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Coelho J, Roush SM, Xu AM, Puranam K, Mponda M, Kasonkanji E, Mulenga M, Tomoka T, Galeotti J, Brownlee A, Ghadially H, Damania B, Painschab M, Merchant A, Gopal S, Fedoriw Y. HIV and prior exposure to antiretroviral therapy alter tumour composition and tumour: T-cell associations in diffuse large B-cell lymphoma. Br J Haematol 2024. [PMID: 38769021 DOI: 10.1111/bjh.19531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of lymphoma worldwide, accounting for up to 40% of new non-Hodgkin Lymphoma (NHL) globally. People living with HIV are up to 17 times more likely to develop NHL, and as such, DLBCL is the leading cause of cancer death in this high-risk population. While histologically indistinguishable, HIV-associated (HIV+) and HIV-negative (HIV-) DLBCL are molecularly distinct, and biological differences may have implications for the development of future therapeutic interventions. Further, the impact of immunologic differences in people with HIV, including preceding ART, remains largely unknown. Here, we investigate the impact of HIV infection and ART exposure on the clinical features of DLBCL and T-cell immune response by performing imaging mass cytometry on our unique patient cohort in Malawi. In this cohort, HIV infection is positively prognostic, and HIV+/ART-naïve patients have the best outcomes. No established biomarkers other than Ki67 are associated with HIV or ART status, and the only tumour-intrinsic biomarkers that remain prognostic are MYC and MYC/BCL2 protein co-expression. Finally, TCR clonality is associated with distinct tumour-T cell interactions by HIV/ART status, indicating differential anti-tumour immune responses. We demonstrate previously undescribed HIV and ART-related differences in the DLBCL tumour microenvironment.
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Affiliation(s)
- Jenny Coelho
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina (UNC), Chapel Hill, North Carolina, USA
| | - Sophia M Roush
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina (UNC), Chapel Hill, North Carolina, USA
| | - Alexander M Xu
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | | | | | | | - Jonathan Galeotti
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina (UNC), Chapel Hill, North Carolina, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
| | - Amy Brownlee
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina (UNC), Chapel Hill, North Carolina, USA
| | - Hormas Ghadially
- Department of Pathology, School of Medicine and Oral Health, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Blossom Damania
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
- Department of Microbiology and Immunology, School of Medicine, UNC, Chapel Hill, North Carolina, USA
| | - Matthew Painschab
- UNC Project Malawi, Lilongwe, Malawi
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
- Division of Hematology, Department of Medicine, UNC, Chapel Hill, North Carolina, USA
| | - Akil Merchant
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Division of Hematology and Oncology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Satish Gopal
- National Cancer Institute Center for Global Health, Rockville, Maryland, USA
| | - Yuri Fedoriw
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina (UNC), Chapel Hill, North Carolina, USA
- UNC Project Malawi, Lilongwe, Malawi
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
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2
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Vaughan J, Patel M, Suchard M, Gededzha M, Ranchod H, Howard W, Snyman T, Wiggill T. Derangements of immunological proteins in HIV-associated diffuse large B-cell lymphoma: the frequency and prognostic impact. Front Cell Infect Microbiol 2024; 14:1340096. [PMID: 38633747 PMCID: PMC11021765 DOI: 10.3389/fcimb.2024.1340096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/12/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Diffuse large B-cell lymphoma (DLBCL) is an aggressive malignancy of B-cells frequently encountered among people living with HIV. Immunological abnormalities are common in immunocompetent individuals with DLBCL, and are often associated with poorer outcomes. Currently, data on derangements of immunological proteins, such as cytokines and acute phase reactants, and their impact on outcomes in HIV-associated DLBCL (HIV-DLBCL) is lacking. This study assessed the levels and prognostic relevance of interleukin (IL)-6, IL-10 and Transforming Growth Factor Beta (TGFβ), the acute phase proteins C-reactive protein (CRP) and ferritin; serum free light chains (SFLC) (elevation of which reflects a prolonged pro-inflammatory state); and the activity of the immunosuppressive enzyme Indoleamine 2,3-dioxygenase (IDO)in South African patients with DLBCL. Methods Seventy-six patients with incident DLBCL were enrolled, and peripheral blood IL-6, IL-10, TGFβ, SFLC and IDO-activity measured in selected patients. Additional clinical and laboratory findings (including ferritin and CRP) were recorded from the hospital records. Results Sixty-one (80.3%) of the included patients were people living with HIV (median CD4-count = 148 cells/ul), and survival rates were poor (12-month survival rate 30.0%). The majority of the immunological proteins, except for TGFβ and ferritin, were significantly higher among the people living with HIV. Elevation of IL-6, SFLC and IDO-activity were not associated with survival in HIV-DLBCL, while raised IL-10, CRP, ferritin and TGFβ were. On multivariate analysis, immunological proteins associated with survival independently from the International Prognostic Index (IPI) included TGFβ, ferritin and IL-10. Conclusion Derangements of immunological proteins are common in HIV-DLBCL, and have a differential association with survival compared to that reported elsewhere. Elevation of TGFβ, IL-10 and ferritin were associated with survival independently from the IPI. In view of the poor survival rates in this cohort, investigation of the directed targeting of these cytokines would be of interest in our setting.
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Affiliation(s)
- Jenifer Vaughan
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa
| | - Moosa Patel
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Haematology Unit, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Melinda Suchard
- Department of Chemical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maemu Gededzha
- National Health Laboratory Services, Johannesburg, South Africa
- Department of Immunology, University of the Witwatersrand, Johannesburg, South Africa
| | - Heena Ranchod
- Department of Chemical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute for Communicable Diseases, Centre for Vaccines and Immunology, Johannesburg, South Africa
| | - Wayne Howard
- Department of Chemical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute for Communicable Diseases, Centre for Vaccines and Immunology, Johannesburg, South Africa
| | - Tracy Snyman
- National Health Laboratory Services, Johannesburg, South Africa
| | - Tracey Wiggill
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa
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3
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Brownlee AJ, Dewey M, Chagomerana MB, Tomoka T, Mulenga M, Khan S, Kampani C, Chimzimu F, Gastier-Foster JM, Westmoreland KD, Ozuah NW, Krysiak R, Malamba-Banda C, Painschab MS, Gopal S, Fedoriw Y. Update on pathology laboratory development and research in advancing regional cancer care in Malawi. Front Med (Lausanne) 2024; 11:1336861. [PMID: 38298817 PMCID: PMC10829605 DOI: 10.3389/fmed.2024.1336861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024] Open
Abstract
The pathology laboratory at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi was established in 2011. We published our initial experiences in laboratory development and telepathology in 2013 and 2016, respectively. The purpose of this paper is to provide an update on our work by highlighting the positive role laboratory development has played in improving regional cancer care and research. In addition, we provide a summary of the adult pathology data from specimens received between July 1, 2011, and May 31, 2019, with an emphasis on malignant diagnoses. We compare these summaries to estimates of cancer incidence in this region to identify gaps and future needs.
