As advances in antiretroviral therapy continue to extend life expectancy for people with HIV, clinicians are increasingly focused on preventing and detecting cancers that emerge with aging rather than immunodeficiency.
During the Saturday session “Cancer Prevention and Screening for People Living With HIV,” speakers emphasized that many patients with HIV should receive the same evidence-based cancer screening recommended for the general population, while also addressing risk factors that are disproportionately common in this population.
Gastrointestinal Cancers
Ma Somsouk, MD, MS, professor of medicine at the University of California, San Francisco, focused on gastrointestinal cancers, noting that the cancer landscape among people with HIV has changed substantially over time.
“Cancer burden is shifting with age in the HIV population,” Dr. Somsouk said.
Adults older than 45 years now account for an estimated 70% of people with HIV, while AIDS-related cancers continue to decline. At the same time, other cancers are becoming more common, with prostate and liver cancers among the most frequently diagnosed.
Although liver and anal cancer risks remain elevated among people with HIV, effective prevention strategies already exist. Dr. Somsouk pointed to smoking cessation, diabetes management and treatment of hepatitis B and hepatitis C as important interventions.
Anal cancer risk is approximately 19 times higher among people with HIV than in the general U.S. population, while liver cancer risk is more than three times higher. By contrast, stomach, colon and rectal cancers appear to occur at slightly lower rates, although the reasons remain unclear.
For colorectal cancer screening, however, Dr. Somsouk emphasized that most patients with HIV should be screened similarly to the general U.S. population.
“When we think about who to screen and when to screen, we treat them in accordance with the average U.S. population,” he said.
Routine screening is generally recommended beginning at age 45, although earlier evaluation may be appropriate for patients with symptoms or a family history of colorectal cancer.
He reviewed several screening options, including colonoscopy, fecal immunochemical testing, stool DNA-FIT testing and CT colonography. While colonoscopy remains the reference standard because it allows for the detection and removal of polyps during the same procedure, Dr. Somsouk stressed that test completion is the most important factor.
“The best test is the one you can get your patient to complete,” he said.
He also stressed the importance of appropriate follow-up after abnormal screening results. Patients with a positive stool-based test require diagnostic colonoscopy, and delays can increase the risk of detecting cancer at a later stage.
“It’s imperative that providers are aware that these individuals are at a high risk for a prevalent cancer,” he said.
Turning to gastric cancer, he noted that risk often reflects ancestry, migration patterns and exposure to Helicobacter pylori. More than half of the world’s population carries H. pylori, and chronic infection can drive a progression from gastritis to gastric atrophy and eventually cancer. Smoking and high salt intake may accelerate that process.
Dr. Somsouk highlighted evidence showing substantial reductions in gastric cancer risk following eradication of H. pylori. “I can’t overemphasize the need to eradicate H. pylori when found,” he said.
For people with HIV, he advised clinicians to be mindful of potential interactions between H. pylori treatment regimens and antiretroviral therapy. He also discussed risk factors that should prompt consideration of endoscopy, including peptic ulcer disease, iron-deficiency anemia, family history of gastric cancer, nonsteroidal anti-inflammatory drug use and immigration from regions with high gastric cancer incidence. Patients with chronic gastroesophageal reflux disease and risk factors for Barrett’s esophagus may also warrant evaluation.
Lung Cancer
The growing burden of age-related cancers among people with HIV extends beyond the gastrointestinal tract. Chyke Doubeni, MD, MPH, chief health equity officer at Ohio State University Wexner Medical Center, discussed lung cancer prevention and early detection.
“Lung cancer is the most common cause of [cancer-related] death in the U.S. and globally,” Dr. Doubeni said.
Although smoking rates have declined nationally, and more lung cancers are now being diagnosed at earlier stages, disparities remain. Survival for localized lung cancer is substantially higher than for metastatic disease, underscoring the importance of prevention and screening.
People with HIV face particular challenges because smoking remains significantly more common in this population. Dr. Doubeni cited data showing that 54% of people with HIV smoke, compared with approximately 20% of the overall U.S. population. Among people with HIV who use injection drugs, smoking prevalence reaches 74%.
“Most lung cancer deaths are preventable,” Dr. Doubeni said.
He described lung cancer screening as an ongoing process rather than a one-time intervention, beginning with tobacco prevention and cessation. Building trust is essential, he said, particularly because stigma, trauma and limited access to care can create barriers to both screening and treatment.
Current screening recommendations focus on adults aged 50 to 80 years with at least a 20-pack-per-year smoking history who currently smoke or have quit within the previous 15 years. However, Dr. Doubeni noted that many patients who die from lung cancer do not meet those criteria. He pointed to updated American Cancer Society recommendations that eliminate the 15-year quit-time restriction, reflecting evidence that lung cancer risk declines after smoking cessation but does not disappear.
For infectious diseases clinicians caring for people with HIV, Dr. Doubeni encouraged taking an active role in tobacco cessation and cancer prevention.
“With modern ART, people living with HIV are living longer and dying of age-related conditions,” Dr. Doubeni said. “Tobacco-related deaths are preventable, but require minimizing missed opportunities in prevention.”