Chapter 28: Skin Cancers in Patients with HIV

SUMMARY

• Compared with HIV-uninfected persons of the same age, persons living with HIV/AIDS (PLWH) have substantially higher risks of some cancers, called AIDS-defining cancers (ADCs), which by their mere presence confer a diagnosis of AIDS.

• AIDS-defining cancers (ADCs) such as Kaposi sarcoma, aggressive B-cell non-Hodgkin lymphoma, and cervical cancer are associated with loss of immunoregulation of oncogenic viruses.¹

• The incidence of ADCs declined precipitously after the introduction of combinations of antiretroviral therapy. However, PLWH still have a 500-fold, 12-fold, and 3-fold higher risk of developing Kaposi sarcoma, non-Hodgkin lymphoma (NHL), and cervical cancer, respectively, compared with the general population.¹

DON’T FORGET

• Paradoxically, the longevity achieved by antiretroviral therapy has resulted in higher rates of cancers that prevail in older age or are induced by prolonged exposure to physical (skin cancer), chemical (lung, skin cancers), and biologic (skin, anal, genital, liver cancers) mutagens.

• These malignancies, categorized as non–AIDS-defining cancers (NADCs), occur more frequently in PLWH, but their incidences, compared with those in the general population, are not as discordantly high as those for ADCs, and their appearance is not diagnostic of progression to AIDS.¹

CLINICAL PEARLS

• The contribution of skin cancers, especially basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), to the morbidity of PLWH is substantial and becoming increasingly recognized. However, possibly because of their relatively low mortality, many HIV-associated cancer studies that do not include dermatologists have only calculated rates of squamous cell carcinomas from selected body regions, mainly the anal region. The primary risk factor for photoinduced BCC and SCC in HIV-infected persons, especially those controlled on cART, is solar radiation rather than immunosuppression; therefore, the use of sunblock and other preventive UV-protective methods should be discussed thoroughly and its use highly encouraged in all persons living with HIV.

• Data supporting an increased incidence of melanoma and other skin cancers are less conclusive. Skin cancer in PLWH is more likely to appear in atypical areas for these malignancies.

• Photodamaged PLWH are at high risk of cutaneous SCC and possibly BCC.

• Skin cancer screening should be part of the routine care of PLWH, including those from ethnoracial groups, regardless of their immune status.

• Antiretroviral therapy should be encouraged in all HIV-infected persons to reduce morbidity and mortality, the risk of transmission to others, the risk of AIDS-defining malignancy, and the course and prevalence of skin cancer.¹ The protective effects of cART against the development of NMSC and improvement of survival are well documented in several studies.

PATIENT EDUCATION POINTS

• HIV-induced immunosuppression has been associated with accelerated malignant progression of precancerous lesions, rapid tumor growth and invasion, aggressive behavior, more advanced staging at diagnosis, worse prognosis, more frequent recurrence after treatment, and postsurgical complications. The primary risk factor for photoinduced BCC and SCC in HIV-infected persons, especially those controlled on cART, is solar radiation rather than immunosuppression; therefore, the use of sunblock and other preventive ...