Predictors of Survival After a Diagnosis of Non-Hodgkin Lymphoma in a Resource-Limited Setting: A Retrospective Study on the Impact of HIV Infection and Its Treatment

Abstract

Objective We examined factors associated with survival among patients with newly diagnosed non-Hodgkin's lymphoma (NHL) in Uganda. Methods Information was abstracted from medical records for all NHL patients >13 years of age at the Uganda Cancer Institute between January 2004 and August 2008. Cox proportional hazard models were used to identify predictors of NHL survival. Results 160 patients with NHL were identified; 51 (31.9%) were known to be human immunodeficiency virus (HIV) positive. Overall, 154 patients had records sufficient for further analysis. The median person-time observed was 104 days (interquartile range (IQR) 26–222). Median survival after presentation among those whose mortality status was confirmed was 61 days (IQR 25–203). HIV-positive patients receiving antiretroviral therapy (ART) had survival rates approximating those of HIV-negative persons, but the adjusted hazard of death was significantly elevated among HIV-positive patients not receiving ART (aHR 8.99, p < 0.001) compared to HIV-negative patients. Both B-symptoms (HR 2.08, p = 0.05) and female gender (HR 1.72, p = 0.05) were associated with higher mortality. Conclusions In Uganda, overall survival of NHL patients is poor, and predictors of survival differed from those described in resource-rich regions. HIV is a common co-morbidity to NHL, and its lack of treatment was among the strongest predictors of mortality. Strategies are needed for optimal management of HIV-infected individuals with cancer in resource-limited settings.

Profile of cause of death assigned to adults on antiretroviral therapy in Soweto

“…8 In Uganda, only 20 of 154 patients with non-Hodgkin lymphoma, irrespective of HIV status, were known to be alive a year after diagnosis. 9 The outcome in this study appears better but merits a dedicated study as some patients who died might not have accessed ART. Non-AIDS-defining cancers are likely to increase with longer duration on ART and increasing age.…”

Meeting the challenge of hematologic malignancies in sub-Saharan Africa

“…38 There are limited data examining the impact of HIV on NHL survival in sub-Saharan Africa, although studies suggest that concurrent ART may render survival similar to patients without HIV. 33,39,40 …”

“…Drug shortages have similarly interfered with lymphoma treatment even in the context of an internationally funded clinical trial. 33,40 A global commitment to providing essential drugs to developing countries is clearly articulated in Millennium Development Goal 8.E. Nevertheless, availability of essential †AWP per dose assumes a body surface area of 2 m 2 and weight of 80 kg.…”

“…Consistent increases in NHL, and to a lesser extent HL, have been noted across the region since the onset of the HIV epidemic, and HIV prevalence among NHL and HL patients in many settings ranges from 30% to 70%. 10,12,[32][33][34] In resource-rich countries, clinical trials and observational cohorts have demonstrated comparable outcomes for HIVassociated NHL and HL to patients without HIV, [35][36][37] whereas others have found HIV to be independently associated with mortality. 38 There are limited data examining the impact of HIV on NHL survival in sub-Saharan Africa, although studies suggest that concurrent ART may render survival similar to patients without HIV.…”

“…Studies are also consistent in demonstrating a marked survival benefit with concurrent ART among patients with HIV (overall survival 50%-60% with ART vs Ͻ 20% without ART). 33,40 The pediatric oncology community has long been engaged in sub-Saharan Africa and has shown that prospective, multicenter studies testing specific protocols in childhood endemic BL, as well as nephroblastoma and neuroblastoma, are feasible even in the poorest countries. These studies led to the gradual adaptation of regimens from developed countries to local realities.…”