Miami Cancer Institute’s HIV/Cancer Clinic Utilizes Multidisciplinary Care to Improve Outcomes

Marco Ruiz, MD

The HIV/Cancer Clinic at Miami Cancer Institute offers a multidisciplinary team to address clinical, psychological, and social challenges faced by patients with cancer who also have a human immunodeficiency virus (HIV) infection, according to Marco Ruiz, MD, who added that the clinic will also provide more opportunities to participate on clinical trials dedicated to providing more treatment options to this population.

The institute, which is part of Baptist Health South Florida, has also became a member of the AIDS Malignancy Consortium (AMC). The 2 programs seek to provide these patients with better access to new clinical trials and multidisciplinary care. Through the AMC, the Miami Cancer Institute is offering 5 clinical trials. Notably, the institute also offers stem cell transplantation for those with HIV and select cancers, and seeks to further explore the use of CAR T-cell therapy.

“Patients with HIV and cancer [should] be treated in centers that have expertise,” Ruiz said. “Patients do well when they are exposed to the authorized and FDA-approved therapies. With a very well-developed multidisciplinary team, many of the psychological and social issues can be tackled, and we can see more [improvements] in treatment outcomes.”

In an Interview with OncLive^®, Ruiz, hematologist, chief of HIV Oncology and HIV Stem Cell Transplantation at Miami Cancer Institute, further discussed the new HIV/Cancer Clinic and its goals, challenges faced with patients who have cancer and HIV infection, and clinical trial opportunities that strive to move the needle forward.

OncLive^®: Could you speak to Miami Cancer Institute's HIV/Cancer Clinic? What unmet need will this clinic aim to address?

Ruiz: Miami Cancer Institute is a relatively new cancer center; it has been [around] 4 years since [it] was funded. Since then, there has been a big interest in trying to get some special groups [launched]. To this end, we developed the Hematologic Malignancies and Blood and Marrow Transplant group. Within that group, [we have] the HIV/Cancer Clinic.

We have been practicing and working with patients infected with HIV over the past 20 years. There was always a special interest in trying to develop this HIV/Cancer Clinic. I had the opportunity and the [support] of leadership to develop this clinic. We have already started half-a-day clinic on Thursdays [where we] see all the patients with cancer and HIV infection.

There are many reasons behind the development of this clinic. First, there's a big need in the community. We all know and recognize that Miami and Fort Lauderdale are still within the top 10 cities with newly HIV-diagnosed individuals and new AIDs diagnoses in the community. Therefore, there is a big need to coordinate care with regard to oncology issues for the HIV-infected population. [We want] to develop a very strong academic-oriented clinic and to [foser] cooperation and collaboration within the community, [encourage] participation in research, and [further] develop clinical operations.

What are some of the complexities associated with caring for a patient with both HIV and cancer? Why is a multidisciplinary approach so essential?

From a clinical standpoint, it is challenging sometimes, because you truly [need] experts in the field of HIV and the field of oncology. Many of these patients [who] come [to the clinic are] already on antiretroviral therapy and there's many interactions between [this] therapy and some of the chemotherapy drugs or novel agents that we use. As such, is very important to have a very strong HIV and oncology group. Within our team, we have individuals who have an infectious disease/HIV background as well as those who have an oncology background. My job is to coordinate with all of them on difficulties faced in terms of interactions, adverse effects, etc.

From a psychological standpoint, I have found that patients with HIV still face many issues in the community. It has been almost 40 years since the first HIV diagnosis, but there is still a lot of taboo and resistance in the community [with viewing] HIV as a chronic illness. There is a significant [component to consider] in terms of psychological complications such as depression and anxiety. Therefore, we use a multidisciplinary group [comprised of] psychologists, social workers, and mental health providers who can help us [address] these issues.

The [other thing to mention is challenges with] social networking and interactions. For many cultures, HIV infection is not well received; even though there are many modes of transmission, it remains a big problem. As such, many of these patients live in isolation and some of them don't have well-structured social networks. Knowing this, our social workers try to expand those networks and create some patient-driven programs that will help them to understand what they are going through and get [access to] resources. [Many of these patients] do not know that there are resources out there.

Those are the 3 domains—clinical, psychological, and social—that I have found to be very critical when it comes to caring for these patients. If there is a cancer diagnosis, or any malignancy, on top of this, [it just further] complicates matters.

Where are efforts being focused to improve care for this patient population?

The National Cancer Institute and other national cancer and HIV organizations propose that HIV and cancer care needs to be revisited. We have the same issues that we used to have perhaps 20 years ago, despite the tremendous advances and efforts made in terms of HIV medications. About 20 to 25 years ago, patients who were exposed to HIV therapy, were given almost the equivalent of chemotherapy at those times. Now, more refined medications exist, and they are more acceptable for patients. Still, there are some issues [with these treatments]—especially in terms of compliance. We still have a long way to go [in terms of research].

There is a renewed interest in [further] understanding biology and why patients with HIV tend to develop certain cancers that are more aggressive and that do not respond [to therapy] in the same way that other populations respond. [Efforts are also focused on] determining the characteristics and the burden of cancer in the HIV population. We know that patients infected with HIV [are at] a higher risk to acquire certain malignancies; [however], we don't have a cohort of patients who have been followed by research centers to determine [these] characteristics and the burden of cancer in these populations. Some research [is being done] to [better] understand that.

