Prognoses for patients with AIDS-associated, non-Hodgkin lymphomas (AIDS-NHLs) have improved dramatically as HIV/AIDS has become easier to treat, and “we’re actually seeing patients with long-term remissions that are translating to cure,” a hematologist told colleagues at the virtual 2020 annual meeting of the Association of VA Hematology/Oncology (AVAHO).
“Even those with low CD4 counts initially have more chance of survival compared to the historic patients in the pre-HAART [highly active antiretroviral therapy] era,” explained Erin Reid, MD, MS, of the University of California at San Diego Moores Cancer Center. “They’re seeing complete-response rates and overall-survival rates that are nearly matching what we’re seeing in the non-HIV lymphoma cases. And aggressive infection prophylaxis has seemed to mitigate some of the infectious complications.”
Still, Reid said, a severe form of AIDS-NHL continues to have very poor outcomes, although specific regimens appear to be brightening the picture somewhat.
According to Dr. Reid, AIDS-NHLs are the most common malignancy in the HIV-positive population, and patients with these cancers are more likely to have aggressive lymphomas. These patients are also more likely to have lymphomas associated with Epstein-Barr virus—40 to 80%, depending on the subtype of lymphoma—and Kaposi sarcoma-associated herpesvirus (also known as human herpesvirus-8, or HHV8).
“These viruses are driving these cancers, and it begs the question of whether there’s something we can do to target these viruses within these cancer cells in a way that’s therapeutic,” she said.
Compared with the non-HIV population, patients with AIDS-NHL “are much more likely to present with advanced stage, extranodal disease and central nervous system involvement,” she said.
It’s become clear that HIV control via HAART has benefits in terms of higher tolerance of chemotherapy doses—“we’re able to use more full or traditional dose regimens”—and perhaps cancer suppression too, she said. A 2013 meta-analysis “favored concurrent therapy with chemotherapy [and HAART]. This has become our recommended standard of care for virtually all cases, except the very rare ones where you cannot find a regimen that is compatible from a PK [pharmacokinetics] standpoint.”
Reid also noted that the HAART era has changed the role of CD4 counts in AIDS-NHLs. “While CD4 count still has some predictive value, its impact on mortality appears attenuated,” she said.
With regard to treatment, she emphasized the importance of HAART: “We would recommend concurrent HAART whenever possible with chemotherapy, or start it immediately afterward.”
Aggressive infection prophylaxis also is recommended through granulocyte colony-stimulating factor and agents to target threats from pneumocystis jiroveci pneumonia, gram negative rods, and varicella-zoster virus. “I’ve moved away from fungal prophylaxis over the years, only dealing with it if there’s a known fungal infection,” she said.
As for treatment of AIDS-NHL, Reid Suggested that research supports the EPOCH regimen --etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin. However, “we still need strategies for refractory and relapsed disease,” she said.
Reid noted that she has started to see more plasmablastic cases, although her experience is anecdotal. Plasmablastic lymphoma is much more common in the HIV-positive setting, she said.