:17 --> 21:19on immunotherapy or not?
21:19 --> 21:22How they do in terms of their
21:22 --> 21:24cancer management and prognosis
21:24 --> 21:27relative to the general population,
21:27 --> 21:29because in the general population.
21:29 --> 21:32There may be less concern about how
21:32 --> 21:35your immune system is going to react to
21:35 --> 21:38not only the cancer but to therapies,
21:38 --> 21:39whereas in HIV patients that
21:39 --> 21:41may be a little bit different.
21:41 --> 21:43Can you talk about prognosis
21:43 --> 21:44in these individuals?
21:45 --> 21:48Sure, so so unfortunately this is
21:48 --> 21:52an area where we do see disparities
21:52 --> 21:55in outcome among patients that
21:55 --> 21:58have HIV and a cancer diagnosis,
21:58 --> 22:02and this appears to hold true
22:02 --> 22:05for many different cancer types.
22:05 --> 22:06Whether or not they're
22:06 --> 22:08increased in incidence or not.
22:08 --> 22:11So I stated before that you know,
22:11 --> 22:13most colon cancers and most breast cancers
22:13 --> 22:15are not increased in incidence and.
22:15 --> 22:17Patients with HIV compared
22:17 --> 22:18to the general population,
22:18 --> 22:20however, the prognosis,
22:20 --> 22:24even with with those you know with those
22:24 --> 22:27cancers are worse in patients with HIV
22:27 --> 22:30compared to the general population.
22:30 --> 22:32And there's a.
22:32 --> 22:35You know this is there's probably.
22:35 --> 22:36There's probably reflects
22:36 --> 22:38many different factors.
22:38 --> 22:41Certainly there's a concern that patients
22:41 --> 22:44may have inadequate screening and may
22:44 --> 22:47be present at a more advanced stage,
22:47 --> 22:49and that may partly be responsible
22:49 --> 22:50for these poor outcomes.
22:50 --> 22:51However,
22:51 --> 22:53large studies that have controlled
22:53 --> 22:56for stage as well as insurance
22:56 --> 22:58status and access to care have
22:58 --> 23:00similar have reported similarly
23:00 --> 23:03poor outcomes in patients with HIV.
23:03 --> 23:05Compared to those without and that
23:05 --> 23:08really sort of emphasizes that there
23:08 --> 23:10are unique features of the infection
23:10 --> 23:13that we need to better understand,
23:13 --> 23:15and this includes studying cancer,
23:15 --> 23:16biology, and particularly,
23:16 --> 23:18as you say,
23:18 --> 23:20immune related effects of treatments
23:20 --> 23:24of the treatment on patients with HIV
23:24 --> 23:26as well as ensuring that patients get
23:26 --> 23:29screened and and really importantly,
23:29 --> 23:32that they receive appropriate cancer
23:32 --> 23:35treatment and follow-up surveillance.
23:35 --> 23:38And up until the last couple years
23:38 --> 23:41there have not been specific guidance
23:41 --> 23:44or guidelines for patients with
23:44 --> 23:47HIV receiving cancer treatment,
23:47 --> 23:49and that has changed.
23:49 --> 23:52There are now NCCN guidelines that are
23:52 --> 23:55specifically address patients with HIV,
23:55 --> 23:58so I hope that some of these
23:58 --> 24:00disparities can be will be
24:00 --> 24:03improved as we get more attention
24:03 --> 24:05and more research focused on.
24:05 --> 24:06On our patients.
24:07 --> 24:09Yeah, and one of the one
24:09 --> 24:11of the questions I have is,
24:11 --> 24:13you know you had mentioned earlier
24:13 --> 24:15that it's so important that patients
24:15 --> 24:17with HIV who are undergoing cancer
24:17 --> 24:18treatment should really make sure
24:18 --> 24:20that their HIV is well controlled.
24:20 --> 24:24Has anybody looked at the control of HIV?
24:24 --> 24:25So for example,
24:25 --> 24:28looking at CD4 accounts and seeing
24:28 --> 24:31whether that makes a difference both in
24:31 --> 24:34terms of the risk of developing a cancer
24:34 --> 24:37as well as prognosis of of cancers,
24:37 --> 24:39whether they're. HIV related or not?
24:39 --> 24:40Yeah,
24:40 --> 24:43so so yes. And so people have looked
24:43 --> 24:47at biomarkers of of cancer incidents in
24:47 --> 24:50patients on and off antiretroviral therapy,
24:50 --> 24:53so I'll step back and say for sure.