Another big research topic is trying to correlate some of the novel mechanisms of cancer [that develops in the HIV-infected population. [Clearly], many new research studies and endeavors [are being made] at this [time]. It is very interesting that some of the same treatments that we use for HIV are used in patients [with] cancer. For instance, new technologies such as CAR T-cell therapy, [which] has been used in many of our patients with lymphomas and leukemias, is also being used to cure or eradicate HIV. [This approach] is [currently] in its infancy, but with time, we are going to see more and more development in this area. Many parallel situations [can be seen] with HIV and cancer, but there is a lot of [room to] evolve, develop, and research.

Could you elaborate on a case of an allogeneic stem cell transplant done at the Miami Cancer Institute in someone with HIV and an aggressive form of lymphoma?

Allogeneic donor transplant in an HIV-infected patient is not commonly used. There are many reasons [for that, such as] potential interactions and complications. [When treating the patient, the goal is to] treat both the HIV and the lymphoma, or whatever cancer is affecting the patient. Others have tried to eradicate, control, or cure both conditions through the means of an allogeneic transplant, which is a donor transplant. Certain specific characteristics you need to look for before you proceed with [treatment]. In this case, the patient had a highly aggressive lymphoblastic lymphoma [that was] chemotherapy resistant.

We were able to control the disease and put this patient in a complete remission just before we proceeded with transplant. We were able to find a donor who happened to have this specific mutation that allowed us to potentially cure the HIV infection. We proceeded with the transplant and the patient is already going onto month 7, close to over 200 days after transplant. Thus far, the patient’s lymphoma is under complete remission and his HIV is not detectable. We're preparing to enter the first year in which it is going to be critical to assess the possibility of cure.

We have another similar patient who is getting ready and prepared [for transplant]. We're just looking for a donor with a specific mutation to prepare. [Clearly], the expertise with this clinic helped to open possibilities for patients that perhaps were not available before.

Now that Miami Cancer Institute has become a member of the AIDS Malignancy Consortium, what are some of the clinical trials that are being offered?

The consortium is a national organization [with] about 37 members; [Miami Cancer Institute is] 1 of the members. [The organization] recognizes excellence in HIV care. We're trying to [introduce] about 10 clinical trials for patients with HIV and cancer. The majority of [the trials are related to] lymphoma, [but also are being done in] Kaposi sarcoma, cervical cancer with human papillomavirus, and lung cancer. [These trials] will be open at Miami Cancer Institute through the AIDS Malignancy Consortium.

[We also] hope to be able to lead the bone marrow transplant subdivision within the AIDS Malignancy Consortium because of our expertise in doing bone marrow transplant. Hopefully, we will be able to work with [these experts] and scientific committees to develop a group. [For that group,] hopefully we will [receive] good samples, [gather] clinical data, and develop a database for these patients.

Other national organizations [are trying to do] the same [thing], including the American Society for Transplantation and Cellular Therapy. We are trying to [offer this] opportunity. We are excited about the possibilities: the clinical trials that [we can] offer the community and our patients and the partnering options [that we have] with other institutions.

What impact do you foresee this clinic having?

Our patients are going to have the opportunity to come to a center that offers a multidisciplinary approach to care for them. In my [prior] experience, a cohesive approach to patients with HIV and cancer [has been lacking]. Some providers, and even some of the oncologists in the HIV world, [deduce that] the patient is not going to be fit enough to receive any treatments. For other [providers] it is the opposite, [and they] will treat it regardless. Expertise is needed.

This [clinic] will have a significant impact on [this;] more patients will come to Miami Cancer Institute, a center that offers a multidisciplinary approach to HIV cancer care. It's also going to provide the opportunity to participate on clinical trials.

[The clinic] is also going to open [doors] for research. Seeing as we are going to be part of the AIDS Malignancy Consortium, we need to establish research proposals not only from a clinical trials standpoint, but also from a basic science research [standpoint so that we can] explore novel pathways for cancer development in infected patients. What is the role, for instance, of HIV, Epstein Barr, and other viruses within the HIV milieu and how do they interact to develop new cancer pathways? In terms of research, that will be a good [area for exploration], because we may have the opportunity to develop more of these basic science research studies [to answer these kinds of questions].

[There are also] potential opportunities in the academic setting. We are going to be able to teach students, residents, and fellows, as well as participate in academic community endeavors.

What is your take-home message for your colleagues treating patients with both HIV and cancer?

[They should know that the] option of transplant for HIV-infected patients is there: autologous and allogeneic. We will soon develop CAR T-cell therapy for HIV-infected patients as another treatment platform that we will hopefully [be able to] offer. Not many centers have that [modality], so it is a potential research opportunity in terms of clinical trials that we can offer for these patients.

It is hopefully a new era for HIV [and] oncology. What we need to do is concentrate on the fact that we can achieve improved outcomes in these patients and the multidisciplinary approach is very much needed under these circumstances.

Reference

1. Miami Cancer Institute launches HIV/Cancer Clinic and joins AIDS Malignancy Consortium. News release. Baptist Health South Florida. July 7, 2021. Accessed October 15, 2021. https://bapth.lt/3n1tTjR