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Affiliation(s)
- Amy J. Brownlee
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Morgan Dewey
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Maganizo B. Chagomerana
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Tamiwe Tomoka
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Maurice Mulenga
- Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
| | - Shiraz Khan
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
| | - Coxcilly Kampani
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Fred Chimzimu
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Julie M. Gastier-Foster
- Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Kate D. Westmoreland
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Division of Pediatric Hematology Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Nmazuo W. Ozuah
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Robert Krysiak
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Chikondi Malamba-Banda
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Malawi University of Science and Technology, Limbe, Malawi
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Matthew S. Painschab
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Satish Gopal
- Center for Global Health, National Cancer Institute (NIH), Bethesda, MD, United States
| | - Yuri Fedoriw
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
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4
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Li X, Xu Q, Gao C, Yang Z, Li J, Sun A, Wang Y, Lei H. Development and validation of nomogram prognostic model for predicting OS in patients with diffuse large B-cell lymphoma: a cohort study in China. Ann Hematol 2023; 102:3465-3475. [PMID: 37615680 PMCID: PMC10640527 DOI: 10.1007/s00277-023-05418-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
This study comprehensively incorporates pathological parameters and novel clinical prognostic factors from the international prognostic index (IPI) to develop a nomogram prognostic model for overall survival in patients with diffuse large B-cell lymphoma (DLBCL). The aim is to facilitate personalized treatment and management strategies. This study enrolled a total of 783 cases for analysis. LASSO regression and stepwise multivariate COX regression were employed to identify significant variables and build a nomogram model. The calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) curve were utilized to assess the model's performance and effectiveness. Additionally, the time-dependent concordance index (C-index) and time-dependent area under the ROC curve (AUC) were computed to validate the model's stability across different time points. The study utilized 8 selected clinical features as predictors to develop a nomogram model for predicting the overall survival of DLBCL patients. The model exhibited robust generalization ability with an AUC exceeding 0.7 at 1, 3, and 5 years. The calibration curve displayed evenly distributed points on both sides of the diagonal, and the slopes of the three calibration curves were close to 1 and statistically significant, indicating high prediction accuracy of the model. Furthermore, the model demonstrated valuable clinical significance and holds the potential for widespread adoption in clinical practice. The novel prognostic model developed for DLBCL patients incorporates readily accessible clinical parameters, resulting in significantly enhanced prediction accuracy and performance. Moreover, the study's use of a continuous general cohort, as opposed to clinical trials, makes it more representative of the broader lymphoma patient population, thus increasing its applicability in routine clinical care.
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Affiliation(s)
- Xiaosheng Li
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Qianjie Xu
- Department of Health Statistics, School of Public Health, Chongqing Medical University, Chongqing, 400016, China
| | - Cuie Gao
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Zailin Yang
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Jieping Li
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Anlong Sun
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Ying Wang
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Haike Lei
- Chongqing Cancer Multi-omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, 400030, China.
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5
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Mezger NCS, Hämmerl L, Griesel M, Seraphin TP, Joko-Fru YW, Feuchtner J, Zietsman A, Péko JF, Tadesse F, Buziba NG, Wabinga H, Nyanchama M, Chokunonga E, Kéita M, N’da G, Lorenzoni CF, Akele-Akpo MT, Mezger JM, Binder M, Liu B, Bauer M, Henke O, Jemal A, Kantelhardt EJ. Guideline Concordance of Treatment and Outcomes Among Adult Non-Hodgkin Lymphoma Patients in Sub-Saharan Africa: A Multinational, Population-Based Cohort. Oncologist 2023; 28:e1017-e1030. [PMID: 37368350 PMCID: PMC10628567 DOI: 10.1093/oncolo/oyad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/24/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Although non-Hodgkin lymphoma (NHL) is the 6th most common malignancy in Sub-Saharan Africa (SSA), little is known about its management and outcome. Herein, we examined treatment patterns and survival among NHL patients. METHODS We obtained a random sample of adult patients diagnosed between 2011 and 2015 from 11 population-based cancer registries in 10 SSA countries. Descriptive statistics for lymphoma-directed therapy (LDT) and degree of concordance with National Comprehensive Cancer Network (NCCN) guidelines were calculated, and survival rates were estimated. FINDINGS Of 516 patients included in the study, sub-classification was available for 42.1% (121 high-grade and 64 low-grade B-cell lymphoma, 15 T-cell lymphoma and 17 otherwise sub-classified NHL), whilst the remaining 57.9% were unclassified. Any LDT was identified for 195 of all patients (37.8%). NCCN guideline-recommended treatment was initiated in 21 patients. This corresponds to 4.1% of all 516 patients, and to 11.7% of 180 patients with sub-classified B-cell lymphoma and NCCN guidelines available. Deviations from guideline-recommended treatment were initiated in another 49 (9.5% of 516, 27.2% of 180). By registry, the proportion of all patients receiving guideline-concordant LDT ranged from 30.8% in Namibia to 0% in Maputo and Bamako. Concordance with treatment recommendations was not assessable in 75.1% of patients (records not traced (43.2%), traced but no sub-classification identified (27.8%), traced but no guidelines available (4.1%)). By registry, diagnostic work-up was in part importantly limited, thus impeding guideline evaluation significantly. Overall 1-year survival was 61.2% (95%CI 55.3%-67.1%). Poor ECOG performance status, advanced stage, less than 5 cycles and absence of chemo (immuno-) therapy were associated with unfavorable survival, while HIV status, age, and gender did not impact survival. In diffuse large B-cell lymphoma, initiation of guideline-concordant treatment was associated with favorable survival. INTERPRETATION This study shows that a majority of NHL patients in SSA are untreated or undertreated, resulting in unfavorable survival. Investments in enhanced diagnostic services, provision of chemo(immuno-)therapy and supportive care will likely improve outcomes in the region.
