Modified EPOCH for high‐risk non‐Hodgkin lymphoma in sub‐Saharan Africa

Abstract

Aggressive non‐Hodgkin lymphoma (NHL) is among the most common cancers in sub‐Saharan Africa (SSA), where CHOP is standard treatment and outcomes are poor. To address this, we treated 17 newly diagnosed adult patients in Malawi with Burkitt (n = 8), plasmablastic (n = 8), and primary effusion lymphoma (n = 1) with a modified EPOCH regimen between 2016 and 2019. Twelve patients (71%) were male and the median age was 40 years (range 16‐63). Eleven (65%) were HIV infected, median CD4 count was 218 cells/µL (range 9‐460), and nine (82%) had suppressed HIV RNA < 400 copies/mL. Patients received a median of six cycles (range 2‐8) and median follow‐up was 14 months (range 2‐34) among patients still alive. Grade 3/4 neutropenia was observed in 26% of cycles and in 65% of patients. Sixteen (94%) responded to EPOCH and 10 (59%) achieved a complete response. One‐year overall survival (OS) was 62% (95% confidence interval [CI], 42%‐91%). Five patients (29%) died from progressive NHL and three (18%) from treatment‐related complications. These data suggest EPOCH with setting‐appropriate modifications may be a practical, safe, and effective option for improving high‐risk NHL outcomes in Malawi and comparable settings, which deserves further prospective evaluation.

Phase II trial of a novel chemotherapy regimen CVEP (cyclophosphamide, vinblastine, etoposide and prednisolone) for acquired immunodeficiency syndrome (AIDS)‐associated lymphomas

“…We have not done formal cost‐effectiveness and quality‐of‐life analysis; however, this reduction in the use of G‐CSF, no requirement of central catheters, no use of rituximab and predominantly outpatient therapy appears to perform better than dose‐adjusted EPOCH‐based therapy. The CVEP regimen can be utilised for DLBCL and PBL in low–middle income countries, including sub‐Saharan Africa, which faces a significant burden of AIDS‐related NHL and use of dose‐adjusted EPOCH is impractical in such a scenario as reflected in a study using modified EPOCH, which led to 18% treatment‐related mortality 28 . Significant challenges are faced by these patients in resource‐constrained settings, which leads to treatment abandonment as reflected in exclusion of 34 patient at the time of screening due to lack of social support to continue therapy.…”

“…The CVEP regimen can be utilised for DLBCL and PBL in low-middle income countries, including sub-Saharan Africa, which faces a significant burden of AIDS-related NHL and use of dose-adjusted EPOCH is impractical in such a scenario as reflected in a study using modified EPOCH, which led to 18% treatmentrelated mortality. 28 Significant challenges are faced by these patients in resource-constrained settings, which leads to treatment abandonment as reflected in exclusion of 34 patient at the time of screening due to lack of social support to continue therapy. Administration of a regimen requiring central catheter and supportive care in the face of such constraints is even more challenging.…”

Trends Analysis of Non-Hodgkin Lymphoma at the National, Regional, and Global Level, 1990–2019: Results From the Global Burden of Disease Study 2019

“…In contrast, in South Africa, excluding major changes in society and the lifestyles of the people, scholars hypothesized that the development of NHL was delayed because of the receipt of various anti-infective treatments (43)(44)(45)(46). Researchers have applied a low-intensity EPOCH (etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin) infusion regimen in sub-Saharan Africa, which may have contributed to the decline in DALYs in Malawi because the infusion regimen is a treatment that can improve outcomes for adolescents and adults with Burkitt lymphoma (BL) in Malawi and reduce drug toxicity reactions (47). There were several limitations in this study.…”

Implementation and Evaluation of Educational Videos to Improve Cancer Knowledge and Patient Empowerment

“…There are numerous ongoing prospective clinical research studies for patients, led by the UNC Project Malawi research team. [21][22][23][24][25][26][27][28][29] Patients enrolled in these studies are followed by UNC Project-Malawi providers and undergo a comprehensive informed consent before enrollment, which includes additional cancer education. Before implementing patient educational videos in clinic, patients received cancer education from their individual providers per local standards of care.…”