In the early 1980s and into the 1990s, HIV/AIDS and HIV-associated cancers emerged in epidemic numbers causing significant mortality among infected individuals. Scientists across disease areas joined forces to attack the problem. Specialists in infectious diseases and immunology worked with oncologists who treated cancers associated with advanced HIV infection (“AIDS-defining cancers”): lymphomas, Kaposi sarcoma, and cervical cancer. Collaborating researchers developed new drugs, antiretrovirals, targeting HIV (human immunodeficiency virus). Over the next two decades, breakthrough antiretroviral therapies were allowing people with HIV to manage their disease, a medical victory that continues. Cases of AIDS plummeted, as did the incidence of AIDS-related cancers and overall mortality among people with HIV. Many researchers and oncologists turned their attention elsewhere.
Fast forward 30 years. Patients with HIV are again at higher risk for certain cancers and it is increasingly apparent that patients with HIV and cancer are also suffering worse outcomes. The reasons behind these developments are unknown and difficult to study, partly because people with HIV diagnosed with cancer are dispersed among disease-specific oncologists.
To address these issues, the Yale Section of Infectious Diseases and the Nathan Smith Clinic, Smilow Cancer Hospital, and Yale Cancer Center recently launched an HIV and Cancer Program and dedicated clinic, a novel approach for integrated care for people with HIV and cancer. Its founding co-directors are Brinda Emu, MD, Associate Professor of Medicine (Infectious Diseases), an infectious diseases specialist in viral immunology who has been caring for HIV patients for more than 20 years; and Jill Lacy, MD, Professor of Medicine (Medical Oncology), who began her career during the height of the AIDS crisis, caring for patients with AIDS-related cancers. This integrated approach to HIV and cancer care with a dedicated team of oncologists and HIV providers is the first of its kind.
“We’re a natural team for this,” said Dr. Emu. "The program comes from a history of caring for patients with HIV, and also seeing a real change in the types of cancers as well as an increasing number of cancers in our HIV clinics.” The non-AIDS defining cancers include liver, lung, anal, melanoma, renal cell, and head and neck cancers, among others.
Dr. Emu recognized the need to return to an interdisciplinary approach that addresses the unique challenges of treating patients with cancer who also have underlying immune dysfunction due to a chronic infection controlled by strong antiretroviral drugs.
“Most oncologists now see very few patients with HIV,” said Dr. Lacy. “We no longer know the HIV drugs that well, and we wonder how the patients will tolerate cancer treatments. There’s a lot of uncertainty about drug interactions. So, there’s a great need again for interdisciplinary attention. Bringing everyone together for clinical care, research, and tumor board discussions will be a vast improvement for these patients.”
The same is true from the HIV side, adds Dr. Emu. HIV physicians see few patients with cancer and don’t feel equipped to answer their questions about the interplay between an HIV diagnosis and cancer. “I think this partnership will improve care from both sides,” said Dr. Emu.
We’re a natural team for this. The program comes from a history of caring for patients with HIV, and also seeing a real change in the types of cancers as well as an increasing number of cancers in our HIV clinics.
Brinda Emu, MD
She and Dr. Lacy also expect the new program to help remedy another issue: the stark lack of data about HIV and cancer. “Historically, a large percentage of Industry-sponsored cancer clinical trials have not included patients with HIV,” said Dr. Emu. “Recent evaluation revealed that 90% of studies of immune checkpoint inhibitors have specifically excluded patients with HIV.”
Dr. Lacy notes that the lack of data about how immune checkpoint inhibitors interact with antiretrovirals discourages some oncologists from prescribing these incredibly effective therapies to HIV patients. “I think that’s where this clinic can be hugely impactful,” she said. “Oncologists can have discussions with people like Brinda who really know the field, and we can feel comfortable with the treatment plan we come up with.”
Dr. Emu notes that HIV physicians and patients are focused on maintaining immunological health and may be leery of cancer treatments that cause immunosuppression, such as radiation and chemotherapy, or drugs that intensify immunological response, like immune checkpoint inhibitors. Because the data is so thin, HIV patients sometimes make decisions based on fear rather than evidence, and oncologists may reduce dosages when a patient’s T cell count drops.
Drs. Emu and Lacy have identified Smilow Cancer Hospital oncologists in every disease area to help build Yale’s expertise in HIV and cancer. Under the new program, when Dr. Emu or another HIV physician sees a patient with cancer, they will contact the patient’s oncologist to talk through issues such as drug interactions and possible treatments. The program provides information, support, and guidance to HIV patients, physicians, and oncologists.
Drs. Emu and Lacy also are determined to start filling the data gap by enrolling HIV patients in clinical trials for cancer. There is already some evidence, she adds, that HIV alters cancer biology. Her lab has found that tumor micro-environments in non-small cell lung cancer and in head and neck cancer look different in patients with and without HIV. Does that difference influence a patient’s prognosis? What are the implications for treatment? Such basic questions underscore the urgent need for this new program.
The clinic has been open for patient referral as of July 2022, and there has been great enthusiasm from patients and providers. By caring for patients in a comprehensive multidisciplinary way, including providing the necessary social support while engaging in cancer care, the team has already been able to identify important clinical and research questions relevant to the care of patients with HIV and cancer. By engaging a dedicated team of surgical, medical, and radiation oncologists, pathologists, and infectious diseases specialists, they are using team science and multidisciplinary care approaches to bringing improved cancer care to the community.