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Affiliation(s)
- Nikolaus Christian Simon Mezger
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Lucia Hämmerl
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Mirko Griesel
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Tobias Paul Seraphin
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Yvonne Walburga Joko-Fru
- African Cancer Registry Network, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jana Feuchtner
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Annelle Zietsman
- African Cancer Registry Network, Oxford, UK
- Dr AB May Cancer Care Centre, Windhoek, Namibia
| | - Jean-Félix Péko
- African Cancer Registry Network, Oxford, UK
- Registre des cancers de Brazzaville, Brazzaville, Republic of the Congo
| | - Fisihatsion Tadesse
- African Cancer Registry Network, Oxford, UK
- Division of Hematology, Department of Internal Medicine, University and Black Lion Hospital, Addis Ababa, Ethiopia
| | - Nathan Gyabi Buziba
- African Cancer Registry Network, Oxford, UK
- Eldoret Cancer Registry, School of Medicine, Moi University, Eldoret, Kenya
| | - Henry Wabinga
- African Cancer Registry Network, Oxford, UK
- Kampala Cancer Registry, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nyanchama
- African Cancer Registry Network, Oxford, UK
- National Cancer Registry, Kenya Medical Research Institute, Nairobi, Kenya
| | - Eric Chokunonga
- African Cancer Registry Network, Oxford, UK
- Zimbabwe National Cancer Registry, Harare, Zimbabwe
| | - Mamadou Kéita
- African Cancer Registry Network, Oxford, UK
- Service du Laboratoire d’Anatomie et Cytologie Pathologique, Bamako, Mali
- CHU du point G , Bamako, Mali
| | - Guy N’da
- African Cancer Registry Network, Oxford, UK
- Registre des cancers d’Abidjan, Abidjan, Côte d’Ivoire
| | - Cesaltina Ferreira Lorenzoni
- African Cancer Registry Network, Oxford, UK
- Departamento de Patologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Hospital Central de Maputo, Mozambique
- Registo de Cancro, Ministério da Saúde, Maputo, Mozambique
| | - Marie-Thérèse Akele-Akpo
- African Cancer Registry Network, Oxford, UK
- Département d’anatomo-pathologie, Faculté des Sciences de la Santé, Cotonou, Benin
| | | | - Mascha Binder
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Biying Liu
- African Cancer Registry Network, Oxford, UK
| | - Marcus Bauer
- Institute of Pathology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Oliver Henke
- Section Global Health, Institute for Public Health and Hygiene, University Hospital Bonn, Germany
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, USA
| | - Eva Johanna Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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6
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Gopal S. The case for prioritizing malignant hematology services in low- and middle-income countries. Semin Hematol 2023; 60:189-191. [PMID: 37723025 PMCID: PMC10840687 DOI: 10.1053/j.seminhematol.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023]
Abstract
A clear case for can be made for prioritizing malignant hematology services in low- and middle-income countries based on large public health burden, convincing demonstrations of cure and control, innovation opportunities with likely worldwide implications, and sizable returns on investment for health systems and societies. We must now ensure that need and opportunity are matched by commensurate levels of investment and attention.
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Affiliation(s)
- Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD.
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7
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Saikumar Lakshmi P, Oduor CI, Forconi CS, M'Bana V, Bly C, Gerstein RM, Otieno JA, Ong'echa JM, Münz C, Luftig MA, Brehm MA, Bailey JA, Moormann AM. Endemic Burkitt lymphoma avatar mouse models for exploring inter-patient tumor variation and testing targeted therapies. Life Sci Alliance 2023; 6:e202101355. [PMID: 36878637 PMCID: PMC9990458 DOI: 10.26508/lsa.202101355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 03/08/2023] Open
Abstract
Endemic Burkitt lymphoma (BL) is a childhood cancer in sub-Saharan Africa characterized by Epstein-Barr virus and malaria-associated aberrant B-cell activation and MYC chromosomal translocation. Survival rates hover at 50% after conventional chemotherapies; therefore, clinically relevant models are necessary to test additional therapies. Hence, we established five patient-derived BL tumor cell lines and corresponding NSG-BL avatar mouse models. Transcriptomics confirmed that our BL lines maintained fidelity from patient tumors to NSG-BL tumors. However, we found significant variation in tumor growth and survival among NSG-BL avatars and in Epstein-Barr virus protein expression patterns. We tested rituximab responsiveness and found one NSG-BL model exhibiting direct sensitivity, characterized by apoptotic gene expression counterbalanced by unfolded protein response and mTOR pro-survival pathways. In rituximab-unresponsive tumors, we observed an IFN-α signature confirmed by the expression of IRF7 and ISG15. Our results demonstrate significant inter-patient tumor variation and heterogeneity, and that contemporary patient-derived BL cell lines and NSG-BL avatars are feasible tools to guide new therapeutic strategies and improve outcomes for these children.
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Affiliation(s)
- Priya Saikumar Lakshmi
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Cliff I Oduor
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Catherine S Forconi
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Viriato M'Bana
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Courtney Bly
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Rachel M Gerstein
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Juliana A Otieno
- Jaramogi Oginga Odinga Teaching and Referral Hospital, Ministry of Medical Services, Kisumu, Kenya
| | - John M Ong'echa
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Christian Münz
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zürich, Zurich, Switzerland
| | - Micah A Luftig
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, USA
| | - Michael A Brehm
- Program in Molecular Medicine and the Diabetes Center of Excellence, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Ann M Moormann
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
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8
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Tilly AE, Evans A, Chen JS, Manda A, Salima A, Bingo S, Chikasema M, Westmoreland KD. Kusankha Pamodzi: Health Care Decision-Making Preferences Among Patients with Cancer in Malawi. Palliat Med Rep 2023; 4:127-132. [PMID: 37138948 PMCID: PMC10150710 DOI: 10.1089/pmr.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
Abstract
Background Oncology teams are encouraged to include patient preferences and goals of care in determining appropriate treatment courses. There are no existing data from Malawi exploring decision-making preferences among cancer patients. Methods In the oncology clinic in Lilongwe, Malawi, 50 patients were surveyed for decision making. Results Most participants (70%, n = 35) preferred to engage in shared decision making regarding cancer treatment. About half (52%, n = 24) did not feel that their medical team involved them in decision making and 64% (n = 32) felt that they were never or only sometimes listened to by the medical team. Nearly all (94%, n = 47) preferred to have their medical team inform them how likely treatments are to lead to cure. Conclusions Shared decision making was the preferred mode of treatment decision making by the majority of the surveyed cancer patients in Malawi. Cancer patients in Malawi may have similar preferences to cancer patients in other low-resource settings regarding decision making and communication.
