Adopting lung cancer screening recommendations for an HIV-infected individual with a smoking history

Provided by Clinical Care Options, LLC | August 30, 2017

David A. Wohl, MD
Professor of Medicine
School of Medicine
Site Leader, AIDS Clinical Trials Unit-Chapel Hill
University of North Carolina at Chapel Hill
Director, North Carolina AIDS Training and Education Center
Chapel Hill, North Carolina
Co-Director, HIV Services
North Carolina Department of Correction
Raleigh, North Carolina
 
David A. Wohl, MD, has disclosed that he has received consulting fees from Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV and funds for research support from Gilead Sciences.

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Case Study

Lung cancer screening in HIV-infected individual who smokes

In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. In the case below, an HIV-infected female smoker in her late 50s illustrates how paying attention to the more mundane tasks of preventive health maintenance, such as lung cancer screening, can be the most important thing you do, second to getting HIV suppressed, to help your patients live and be well.

Case Details

A 57-year-old female surviving past relationships and choices that have left her mentally and physically scarred, as well as HIV infected, has been regaining control of her life and striving to be healthier. Five years ago, she started ART, and her plasma HIV-1 RNA dropped and has been undetectable since. Two years ago, she completed a course of HCV therapy and was cured of that virus, acquired 20 years earlier when sharing needles. She comes to every clinic visit and, other than her lifelong depression, mostly kept at bay with citalopram, and chronic lower back pain, she has no major medical problems. However, she has smoked for 35 years and clings to her daily pack of cigarettes, even after overcoming addictions to heroin, cocaine, and alcohol.

The Combustible Mix of Smoking and HIV

Smoking can kill anyone, but it seems particularly lethal for those who are HIV infected. CD4+ cell count depletion reduces the body's surveillance system for detection and destruction of neoplastic cells. In addition, there may be alterations in cellular function in the respiratory tract that can accelerate smoking-related damage. It is no surprise, then, that lung cancer and chronic obstructive lung disease are both prevalent among HIV-infected people. Approximately 40% to 60% of HIV-positive people in the United States are smokers, whereas smoking rates in the general US population are below 20%.

The impact of smoking is clearly demonstrated in analysis from the large D:A:D cohort of HIV-infected persons. Compared with those who never smoked, current smokers had a greater than 1.5-fold risk of a nonlung, smoking-associated cancer and a greater than 8-fold risk of lung cancer. Of importance, over time, people who quit smoking experienced rates of nonlung cancers that appeared to decline to levels seen in the never smokers. Unfortunately, this was not seen for lung cancer, where rates remained elevated even among those who quit smoking 1 to more than 5 years earlier.

Prevention and Intervention

Smoking cessation is a medical challenge and should be approached as such. Patient motivation is an essential element and can be cultivated with understanding, support, information, and persistence. Pharmacologic approaches, including nicotine replacement systems and varenicline, can be helpful for some, particularly when combined with evidence-based behavioral counseling. Too often, providers rely solely on a prescribed medication to tackle this complex health hazard, when a comprehensive approach is needed. Helpful guidance regarding smoking cessation can be obtained from the American Lung Association.

In addition to supporting smoking cessation, HIV providers must also become more aware of guidelines for lung cancer screening. The US Preventive Services Task Force (USPSTF) now recommends annual screening for lung cancer using low-dose CT scans of the chest for those 55 to 80 years of age who have a 30 pack-year history and either currently smoke or quit within the past 15 years. This somewhat radical recommendation from a fairly conservative panel is based on findings from a large clinical trial. Despite the heavy smoking burden and enhanced risk for lung cancer among those living with HIV and the release of this recommendation back in late 2013, it seems that the HIV-treating community has been slow to embrace or even acknowledge this practice. A set of small studies suggests we should pay more attention. In one study, 224 HIV-infected people who were current or former smokers underwent CT scanning of the chest, and 1 case of lung cancer was detected. A French study looked at 442 HIV-infected patients who smoked and identified 9 lung cancers, 6 detected at an early stage.

Discussing and undergoing annual, low-dose CT screening is recommended and important for the preventive care of the patient described above and for those whose age, pack-year, and smoking status parameters qualify. Integration of this simple, yearly test is an immediate step available to clinicians that can optimize the care of HIV-infected patients.

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