24:53 --> 24:57You know, being controlled and having
24:57 --> 25:00HIV control on antiretroviral treatment
25:00 --> 25:03significantly decreases overall cancer
25:03 --> 25:08incidence and so that that's the first thing.
25:08 --> 25:10But even with control.
25:10 --> 25:12Of HIV infection,
25:12 --> 25:15there do appear to be some.
25:15 --> 25:18Immunologic factors that that are
25:18 --> 25:20associated with increased cancer incidence,
25:20 --> 25:21and interestingly,
25:21 --> 25:24it's not the CD 4 count itself that
25:24 --> 25:27that increases your incidence of
25:27 --> 25:29malignancy among patients with HIV,
25:29 --> 25:34but the ratio of CD4 cells to CD 8 cells.
25:34 --> 25:37So there does seem to be immunologic
25:37 --> 25:40factors that predispose to risk in terms
25:40 --> 25:43of are there immunologic factors that
25:43 --> 25:46predispose or conserve as biomarkers.
25:46 --> 25:48The prognosis this is an active
25:48 --> 25:49area of study.
25:49 --> 25:51This is something that that we're
25:51 --> 25:54actually looking at in my lab and others
25:54 --> 25:57other labs as well to see whether there
25:57 --> 26:00are differences that can be identified
26:00 --> 26:02within the tumor microenvironment.
26:02 --> 26:07That may portend a better or worse prognosis
26:07 --> 26:10with immunotherapy or or chemotherapy,
26:10 --> 26:12because I think we haven't really
26:12 --> 26:13studied that in depth before.
26:13 --> 26:15We don't know the answer to that,
26:15 --> 26:17but as we've been alluding to.
26:17 --> 26:20And as we have some data to suggest
26:20 --> 26:22the microenvironment of the tumor
26:22 --> 26:25in the setting of HIV is different,
26:25 --> 26:28and what that means for prognosis is
26:28 --> 26:31something that really needs a lot more study,
26:31 --> 26:33and it because it's so.
26:33 --> 26:34It's so important.
26:34 --> 26:37So Brenda. One of the things that you
26:37 --> 26:40just mentioned I just found so intriguing
26:40 --> 26:44was that you found that the the phenotype
26:44 --> 26:48of these CD four cells and CD 8.
26:48 --> 26:50Cells these immune cells actually
26:50 --> 26:53is different and can predict
26:53 --> 26:56malignancy a year prior to diagnosis.
26:56 --> 26:58Did I hear that right?
26:58 --> 27:00So that's incredibly interesting
27:00 --> 27:03my my two follow up questions to
27:03 --> 27:06that are the following number one.
27:06 --> 27:09Is it to any particular type
27:09 --> 27:13of malignancy so that you would
27:13 --> 27:15know what to expect and #2?
27:15 --> 27:18What do you do with that information?
27:18 --> 27:21It's kind of like you've been given
27:21 --> 27:23a ticking time bomb of you will
27:23 --> 27:26you will get cancer in a year.
27:26 --> 27:28Has it been found that this could be
27:28 --> 27:31useful in terms of increasing screening
27:31 --> 27:33or perhaps even prophylactic treatments?
27:34 --> 27:37Yeah, yeah, I, I think that. You know, I?
27:37 --> 27:39I think it's not at a stage that
27:39 --> 27:40I would say it's predictive yet,
27:40 --> 27:43but the meaning that it's clearly a biomarker
27:43 --> 27:46that that can be clinically useful.
27:46 --> 27:49But what it suggests is that there are
27:49 --> 27:51ongoing systemic changes in the immune
27:51 --> 27:53response in a subset of individuals
27:53 --> 27:56that may predispose them to cancers.
27:56 --> 27:57And that's exactly right.
27:57 --> 28:01I think the idea is that if you can
28:01 --> 28:04identify patients at increased risk that
28:04 --> 28:07you may alter screening early diagnosis.
28:07 --> 28:11In order to get patients you know
28:11 --> 28:14diagnosed at earlier stages going forward,
28:14 --> 28:17this is early data and it's but it
28:17 --> 28:20it is different from the general
28:20 --> 28:23population that we're seeing changes
28:23 --> 28:26in the peripheral blood that signify
28:26 --> 28:29sort of immunologic risk potentially
28:29 --> 28:32to to malignancies that could be
28:32 --> 28:33used as biomarkers.
28:33 --> 28:36Doctor Brinda Emu is an associate
28:36 --> 28:37professor of internal medicine
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:46and past editions of the program
28:46 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public radio
28:55 --> 28:57funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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May 29, 2022

Yale Cancer Center

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