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Affiliation(s)
- Alyssa E. Tilly
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Address correspondence to: Alyssa E. Tilly, MD, UNC Project-Malawi, Lilongwe A-104, Malawi,
| | - April Evans
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jane S. Chen
- UNC Project-Malawi, Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | | | - Katherine D. Westmoreland
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Comparison of baseline lymphoma and HIV characteristics in Malawi before and after implementation of universal antiretroviral therapy. PLoS One 2022; 17:e0273408. [PMID: 36048901 PMCID: PMC9436050 DOI: 10.1371/journal.pone.0273408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 08/08/2022] [Indexed: 11/19/2022] Open
Abstract
Access to antiretroviral therapy (ART) led to epidemiological changes in human immunodeficiency virus (HIV) associated lymphoma in high-income countries such as reductions in diffuse large B-cell lymphoma (DLBCL) and stable or increased Hodgkin lymphoma (HL) and Burkitt lymphoma (BL). In 2016, Malawi implemented a universal ART (UART) policy, expanding ART eligibility to all persons living with HIV (PLWH). We compare the distribution of lymphoma subtypes and baseline HIV and prognostic characteristics for lymphoma patients in Malawi before and after implementation of UART. We enrolled patients with pathologically confirmed incident lymphoproliferative disorders into a observational clinical cohort. At diagnosis, a comprehensive clinicopathological evaluation was performed. Of 412 participants, 156 (38%) were pre-UART (2013-June 2016) and 256 (62%) post-UART (July 2016–2020). HIV prevalence was 50% in both groups. The most common pre-UART diagnoses were DLBCL [75 (48%)], low-grade non-Hodgkin lymphoma (NHL) [19 (12%)], HL [17 (11%)] and, BL [13 (8%)]. For post-UART they were DLBCL [111 (43%)], NHL [28 (11%)], BL [27 11%)] and, HL [20 (8%)]. Among PLWH, 44 (57%) pre-UART initiated ART prior to lymphoma diagnosis compared to 99 (78%) post-UART (p = 0.02). HIV-ribonucleic acid was suppressed <1000 copies/mL in 56% (33/59) pre-UART and 71% (73/103) post-UART (p = 0.05). CD4 T-cell counts were similar for both groups. We observed similar findings in the subset of participants with DLBCL. Overall, there were no significant changes in incident lymphoma subtypes (p = 0.61) after implementation of UART, but HIV was better controlled. Emerging trends bear monitoring and may have implications for prognosis and health system priority setting. Trial registration: ClinicalTrials.gov identifier:NCT02835911.
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Tilly AE, Ellis GK, Chen JS, Manda A, Salima A, Mtangwanika A, Tewete B, Kaimila B, Kasonkanji E, Kayira E, Chikasema M, Nyirenda R, Bingo S, Chiyoyola S, Seguin R, Gopal S, Zuze T, Tomoka T, Westmoreland KD. Implementation and Evaluation of Educational Videos to Improve Cancer Knowledge and Patient Empowerment. JCO Glob Oncol 2022; 8:e2100315. [PMID: 35175832 PMCID: PMC8863121 DOI: 10.1200/go.21.00315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/15/2021] [Accepted: 01/12/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Low health literacy is a leading cause of treatment abandonment among patients receiving cancer care at Kamuzu Central Hospital (KCH) in Malawi. METHODS We developed cancer educational videos featuring Malawian providers and played them in the KCH oncology clinic. The videos addressed cancer-related topics, including disease biology, common myths, diagnostic procedures, treatment, side effects, and survivorship. After 6 months of implementation, we compared results from 50 pre- and postintervention surveys to assess change in cancer knowledge and care experience. RESULTS Both pre- and postintervention cancer knowledge were good: a median of nine questions were answered correctly of 11 in both assessments. Despite the intervention, most continued to incorrectly identify cancer as an infection (pre: n = 26, 52%; post: n = 25, 50%; P = 1.0), although improvements were observed in patients' knowledge of correct actions for fever at home (pre: n = 38, 76%; post: n = 43, 86%; P = .31). Care experiences were overall good. Postintervention results indicate that more patients felt always listened to by their providers (pre: n = 18, 36%; post: n = 29, 58%; P < .01). However, we also noted a higher rate of patient dissatisfaction of care as more patients felt that they could not understand chemotherapy counseling (pre: n = 11, 22%; post: n = 22, 44%; P < .01). Assessments of video satisfaction indicate that patients found the videos very helpful in terms of understanding their disease (n = 47, 96%) and side effects (n = 48, 98%) and felt empowered to speak up with their providers (n = 46, 96%). CONCLUSION Standardized education materials for patients that can be feasibly implemented throughout sub-Saharan Africa are urgently needed. Cancer educational videos are a low-cost way to educate and empower patients with cancer in resource-constrained settings although in-person discussions remain a crucial part of care.
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Affiliation(s)
- Alyssa E. Tilly
- UNC Project-Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Jane S. Chen
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | | | | | | | | | | | | | | | - Satish Gopal
- UNC Project-Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC
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11
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Painschab MS, Kohler R, Kimani S, Mhango W, Kaimila B, Zuze T, Mithi V, Kasonkanji E, Mumba N, Nyasosela R, Wheeler S, Gopal S. Comparison of best supportive care, CHOP, or R-CHOP for treatment of diffuse large B-cell lymphoma in Malawi: a cost-effectiveness analysis. Lancet Glob Health 2021; 9:e1305-e1313. [PMID: 34303416 PMCID: PMC8403678 DOI: 10.1016/s2214-109x(21)00261-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/05/2021] [Accepted: 05/25/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cost-effectiveness data for cancer treatment are needed from sub-Saharan Africa, where diffuse large B-cell lymphoma (DLBCL) is a common, curable cancer. In high-income countries, the standard of care for DLBCL is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemoimmunotherapy. Rituximab is often not available in sub-Saharan Africa due to perceived unaffordability, and treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) is common. We aimed to evaluate the cost-effectiveness of treatment in Malawi, comparing best supportive care, CHOP, or R-CHOP in patients with DLBCL. METHODS For this cost-effectiveness analysis, we used published Malawi microcosting data, clinical data from a prospective cohort treated with CHOP, and clinical trial data evaluating R-CHOP. We used a decision-tree model to calculate costs per disability-adjusted life-year (DALY) averted from the health system perspective for the treatment of patients with DLBCL with best supportive care, CHOP, or R-CHOP, running the model on a per-patient basis and a Malawi population-level basis. We used the WHO definitions of cost-effective (three times the GDP per capita of the country) and extremely cost-effective (equal to the GDP per capita of the country) as willingness-to-pay thresholds for Malawi. FINDINGS On a per-patient level, compared with best supportive care, CHOP was estimated to avert a mean 7·4 DALYs at an incremental cost of US$1384, for an incremental cost-effectiveness ratio (ICER) of $189 per DALY averted, which is substantially lower than the willingness-to-pay threshold (extremely cost-effective). Compared with CHOP, R-CHOP was estimated to avert 2·8 DALYs at an incremental cost of $3324, resulting in an ICER of $1204 per DALY averted, which is slightly higher than the cost-effective willingness-to-pay threshold. In probabilistic sensitivity analyses, CHOP remained cost-effective for DLBCL treatment in more than 99% of simulations, whereas R-CHOP was lower than the threshold in 46% of simulations. INTERPRETATION We estimated CHOP to be cost-effective for DLBCL treatment in Malawi, and that the addition of rituximab might be cost-effective. Despite upfront costs, DLBCL treatment is probably a prudent investment relative to other accepted health interventions in sub-Saharan Africa. FUNDING National Institutes of Health.
