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Cancer Treatment in Patients With HIV Infection and Non-AIDS-Defining Cancers: A Survey of US Oncologists
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May 1 2023
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By Gita Suneja, MD, Matthew Boyer, BA, Baligh R. Yehia, MD, Meredith S. Shiels, PhD, Eric A. Engels, MD,
Justin E. Bekelman, MD, and Judith A. Long, MD
University of Utah, Salt Lake City, UT; Marshall University, Huntington, WV; University of Pennsylvania; Veterans Affairs
Center for Health Equity Research and Promotion, Philadelphia, PA; and National Cancer Institute, Bethesda, MD
Provider-level factors are associated with delivery of nonstandard cancer treatment to HIV-infected patients. Policy change, provider education, and multidisciplinary collaboration are needed to improve access to cancer treatment.
In this national survey, we found that cancer care providers were less likely to offer cancer treatment to HIV-infected patients if they have concerns about toxicity and efficacy of cancer therapy and are more likely to offer treatment if they are comfortable discussing adverse effects and prognosis. The majority of respondents felt that currently existing cancer management guidelines were insufficient for management of HIV-infected patients. These findings may help to explain the cancer treatment disparity observed in recent studies and have important implications for policy and clinical practice. Inclusion of HIV-infected patients in cancer clinical trials, development of cancer treatment guidelines specific to HIV-infected patients, and enhanced care coordination between oncologists and HIV specialistsmay reduce cancer treatment disparities for HIV-infected patients with cancer. Improving cancer outcomes in the HIV-infected population is of paramount importance as survival with HIV continues to improve and cancer becomes an increasingly important cause of mortality in the HIV-infected population.27
We undertook this study to identify provider-level factors that contribute to observed disparities in cancer treatment between HIV-infected and non-HIV-infected patients. In this national survey of medical and radiation oncologists, we found that a substantial proportion of physicians (21%) would alter their treatment recommendations based on HIV status. The likelihood of offering standard treatment was associated with concerns about toxicity, efficacy, and comfort level with discussing cancer treatment adverse effects and prognosis. Policy changes in conjunction with educational initiatives are needed to improve the quality of cancer care delivered to HIV-infected patients.
Many providers cited concerns regarding safety and efficacy of cancer treatment in HIV-infected patients. These concerns are not surprising, given the dearth of high-quality data and resulting lack of evidence-based guidelines specific to HIV-infected patients with non-AIDS-defining cancers. Clinical trial data are available to inform management of HIV-infected patients with non-Hodgkin lymphoma and anal cancer, but not most other non-AIDS-defining cancers. This is because HIV-infected patients have historically been excluded from clinical trials, so randomized trial data regarding treatment outcomes are largely unavailable.14 More recently, the National Cancer Institute Cancer Therapy Evaluation Program has advised that HIV-infected individuals not be arbitrarily excluded from clinical trial participation.20 In addition, the AIDS Malignancy Consortium, a National Cancer Institute-supported clinical trials group, organized the Non-AIDS-Defining Cancers Working Group in 2009 to evaluate the safety and efficacy of cancer therapies in HIV-infected patients. Other clinical trial cooperative groups should follow suit, both to improve accessibility of novel therapeutics among HIV-infected patients and to broaden the generalizability of clinical trial results to the HIV-infected population.
Another factor driving provider concerns may be limited experience managing patients with HIV infection and inadequate forums for case discussion; > 30% of respondents had not treated an HIV-infected patient in the last year, and of providers who had, 45% reported they rarely or never consulted with an HIV specialist when developing a cancer management plan.
Purpose:
HIV-infected individuals with non-AIDS-defining cancers are less likely to receive cancer treatment compared with uninfected individuals. We sought to identify provider-level factors influencing the delivery of oncology care to HIV-infected patients.
Although randomized data are lacking, retrospective studies and case reports from the modern HAART era suggest that chemotherapy and radiotherapy can generally be administered safely and with limited treatment toxicity.15,16,21 Nonetheless, these findings have not been incorporated into cancer treatment guidelines, and the majority of respondents in our study felt that available guidelines were insufficient to aid in clinical decision making for HIV-infected patients with cancer.
ABSTRACT
Methods:
A survey was mailed to 500 randomly selected US medical and radiation oncologists. The primary outcome was delivery of standard treatment, assessed by responses to three specialty-specific management questions. We used the χ2 test to evaluate associations between delivery of standard treatment, provider demographics, and perceptions of HIV-infected individuals. Multivariable logistic regression identified associations using factor analysis to combine several correlated survey questions.
Results:
Our response rate was 60%; 69% of respondents felt that available cancer management guidelines were insufficient for the care of HIV-infected patients with cancer; 45% never or rarely discussed their cancer management plan with an HIV specialist; 20% and 15% of providers were not comfortable discussing cancer treatment adverse effects and prognosis with their HIV-infected patients with cancer, respectively; 79% indicated that they would provide standard cancer treatment to HIV-infected patients.
In multivariable analysis, physicians comfortable discussing adverse effects and prognosis were more likely to provide standard cancer treatment (adjusted odds ratio, 1.52; 95% CI, 1.12 to 2.07). Physicians with concerns about toxicity and efficacy of treatment were significantly less likely to provide standard cancer treatment (adjusted odds ratio, 0.67; 95% CI, 0.53 to 0.85).
Conclusion:
Provider-level factors are associated with delivery of nonstandard cancer treatment to HIV-infected patients. Policy change, provider education, and multidisciplinary collaboration are needed to improve access to cancer treatment.
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