Nursing Challenges of Caring for Patients with HIV-Related Malignancies

Introduction

The HIV pandemic has had an impact on every segment of society and every facet of health care. It has been estimated that upwards of 1 million Americans are infected with HIV.[1] More than 500,000 Americans have been diagnosed with AIDS over the past 15 years, and approximately three-quarters of these have died as a result of their disease.[2]

Persons infected with HIV not only are susceptible to opportunistic infections but also are at risk for the development of so-called opportunistic malignancies.[3] Currently, the Centers for Disease Control (CDC) surveillance definition of AIDS includes four such malignancies: Kaposi's sarcoma (KS), HIV-related non-Hodgkin's lymphoma (NHL), primary central nervous system (CNS) lymphoma, and invasive squamous cell cancer of the cervix.[4] In the presence of HIV infection, these malignancies constitute a diagnosis of AIDS.

The rapidity with which these malignancies are diagnosed and treated can affect the morbidity experienced by patients. Also, the treatment of these malignancies in patients with an underlying chronic immune deficiency such as AIDS poses numerous challenges, particularly with respect to management of treatment-related side effects and disease complications. By honing their assessment skills and instituting appropriate interventions, oncology nurses can help lessen patients' morbidity and improve their quality of life.

Before proceeding to a discussion of the challenges that face oncology nurses who care for patients with an HIV-related malignancy, a brief review of the four malignancies recognized by the CDC as AIDS-defining is in order.

Kaposi's Sarcoma

One of the initial presenting diagnoses at the start of the AIDS pandemic, KS now accounts for approximately 15% of all index diagnoses.[5] Although the cell of origin of this malignancy is unknown, the factors contributing to its pathogenesis are being elucidated. It has been well established that cyto-kines play a pivotal role in the development of KS.[6] Recently, a newly identified member of the herpesvirus family, called either KS herpesvirus (KSHV) or human herpesvirus type 8 (HHV8), which has been isolated from KS lesions, has been theorized to play a role as well.[7]

An unsightly, often disfiguring disease when it affects the skin, KS is often treated with chemotherapy, biologic-response modifiers, or radiotherapy. All of these treatments can produce side effects, and it is frequently the oncology nurse who assesses these symptoms and plans interventions.

Hiv-Related NHL

It is estimated that 4% to 10% of all HIV-infected patients will develop NHL during the course of their illness.[8] For the most part, these lymphomas tend to be intermediate- or high-grade, extranodal, and advanced-stage at presentation.

Multiagent chemotherapy regimens are the treatment of choice for these patients. These regimens generally produce side effects, which, if ameliorated, can improve quality of life.

Primary CNS Lymphoma

Primary CNS lymphoma, a rare malignancy, is usually diagnosed in patients with end-stage AIDS, occurring typically when the CD4 count is less than 75 cells/mm³. The symptoms of primary CNS lymphoma may be confused with other CNS pathologies, for example, cryptococcal meningitis and toxoplasmosis, and, consequent-ly, diagnosis and treatment may be delayed.[9]

Thus far, chemotherapy has not proven beneficial in these patients. Although radiotherapy may produce short-term benefits, the prognosis is universally poor, with median survival of less than 4 months.[10] Care of these patients focuses on palliation and improving quality of life.

Invasive Squamous Cell Cervical Carcinoma

In 1993, after numerous reports of the alarmingly high incidence of human papilloma virus (HPV) and cervical intraepithelial neoplasia in women infected with HIV, as well as anecdotal observations about the rapid progression and virulence of invasive squamous cell cervical carcinoma in such women, the CDC added invasive squamous cell cervical carcinoma to the list of malignancies constituting an AIDS diagnosis.[4,11,12] Because so few cases of this malignancy exist, and because traditional therapy does not alter outcome, the treatment of choice for these women is unknown.[12]

Again, care for women with HIV-related squamous cell cervical cancer focuses on enhancing quality of life and palliating symptoms. When caring for HIV-infected women, the oncology nurse also should keep in mind the need to include children and significant others in the plan of care, as women are frequently the caretakers of both their ill children and spouse or significant other.[13] In addition, women are more likely to seek care for an ill partner or child before they seek care for themselves.

Other Malignancies

The devastation caused by HIV on the immune system, particularly the cell-mediated arm, results in a diagnosis of malignancy at some point during the illness in approximately 30% to 70% of those with AIDS.[14] Kaposi's sarcoma, NHL, primary CNS lymphomas, and squamous cell cervical cancer constitute 95% of all malignancies diagnosed in HIV-positive patients. A recent report has documented an increased incidence of both Hodgkin's disease and germ-cell tumors in this patient population when compared with the general population.[15] The meaning of this finding is unclear, and further research is needed to determine whether these malignancies may be AIDS-defining.

It should also be kept in mind that an HIV-infected person is at the same risk for age-appropriate malignancies as the noninfected person, and that neoplasms of all organs and body systems have been reported in patients whose serum is HIV-positive. Consequently, it is not uncommon to have a patient dually diagnosed with a malignancy and HIV. The significance of an HIV diagnosis in a patient with a non-AIDS-defining malignancy relates to the treatment options and side effects. Because of the effect of HIV on bone marrow, the patient is more susceptible to myelosuppression, and hence, is at risk of developing opportunistic infections during treatment.[16]

Nursing Challenges

The nursing challenges of caring for patients with an HIV-related malignancy can be divided into three broad categories: (1) those that are the direct result of HIV infection, (2) those that are related to other AIDS-defining diagnoses or their treatment, and (3) those that stem from the malignancy or its treatment. Within each category, the challenges relate primarily to managing symptoms and providing psychosocial support, and may overlap. At times, it may be enough to manage the symptom or side effect without concern for the underlying cause, but usually determining the causative factor is important.

HIV-Related Symptoms

It has been well established that the mere presence of HIV in the body produces symptoms. Primary infection with HIV results in many clinical symptoms, from the viremia noted at initial exposure to an erythematous nonpruritic maculopapular rash, mucocutaneous ulceration, nausea, vomiting, and diarrhea.[17] These symptoms tend to be difficult to manage because the underlying etiology cannot be corrected. As a result, it may take numerous adjustments of medications to achieve a tolerable level of discomfort from symptoms, and total eradication of symptoms may be impossible. It is important to apprise patients of this fact and to allow them time to vent their frustration about it.

AIDS-Related Symptoms

AIDS-related symptoms are those that are associated with AIDS-defining diagnoses. It should be kept in mind that in fewer than 20% of HIV-positive patients, the initial diagnosis of AIDS is made on the basis of development of an AIDS-defining malignancy. It is very likely that patients with an HIV-related malignancy will have a concurrent or prior opportunistic infection. It is just as likely that these patients will be on multiple medications, including alternative therapies, antiretroviral agents, prophylactic medications, and medicines to treat active infection. They may have continual low-grade nausea (with or without vomiting), anorexia, weight loss, and fatigue. In addition, they may be pancytopenic and/or have electrolyte imbalances, due either to the medications or the disease process itself.

Treatment-Related Symptoms

The two most common modalities used to treat an HIV-related malignancies are chemotherapy and/or radiotherapy. The side effects of these two modalities are no different in the HIV-infected population than in the noninfected population. Rather, it is the rapidity and intensity of treatment side effects experienced by HIV-infected patients that differ, as do their responses to interventions. An awareness of these differences will help oncology nurses better manage side effects in this patient population.

The following sections will detail the most common side effects of treatment seen in patients with an HIV-related malignancy, along with tips on their management.