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Affiliation(s)
- Matthew S Painschab
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; University of North Carolina Project Malawi, Lilongwe, Malawi.
| | - Racquel Kohler
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Stephen Kimani
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Bongani Kaimila
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Takondwa Zuze
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Victor Mithi
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Noel Mumba
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Stephanie Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD, USA
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12
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Kimani S, Painschab MS, Kaimila B, Kasonkanji E, Zuze T, Tomoka T, Mulenga M, Nyasosela R, Chikasema M, Mtangwanika A, Chawinga M, Mhango W, Nicholas S, Chimzimu F, Kampani C, Krysiak R, Lilly A, Randall C, Seguin R, Westmoreland KD, Montgomery ND, Fedoriw Y, Gopal S. Safety and efficacy of rituximab in patients with diffuse large B-cell lymphoma in Malawi: a prospective, single-arm, non-randomised phase 1/2 clinical trial. Lancet Glob Health 2021; 9:e1008-e1016. [PMID: 34022150 PMCID: PMC9338824 DOI: 10.1016/s2214-109x(21)00181-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/12/2021] [Accepted: 03/30/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are no clinical trials involving patients with diffuse large B-cell lymphoma (DLBCL) in sub-Saharan Africa since antiretroviral therapy (ART) for HIV became widely available in this region. We aimed to establish the safety and efficacy of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in patients with DLBCL in Malawi. METHODS This prospective, single-arm, non-randomised phase 1/2 clinical trial was done at Kamuzu Central Hospital Cancer Clinic (Lilongwe, Malawi). Eligible patients were adults (aged 18-60 years) with newly diagnosed DLBCL, an Eastern Cooperative Oncology Group performance status of 0-2, a CD4 count of 100 cells per μL or higher (if HIV-positive), measurable disease by physical examination, an absolute neutrophil count of 1000 × 109 cells per L or higher, a platelet count of 100 × 109 platelets per L or higher, a serum creatinine concentration of 132·60 μmol/L or less, a total bilirubin concentration of 34·21 μmol/L or less, a negative urine pregnancy test in women of childbearing potential, and no previous cytotoxic therapy. Pregnant or breastfeeding women, and individuals with CNS involvement from DLBCL, chronic hepatitis B infection (unless they were receiving tenofovir plus lamivudine), or any other comorbidities that would compromise the protocol objectives were excluded. Eligible patients received intravenous rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, and vincristine 1·4 mg/m2 (maximum 2 mg/m2), and oral prednisone 100 mg or an equivalent drug every 21 days for up to six cycles. HIV-positive patients received concurrent ART. The primary outcome was the proportion of patients with National Cancer Institute Common Terminology Criteria for Adverse Events grade 3 or 4 non-haematological toxic effects or treatment-related deaths after six cycles of treatment. Secondary efficacy outcomes included the proportion of patients with a complete response after six cycles of treatment, and progression-free survival and overall survival at 12 months and 24 months. This trial is registered with ClinicalTrials.gov, NCT02660710. FINDINGS Between Aug 1, 2016, and July 31, 2019, 76 patients were screened, of whom 37 were eligible for the study and received R-CHOP. The median age of patients was 44 years (IQR 39-49) and 16 (43%) were women. Of all 37 patients, 20 (54%) had stage III or IV DLBCL, and the age-adjusted international prognostic index was 2 or higher in 25 (68%) patients. 27 (73%) patients were HIV-positive, with a median CD4 count of 208 cells per μL (IQR 144-422), and 21 (78%) patients were receiving ART at enrolment. Patients completed a median of six cycles (IQR 4-6). Grade 3 or 4 non-haematological toxic effects were reported in 12 (32% [95% CI 19-49]) patients, the most common of which was infection (nine [24%] patients). Of 16 (43%) deaths, ten were due to progression of DLBCL, four were due to treatment-related complications, and two were due to other causes, yielding a treatment-related mortality of 11% (95% CI 4-26%). Grade 3 or 4 neutropenia was observed in 26 (70%) patients, and grade 3 or 4 anaemia was observed in 11 (29%) patients. A total of 22 (59%) patients had a complete response. Overall survival was 68% (95% CI 50-80) at 12 months and 55% (37-70) at 24 months, and progression-free survival was 59% (42-73) at 12 months and 53% (35-68) at 24 months. INTERPRETATION R-CHOP could be feasible, safe, and efficacious in patients with DLBCL in Malawi. This is the first completed clinical trial on DLBCL focused on sub-Saharan African populations. Given the paucity of data on treatment of DLBCL from this region, these results could inform emerging cancer treatment programmes in sub-Saharan Africa. FUNDING The University of North Carolina Lineberger Comprehensive Cancer Center.
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Affiliation(s)
- Stephen Kimani
- Department of Medicine, Division of Hematology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Matthew S Painschab
- Department of Medicine, Division of Hematology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Bongani Kaimila
- University of North Carolina Project-Malawi, Lilongwe, Malawi; University of Malawi, College of Medicine, Lilongwe Campus, Lilongwe, Malawi
| | | | - Takondwa Zuze
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Tamiwe Tomoka
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi; University of Malawi, College of Medicine, Lilongwe Campus, Lilongwe, Malawi
| | - Maurice Mulenga
- Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
| | - Richard Nyasosela
- Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
| | - Maria Chikasema
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Mena Chawinga
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Simon Nicholas
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Fred Chimzimu
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Robert Krysiak
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Amy Lilly
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cara Randall
- Department of Pathology, Anatomy and Laboratory Medicine, West Virginia University, Morgantown, WV, USA
| | - Ryan Seguin
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Katherine D Westmoreland
- Department of Medicine, Division of Hematology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Nathan D Montgomery
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Yuri Fedoriw
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD, USA.
