Jay S. Cooper, MD

Malignancies have been detected in approximately 40% of all patients with acquired immunodeficiency syndrome (AIDS) sometime during the course of their illness.

Malignancies have been detected in approximately 40% of all patients with acquired immunodeficiency syndrome (AIDS) sometime during the course of their illness. These cancers have been both a primary cause of death in some patients and also a source of considerable morbidity. In the current era of highly active antiretroviral therapy (HAART), patients infected with the human immunodeficiency virus (HIV) are surviving longer than ever. HAART appears to have substantially reduced the incidence of Kaposi’s sarcoma (KS) and non-Hodgkin lymphoma (NHL) and may enhance the efficacy of treatment for those patients who do develop these tumors. Unfortunately, HAART has not shown a similar effect on the development of other types of neoplasms, and caring for patients who develop malignancies in the setting of HIV remains a challenge. Furthermore, HAART is not available universally, with many patients in resource-poor developing countries not having access to antiretroviral drugs.

In the past, locoregionally advanced head and neck cancer routinely was treated by surgery followed by adjuvant radiation therapy, unless the disease was too extensive to be resected and treatment defaulted to radiation therapy alone.

In this edition of Clinical Quandaries, Trombetta et al present a 64-year-old man who seeks care because of a new, asymptomatic right midneck mass. Because the mass is not warm or tender and the patient does not have an elevated temperature, an infectious etiology is unlikely. We are not told if he is a smoker or drinker and we assume he does not have any other signs or symptoms (such as recent-onset hoarseness) that would point us to a head and neck cancer as a primary source.

What do we know for sureabout the health implicationsof inappropriateweight and nutrition? We know thatapproximately 60% of US adults currentlyare considered overweight orobese[1] and approximately 300,000deaths a year in this country are associatedwith overweight and obesity.And, most importantly for this discussion,we know that randomizedcontrolled trials suggest that lifestylechanges resulting in the loss of excessweight reduce the risk cardiovasculardisease, lower blood pressure, lowerblood sugar, and improve lipid levels.[2] In essence, there is a chain ofevidence: A medical condition exists,the condition causes adverse outcomes,with interventions the conditioncan be reversed, and the problemsit causes can be ameliorated.

The first 15 years of the AIDS pandemic can be summarized simply by the oxymoron "constant change." The syndrome unfailingly has presented new challenges and demanded nearly continual refinement of our patterns of management. In the future, progressively more effective antiretroviral therapy paradoxically may permit infected patients to live longer and fall victim to more HIV-related and HIV-independent malignancies. Swift's review of the role of radiation therapy in the setting of HIV infection therefore provides a useful "snapshot" of current standards and a necessary warning of likely changes to come. Several points warrant emphasis.