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Nursing Challenges of Caring for Patients with HIV-Related Malignancies

Nursing Challenges of Caring for Patients with HIV-Related Malignancies

ABSTRACT: As many as 40% of individuals infected with HIV will be diagnosed with a malignancy during the course of their illness. Although neoplasms of all organ systems have been reported in infected patients, Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL), primary central nervous system (CNS) lymphoma, and invasive squamous cell cervical carcinoma are considered to be diagnostic of AIDS in the presence of HIV infection. The rapidity with which these malignancies are diagnosed can affect the morbidity experienced by patients. The management of patients with AIDS-related malignancies poses several challenges for oncology nurses. First, most such patients are treated with either chemotherapy or radiotherapy, and use of these modalities is complicated by the underlying HIV infection. Second, patients with AIDS-related malignancies experience numerous symptoms, and again, management of these symptoms is compounded by the underlying disease. By applying their knowledge and experience, oncology nurses can greatly lessen morbidity in these patients. [ONCOLOGY 10(10):1509-1527]

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.

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