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13
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Impact of Antiretroviral Therapy on Cancer Treatment Outcomes among People Living with HIV in Low- and Middle-Income Countries: a Systematic Review. Curr HIV/AIDS Rep 2021; 18:105-116. [PMID: 33528741 DOI: 10.1007/s11904-021-00542-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW The relationship between antiretroviral therapy (ART) and cancer treatment outcomes among people living with HIV (PLWH) in low- and middle-income countries (LMICs) is complex and poorly understood for many cancers. We aimed to summarize existing evidence from LMICs regarding the benefit of ART on cancer treatment-related outcomes. RECENT FINDINGS We included twelve observational studies that reported associations between ART status and cancer treatment outcomes among HIV-positive patients in LMICs. Most confirmed ART was associated with improved cancer treatment outcomes. Heterogeneity in cancers under study, outcome measurement, categorization of ART status, and reporting of HIV-related immune function made formal comparison between studies untenable. Where evaluated, ART generally has a positive effect on cancer outcomes in people with HIV in LMICs. However, there remains a substantial gap in the literature regarding the impact of ART on treatment outcomes for most cancer types. Future research should focus on the optimal timing and integration of ART and cancer treatment for PLWH with strategies applicable to constrained-resource settings.
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14
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Kimani SM, Painschab MS, Horner MJ, Muchengeti M, Fedoriw Y, Shiels MS, Gopal S. Epidemiology of haematological malignancies in people living with HIV. Lancet HIV 2020; 7:e641-e651. [PMID: 32791045 PMCID: PMC10199168 DOI: 10.1016/s2352-3018(20)30118-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022]
Abstract
People living with HIV or AIDS are at increased risk of Hodgkin and non-Hodgkin lymphoma compared with HIV-negative individuals. Data on the risk of multiple myeloma or leukaemia are inconsistent and of low quality but the risk does not seem to be increased. Specific haematological malignancies occur in different contexts of age, CD4 cell count, HIV control, viral co-infections, or chronic inflammation, and the expansion of combination antiretroviral therapy has led to varied demographic and epidemiological shifts among people with HIV. Increased use of combination antiretroviral therapy has substantially reduced the risks of diffuse large B-cell lymphoma, Burkitt lymphoma, and primary CNS lymphoma, and to a lesser extent, Hodgkin lymphoma. There is no effect of combination antiretroviral therapy use on multiple myeloma or leukaemia. Although many cases of HIV are in low-income and middle-income countries, high-quality epidemiological data for haematological malignancies from these regions are scarce. Closing this gap is an essential first step in decreasing mortality from HIV-associated haematological malignancies worldwide. Finally, although multicentric Castleman disease is not a neoplastic condition, it is an emerging precursor to neoplastic high-grade B-cell lymphoproliferation among people with HIV, especially for individuals on long-term combination antiretroviral therapy with well controlled HIV.
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Affiliation(s)
- Stephen M Kimani
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Matthew S Painschab
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Marie-Josèphe Horner
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Yuri Fedoriw
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Satish Gopal
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi.
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15
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Fedoriw Y, Selitsky S, Montgomery ND, Kendall SM, Richards KL, Du W, Tomoka T, Mulenga M, Parker JS, Dave SS, Gopal S. Identifying transcriptional profiles and evaluating prognostic biomarkers of HIV-associated diffuse large B-cell lymphoma from Malawi. Mod Pathol 2020; 33:1482-1491. [PMID: 32080349 DOI: 10.1038/s41379-020-0506-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 12/17/2022]
Abstract
Lymphoma incidence in sub-Saharan Africa (SSA) is increasing due to HIV and population aging. Diffuse Large B-cell lymphoma (DLBCL), the most common lymphoma in SSA and worldwide, is highly associated with HIV, but molecular studies of HIV-associated DLBCL are scarce globally. We describe profiling of DLBCL from Malawi, aiming to elucidate tumor biology and identify clinically meaningful biomarkers specifically for SSA. Between June 1, 2013 and June 1, 2016, 59 cases of DLBCL (32 HIV+/27 HIV-) enrolled in the Kamuzu Central Hospital Lymphoma Study were characterized, of which 54 (92%) were negative for Epstein-Barr virus. Gene expression profiling (GEP) by whole transcriptome sequencing was performed on the first 36 cases (22 HIV+/14 HIV-). Immunohistochemistry (IHC) and GEP results were compared with published data and correlated to clinical outcome and pathologic features. Unsupervised clustering strongly segregated DLBCL by HIV status (p = 0.0003, Chi-squared test), indicating a marked contribution of HIV to expression phenotype. Pathway analysis identified that HIV-associated tumors were enriched in hypoxia, oxidative stress, and metabolism related gene expression patterns. Cell-of-origin subtype, determined by sequencing and IHC, did not associate with differences in overall survival (OS), while Ki-67 proliferation index ≥80% was associated with inferior OS in HIV+ DLBCL only (p = 0.03) and cMYC/BCL2 co-expression by IHC was negatively prognostic across the entire cohort (p = 0.01). This study provides among the first molecular characterizations of DLBCL from SSA, demonstrates marked gene expression differences by HIV status, and identifies genomic and immunophenotypic characteristics that can inform future basic and clinical investigations.
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Affiliation(s)
- Yuri Fedoriw
- University of North Carolina, Chapel Hill, NC, USA.
| | | | | | - Sviatoslav M Kendall
- Duke Cancer Institute and Center for Genomic and Computational Biology, Durham, NC, USA
| | | | - Wei Du
- Cornell University, New York, NY, USA
| | - Tamiwe Tomoka
- UNC Project-Malawi, Lilongwe, Malawi.,University of Malawi College of Medicine, Lilongwe, Malawi
| | | | | | - Sandeep S Dave
- Duke Cancer Institute and Center for Genomic and Computational Biology, Durham, NC, USA
| | - Satish Gopal
- University of North Carolina, Chapel Hill, NC, USA.,UNC Project-Malawi, Lilongwe, Malawi
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16
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Somay K, Çöpür S, Osmanbaşoğlu E, Masyan H, Arslan H, Akay OM, Tekin S, Ferhanoğlu B. HIV-ASSOCIATED NON HODGKIN LYMPHOMA: A CASE SERIES STUDY FROM TURKEY. Afr J Infect Dis 2020; 14:42-47. [PMID: 33884350 PMCID: PMC8047295 DOI: 10.21010/ajid.v14i2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/14/2020] [Accepted: 06/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Human immunodeficiency virus (HIV) is a global health concern with major risks for opportunistic infections and predisposition to malignancies including Kaposi sarcoma associated with Human Herpes Virus-8 (HHV-8) and non-Hodgkin lymphoma (NHL) commonly associated with Epstein Barr Virus (EBV). Although the exact mechanisms of predisposition to certain malignancies are unclear, HIV (+) cancer patients typically have poorer prognosis. Materials and Methods: We included all five HIV positive NHL patients receiving antiretroviral therapy (ART) and chemotherapy in our clinic and aim to determine their follow-up outcomes associated with ART. Results: The use of ART in conjunction with chemotherapy regimens lead to better therapeutic outcome in our cases with no mortality over three years of follow-up despite high rates of poor prognostic factors and studies demonstrating 1-year survival rates of approximately 30% in HIV-associated lymphoma. No significant adverse effect has been recorded. Conclusion: We recommend use of ART along with chemotherapy regimens in HIV positive lymphoma patients for better treatment response.
