Inclusive Cancer Care: Rethinking Patients Living with HIV and Cancer

Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001-2015 in 14 states

Prostate cancer (PCa) incidence is reportedly lower in men with HIV compared to men without HIV for unknown reasons. We describe PCa incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare. Men (N = 15,167,636) aged 18-64 with ≥7 months of continuous enrollment during 2001-2015 in 14 US states were retained for analysis. Diagnoses of HIV and PCa were identified using non-drug claims. We estimated cause-specific (csHR) comparing incidence of PCa by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions, and stratified by age and race-ethnicity. Hazard of PCa was lower in men with HIV than men without HIV (csHR = 0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR = 0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR = 0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR = 1.17; 95% CI: 0.91, 1.50). Findings were similar in models restricted to men aged 50-64 and 40-49, but not in men aged 18-39. Reported deficits in PCa incidence by HIV status may be restricted to specific groups defined by age and race ethnicity.

Cancer Treatment Decision-Making for People Living With HIV: Physician-Reported Barriers, Facilitators, and Recommendations

BACKGROUND

Compared with the general cancer population, people living with HIV (PLWH) and cancer are less likely to receive treatment and have significantly elevated cancer-specific mortality for many common cancer types. Physician recommendations drive the cancer therapy that patients receive, yet there is limited information assessing how cancer treatment decisions are made for people living with HIV and cancer. We sought to understand oncologist decision-making in PLWH and cancer by eliciting barriers, facilitators, and recommendations for enhancing care delivery.

SETTING

Participants were recruited between May 2019 and May 2021 from one academic medical center in the western United States (n = 13), another in the southeastern United States (n = 7), and community practices nationwide (n = 5).

METHODS

Using an inductive qualitative approach, we conducted in-depth interviews with 25 oncologists from two academic medical centers and community practices.

RESULTS

Facilitators of cancer care delivery included readily available information regarding HIV status and stage, interdepartmental communication, and antiviral therapy adherence. Barriers included a lack of formal education on HIV malignancies, perceptions of decreased life expectancy, fear of inadvertent disclosure, and drug-drug interactions. Recommendations included improved provider communication, patient social and mental health resources, and continuing education opportunities.

CONCLUSION

The study revealed drivers of cancer treatment decision-making, highlighting physician-reported barriers and facilitators, and recommendations to support treatment decision-making. This is the first known study examining oncologists' perceptions of caring for PLWH. Given that cancer is a leading cause of death among PLWH, there is an urgent need to improve care and outcomes.

Improving Cancer Care for People Living With HIV: A Qualitative Study of Provider Knowledge, Attitudes, and Practice

PURPOSE

Cancer is now the leading cause of non-AIDS death in the US population with HIV. People living with HIV (PLWH) are known to have lower cancer treatment rates and worse cancer outcomes. Disparate cancer treatment is driven by health system, patient, and clinician factors. Little attention has been given to the factors oncologists consider when making cancer treatment recommendations to PLWH. This study sought to examine oncologists' knowledge, attitudes, and practices that influence cancer treatment decision-making.

METHODS AND MATERIALS

This study used qualitative methods to explore oncologists' treatment decision-making processes for PLWH and cancer. The sample included 25 radiation, medical, and surgical oncologists from 2 academic centers and 5 community practices. The interview domains were developed from the Andersen Healthcare Utilization Model, the Health Belief Model, and the PEN-3 Model, as well as our prior survey research.

RESULTS

This study describes elements of cancer treatment decision-making for PLWH. Oncologists highlighted the need for formal HIV education to support cancer treatment. One main concern with patient-provider interactions pertained to maintaining patient confidentiality during clinical encounters. Lastly, the importance of multidisciplinary care among health care providers allowed oncologists to facilitate both cancer care and logistical support.

CONCLUSIONS

As cancer becomes an increasingly common cause of death among PLWH, it is critical to understand the drivers of the observed disparities in cancer treatment. To our knowledge, this is the first qualitative study to describe oncologists' knowledge, attitudes, and practices toward patients who have a comorbid diagnosis of HIV and cancer. Several themes for future interventions emerge, including HIV training for cancer care providers, fostering interdisciplinary collaboration, enhancing HIV education for oncology learners and clinicians, and minimizing implicit bias.

Palliative Care Use Among People Living With HIV and Cancer: An Analysis of the National Cancer Database (2004-2018)

PURPOSE

People living with HIV (PLWH) diagnosed with cancer are less likely to receive quality cancer treatment compared with HIV-negative patients. Timely provision of palliative care (PC) during cancer treatment can increase patient's survival and improve quality of life. Our objective was to compare the use of PC by HIV status among adults diagnosed with cancer in the United States.

METHODS

More than 19 million individuals age 18-90 years diagnosed with the 11 most common cancers among PLWH were selected from the National Cancer Database (2004-2018). The National Cancer Database defined PC as any surgery, radiation, systemic therapy, or pain management treatment with noncurative intent. Multivariable logistic regression was used to examine associations between HIV status and PC receipt by cancer site and stage after adjustment for covariates.

RESULTS

The study population included 52,306 HIV-positive (average age: 56.5 years) and 19,115,520 HIV-negative (average age: 63.7 years) cancer cases. PLWH diagnosed with stage I-III cancer were more likely to receive PC compared with their HIV-negative counterparts (adjusted odds ratio [aO]: 1.96; 95% CI, 1.80 to 2.14); however, they were also less likely to receive curative cancer treatment (aOR, 0.48; 95% CI, 0.40 to 0.59). PLWH diagnosed with stage IV cancer were less likely to receive PC (aOR, 0.70; 95% CI, 0.66 to 0.74) compared with HIV-negative patients. When evaluated by cancer site, PLWH diagnosed with stage IV lung (aOR, 0.80; 95% CI, 0.73 to 0.87) and colorectal (aOR, 0.72, 95% CI, 0.54 to 0.95) cancers were less likely to receive PC than HIV-negative patients.

CONCLUSION

PLWH diagnosed with stage IV cancer, particularly lung and colorectal cancers, were less likely to receive PC compared with cancer patients without HIV. PLWH with nonmetastatic disease were more likely to receive PC but less likely to receive curative treatment, reinforcing that clinical strategies are needed to improve the quality of care among PLWH.