Mature outcomes and prognostic indices in diffuse large B‐cell lymphoma in Malawi: a prospective cohort

Abstract

Outcomes for diffuse large B-cell lymphoma (DLBCL) in sub-Saharan Africa (SSA) are poorly described. We report mature data from one of the first prospective SSA cohorts. Patients aged ≥18 years with DLBCL were enrolled in Malawi 2013-2017. Participants were treated with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy and concurrent antiretroviral therapy (ART) if positive for human immunodeficiency virus (HIV+). Eighty-six participants (mean age 47 years, standard deviation 13) were enrolled: 54 (63%) were male and 51 (59%) were HIV+, of whom 34 (67%) were on ART at DLBCL diagnosis. Median CD4 count was 0Á113 cells 9 10 9 /l (interquartile range [IQR] 0Á062-0Á227) and 25 (49%) had HIV viral load <400 copies/ll. Participants received median six cycles CHOP (IQR 4-6). No patients were lost to follow-up and the 2-year overall survival was 38% (95% confidence interval 28-49). In multivariable analyses, Eastern Cooperative Oncology Group performance status (PS) ≥2 and lactate dehydrogenase (LDH) >29 upper limit of normal (ULN) were associated with mortality. HIV status was not associated with mortality. A simplified prognostic model of LDH >29 ULN and PS ≥2 performed at least as well as the age-adjusted International Prognostic Index. DLBCL can be successfully treated in SSA and outcomes did not differ by HIV status. A simplified prognostic model prognosticates well and may be easier to use in resource-limited settings but requires validation.

High pretreatment plasma Epstein‐Barr virus (EBV) DNA level is a poor prognostic marker in HIV‐associated, EBV‐negative diffuse large B‐cell lymphoma in Malawi

“…Clinical characteristics of these patients, stratified by HIV status, are shown in Table . As in previous descriptions of this cohort, HIV‐positive patients were younger than their HIV‐negative counterparts (45.4 vs 56.2 years, P = .03), with similar male predominance in both groups (19:6 vs 12:7, P = .51).…”

Microcosting Analysis of Diffuse Large B-Cell Lymphoma Treatment in Malawi

“…10 After diagnosis, patients underwent comprehensive baseline clinical and laboratory evaluation. First-line treatment was CHOP; second-line treatment of relapsed or refractory DLBCL was a modified EPIC regimen 9,11 or GEMOX (Table 1). We used data from 86 adult patients enrolled from 2013 to 2017 to estimate real-world data on average chemotherapy use, frequencies of adverse events, and so forth, as described in section Health Events and Outcomes.…”

“…The base case of toxicities/adverse events and number of visits for each treatment type were derived directly from clinical trial data from our group in Malawi when available (Table 2). 9,11 For toxicities that were not available from directly measured data and for ranges of frequencies to provide context, frequencies were derived from the literature.…”

“…5-8 We have previously reported our longitudinal experience treating DLBCL in Malawi with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), which is the current regional standard throughout most of SSA. 9 The 2-year overall survival of DLBCL treated with CHOP in Malawi was 38%. 9 We report a microcosting analysis using data derived from the same DLBCL cohort receiving routine clinical care at a national teaching hospital to help address the scarcity of detailed, disease-specific cost data for cancer care in SSA to guide regional policymakers.…”

“…9 The 2-year overall survival of DLBCL treated with CHOP in Malawi was 38%. 9 We report a microcosting analysis using data derived from the same DLBCL cohort receiving routine clinical care at a national teaching hospital to help address the scarcity of detailed, disease-specific cost data for cancer care in SSA to guide regional policymakers.…”