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Affiliation(s)
- Kayra Somay
- Internal Medicine Department, Koç University Medical School, İstanbul, Turkey
| | - Sidar Çöpür
- Koç University Medical School, İstanbul, Turkey
| | | | - Helin Masyan
- Internal Medicine Department, Koç University Hospital, İstanbul, Turkey
| | - Harun Arslan
- Internal Medicine Department, Koç University Hospital, İstanbul, Turkey
| | - Olga Meltem Akay
- Hematology Department, Koç University Medical School, Istanbul, Turkey
| | - Süda Tekin
- Infectious Diseases and Clinical Microbiology Department, Koç University Medical School, Istanbul, Turkey
| | - Burhan Ferhanoğlu
- Hematology Department, Koç University Medical School, Istanbul, Turkey
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17
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Painschab MS, Westmoreland KD, Tomoka T. Improving outcomes for non-Hodgkin lymphoma in Sub-Saharan Africa: where to start? Br J Haematol 2020; 190:139-140. [PMID: 32207147 DOI: 10.1111/bjh.16617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Matthew S Painschab
- University of North Carolina Project-Malawi, Lilongwe, Malawi.,Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Katherine D Westmoreland
- University of North Carolina Project-Malawi, Lilongwe, Malawi.,Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Tamiwe Tomoka
- University of North Carolina Project-Malawi, Lilongwe, Malawi.,University of Malawi College of Medicine, Blantyre, Malawi
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18
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Painschab MS, Kohler RE, Kasonkanji E, Zuze T, Kaimila B, Nyasosela R, Nyirenda R, Krysiak R, Gopal S. Microcosting Analysis of Diffuse Large B-Cell Lymphoma Treatment in Malawi. J Glob Oncol 2020; 5:1-10. [PMID: 31322992 PMCID: PMC6690619 DOI: 10.1200/jgo.19.00059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To describe the cost of treating diffuse large B-cell lymphoma (DLBCL) in Malawi under the following circumstances: (1) palliation only, (2) first-line cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), (3) salvage etoposide, ifosfamide, and cisplatin (EPIC), and (4) salvage gemcitabine and oxaliplatin (GEMOX). METHODS We conducted a microcosting analysis from the health system perspective in the context of a prospective cohort study at a national teaching hospital in Lilongwe, Malawi. Clinical outcomes data were derived from previously published literature from the cohort. Cost data were collected for treatment and 2-year follow-up, reflecting costs incurred by the research institution or referral hospital for goods and services. Costs were collected in Malawian kwacha, inflated and converted to 2017 US dollars. RESULTS On a per-patient basis, palliative care alone cost $728 per person. Total costs for first-line treatment with CHOP chemotherapy was $1,844, of which chemotherapy drugs made up 15%. Separate salvage EPIC and GEMOX cost $2,597 and $3,176, respectively. Chemotherapy drugs accounted for 30% of EPIC and 47% of GEMOX. CONCLUSION To our knowledge, this is among the first published efforts to characterize detailed costs of cancer treatment in sub-Saharan Africa. The per-patient cost of first-line treatment of DLBCL in Malawi is low relative to high-income countries, suggesting that investments in fixed-duration, curative-intent DLBCL treatment may be attractive in sub-Saharan Africa. Salvage treatment of relapsed/refractory DLBCL costs much more than first-line therapy. Formal cost-effectiveness modeling for CHOP and salvage treatment in the Malawian and other low-resource settings is needed to inform decision makers about optimal use of resources for cancer treatment.
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Affiliation(s)
- Matthew S Painschab
- The University of North Carolina Project-Malawi, Lilongwe, Malawi.,University of North Carolina, Chapel Hill, NC
| | | | | | - Takondwa Zuze
- The University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Bongani Kaimila
- The University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | | | - Robert Krysiak
- The University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Satish Gopal
- The University of North Carolina Project-Malawi, Lilongwe, Malawi.,University of North Carolina, Chapel Hill, NC.,University of Malawi College of Medicine, Blantyre, Malawi
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19
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Mezger NCS, Feuchtner J, Griesel M, Hämmerl L, Seraphin TP, Zietsman A, Péko JF, Tadesse F, Buziba NG, Wabinga H, Nyanchama M, Borok MZ, Kéita M, N'da G, Lorenzoni CF, Akele-Akpo MT, Gottschick C, Binder M, Mezger J, Jemal A, Parkin DM, Wickenhauser C, Kantelhardt EJ. Clinical presentation and diagnosis of adult patients with non-Hodgkin lymphoma in Sub-Saharan Africa. Br J Haematol 2020; 190:209-221. [PMID: 32181503 DOI: 10.1111/bjh.16575] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 12/24/2022]
Abstract
Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in Sub-Saharan Africa (SSA). Comprehensive diagnostics of NHL are essential for effective treatment. Our objective was to assess the frequency of NHL subtypes, disease stage and further diagnostic aspects. Eleven population-based cancer registries in 10 countries participated in our observational study. A random sample of 516 patients was included. Histological confirmation of NHL was available for 76.2% and cytological confirmation for another 17.3%. NHL subclassification was determined in 42.1%. Of these, diffuse large B cell lymphoma, chronic lymphocytic leukaemia and Burkitt lymphoma were the most common subtypes identified (48.8%, 18.4% and 6.0%, respectively). We traced 293 patients, for whom recorded data were amended using clinical records. For these, information on stage, human immunodeficiency virus (HIV) status and Eastern Cooperative Oncology Group Performance Status (ECOG PS) was available for 60.8%, 52.6% and 45.1%, respectively. Stage at diagnosis was advanced for 130 of 178 (73.0%) patients, HIV status was positive for 97 of 154 (63.0%) and ECOG PS was ≥2 for 81 of 132 (61.4%). Knowledge about NHL subclassification and baseline clinical characteristics is crucial for guideline-recommended treatment. Hence, regionally adapted investments in pathological capacity, as well as standardised clinical diagnostics, will significantly improve the therapeutic precision for NHL in SSA.
