Moran provides a comprehensive overview of the myriad nursing challenges posed by patients who have a dual diagnosis of HIV disease and cancer. At least two factors make it imperative for nurses to become increasingly proficient in the care of patients with HIV-related malignancies. First, it is now estimated that 1 in every 250 people in this country is infected with HIV, with the largest increases occurring in heterosexual men and women. Second, patients with HIV disease are being seen in virtually all health-care settings, and many dedicated oncology and HIV/AIDS services are now being mainstreamed into general medical services. Thus, nurses who may have had little experience with this patient population in the past are now much more likely to encounter these patients.
As the article demonstrates, patients with an HIV-related malignancy may have involvement of virtually any or many organ systems because of the underlying immunodeficiency and malignant processes or the therapies used for either or both processes. The resultant complexity of symptoms can be extremely frustrating and confusing to the patient and can also tax the nurse's ability to assess and intervene appropriately. Typically, patients are anxious about any new change and tend to imagine that every symptom is related to their illness, forgetting that a cold, headache, or other symptom can occur as a "normal" experience and therefore doesn't always belong in the "HIV/cancer basket." Consequently, patients need to know as much as they can comprehend about the disease process and how to monitor themselves.
In the section of Moran's article that deals with the HIV-related malignancies, the severity of the illnesses would be more demonstrable if the usual incidence of each malignancy was related to the degree of immunosuppression, as is described for primary central nervous system (CNS) lymphoma. For example, early in the epidemic, Kaposi's sarcoma (KS) was frequently the initial AIDS-defining diagnosis; this is now much less common. When KS is diagnosed later in the course of HIV disease, morbidity and mortality are significantly increased.
Another noteworthy aspect of this malignancy is that although KS is seen predominantly in homosexual and bisexual men, it has also been diagnosed in women. In one instance, the KS presented as a vulvar mass. This case demonstrates the vigilance required in clinical observation.
With respect to HIV-related non-Hodgkin's lymphoma (NHL), the severity of the underlying HIV disease affects the prognosis irrespective of the characteristics of the lymphoma. The likelihood of a patient achieving a complete response to therapy depends on a number of factors, including the CD4 count, prior AIDS-defining illnesses, and the presence or absence of extranodal disease.
Currently, as Moran describes, women with invasive squamous cell cancer of the cervix are presenting late in the course of their illness. Because HIV-infected women are at increased risk for cervical dysplasia due to the human papilloma virus (HPV), women who are HIV-positive or those who have a history of sexually transmitted disease should have Pap smears at least every 6 months. Initiation of Pap smears could improve the prognosis for these women.
Given the overlapping symptoms that occur in patients with HIV-related malignancies, it would have been helpful if the article had included a table listing the most frequent side effects and interactions of the commonly used drugs for HIV disease and the specific malignancies. Because symptoms also arise from the involvement of various organ systems, this, too, could have been summarized in a table. Tables such as these could help the clinician and patient discern whether the source of the symptom is most likely related to the treatment regimens or is a manifestation of the underlying pathophysiology.
Although the author includes some specific suggestions for patient education, this is an area that could have been more fully developed. Patients are frequently seen on an ambulatory basis and need to know which symptoms require immediate attention, which are most likely to be self-limited, and which they can self-manage (if they are taught how to do so).
Skin care, for example, is an important aspect of care for the patient with KS. The preservation of skin integrity is extremely important, particularly in the presence of lymphedema. Skin disruption provides a portal of entry for infection, especially by bacteria and fungi. Patients need to be taught to inspect the affected areas regularly to note any change in appearance; the presence, location, and size of any new lesions; signs of skin breakdown; and any alterations in appearance related to therapy.
In the past, the diagnosis of cancer was often viewed as a death sentence. In the last 15 years, this perception has given way to the crisis response to a diagnosis of AIDS. Many view the dual diagnosis of HIV and cancer as an absolute death sentence, a "double whammy," if you will. Nurses need to help patients develop a realistic approach to living with these illnesses, promoting activities that sustain a meaningful quality of life for as long as possible.