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Affiliation(s)
- Nikolaus C S Mezger
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Jana Feuchtner
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Mirko Griesel
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Lucia Hämmerl
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Tobias P Seraphin
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Annelle Zietsman
- African Cancer Registry Network, Oxford, UK.,Dr AB May Cancer Care Centre, Windhoek, Namibia
| | - Jean-Félix Péko
- African Cancer Registry Network, Oxford, UK.,Registre des Cancers de Brazzaville, Brazzaville, Republic of the Congo
| | - Fisihatsion Tadesse
- African Cancer Registry Network, Oxford, UK.,Division of Hematology, Department of Internal Medicine, University and Black Lion Hospital, Addis Ababa, Ethiopia
| | - Nathan G Buziba
- African Cancer Registry Network, Oxford, UK.,Eldoret Cancer Registry, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Henry Wabinga
- African Cancer Registry Network, Oxford, UK.,Kampala Cancer Registry, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nyanchama
- African Cancer Registry Network, Oxford, UK.,National Cancer Registry, Kenya Medical Research Institute, Nairobi, Kenya
| | - Margaret Z Borok
- African Cancer Registry Network, Oxford, UK.,Zimbabwe National Cancer Registry, Harare, Zimbabwe
| | - Mamadou Kéita
- African Cancer Registry Network, Oxford, UK.,Service du Laboratoire d'Anatomie et Cytologie Pathologique, CHU du point G, Bamako, Mali
| | - Guy N'da
- African Cancer Registry Network, Oxford, UK.,Registre des Cancers d'Abidjan, Abidjan, Côte d'Ivoire
| | - Cesaltina F Lorenzoni
- African Cancer Registry Network, Oxford, UK.,Departamento de Patologia, Faculdade de Medicina Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Marie-Thérèse Akele-Akpo
- African Cancer Registry Network, Oxford, UK.,Département d'Anatomo-Pathologie, Faculté des Sciences de la Santé, Cotonou, Benin
| | - Cornelia Gottschick
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Mascha Binder
- Department of Internal Medicine IV, Oncology and Hematology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA
| | - Donald M Parkin
- African Cancer Registry Network, Oxford, UK.,Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Claudia Wickenhauser
- Institute of Pathology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Eva J Kantelhardt
- Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany.,Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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20
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Montgomery ND, Randall C, Painschab M, Seguin R, Kaimila B, Kasonkanji E, Zuze T, Krysiak R, Sanders MK, Elliott A, Miller MB, Kampani C, Chimzimu F, Mulenga M, Damania B, Tomoka T, Fedoriw Y, Dittmer DP, Gopal S. 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. Cancer Med 2020; 9:552-561. [PMID: 31782984 PMCID: PMC6970037 DOI: 10.1002/cam4.2710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 12/18/2022] Open
Abstract
Plasma Epstein-Barr virus (EBV) DNA measurement has established prognostic utility in EBV-driven lymphomas, where it serves as a circulating tumor DNA marker. The value of plasma EBV measurement may be amplified in sub-Saharan Africa (SSA), where advanced imaging and molecular technologies for risk stratification are not typically available. However, its utility in diffuse large B-cell lymphoma (DLBCL) is less certain, given that only a subset of DLBCLs are EBV-positive. To explore this possibility, we measured plasma EBV DNA at diagnosis in a cohort of patients with DLBCL in Malawi. High plasma EBV DNA at diagnosis (≥3.0 log10 copies/mL) was associated with decreased overall survival (OS) (P = .048). When stratified by HIV status, the prognostic utility of baseline plasma EBV DNA level was restricted to HIV-positive patients. Unexpectedly, most HIV-positive patients with high plasma EBV DNA at diagnosis had EBV-negative lymphomas, as confirmed by multiple methods. Even in these HIV-positive patients with EBV-negative DLBCL, high plasma EBV DNA remained associated with shorter OS (P = .014). These results suggest that EBV reactivation in nontumor cells is a poor prognostic finding even in HIV-positive patients with convincingly EBV-negative DLBCL, extending the potential utility of EBV measurement as a valuable and implementable prognostic marker in SSA.
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MESH Headings
- Adult
- Aged
- Biomarkers, Tumor/blood
- DNA, Viral/blood
- DNA, Viral/genetics
- Epstein-Barr Virus Infections/blood
- Epstein-Barr Virus Infections/complications
- Epstein-Barr Virus Infections/diagnosis
- Epstein-Barr Virus Infections/virology
- Female
- Follow-Up Studies
- HIV/isolation & purification
- HIV Infections/blood
- HIV Infections/complications
- HIV Infections/diagnosis
- HIV Infections/virology
- Herpesvirus 4, Human/genetics
- Herpesvirus 4, Human/isolation & purification
- Humans
- Lymphoma, AIDS-Related/blood
- Lymphoma, AIDS-Related/epidemiology
- Lymphoma, AIDS-Related/mortality
- Lymphoma, AIDS-Related/virology
- Lymphoma, Large B-Cell, Diffuse/blood
- Lymphoma, Large B-Cell, Diffuse/epidemiology
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/virology
- Malawi/epidemiology
- Male
- Middle Aged
- Prognosis
- Prospective Studies
- Survival Rate
- Young Adult
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Affiliation(s)
- Nathan D. Montgomery
- Department of Pathology & Laboratory MedicineUniversity of North CarolinaChapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
- UNC Project‐MalawiLilongweMalawi
| | - Cara Randall
- Department of Pathology & Laboratory MedicineUniversity of North CarolinaChapel HillNCUSA
- UNC Project‐MalawiLilongweMalawi
| | - Matthew Painschab
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
- UNC Project‐MalawiLilongweMalawi
- Department of MedicineDivision of Hematology & OncologyUniversity of North CarolinaChapel HillNCUSA
| | | | | | | | | | | | - Marcia K. Sanders
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
| | | | - Melissa B. Miller
- Department of Pathology & Laboratory MedicineUniversity of North CarolinaChapel HillNCUSA
| | | | | | | | - Blossom Damania
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
- Department of Microbiology & ImmunologyUniversity of North CarolinaChapel HillNCUSA
| | | | - Yuri Fedoriw
- Department of Pathology & Laboratory MedicineUniversity of North CarolinaChapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
- UNC Project‐MalawiLilongweMalawi
| | - Dirk P. Dittmer
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
- Department of Microbiology & ImmunologyUniversity of North CarolinaChapel HillNCUSA
| | - Satish Gopal
- Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillNCUSA
- UNC Project‐MalawiLilongweMalawi
- Department of MedicineDivision of Hematology & OncologyUniversity of North CarolinaChapel HillNCUSA
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21
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Zuze T, Ellis GK, Kasonkanji E, Kaimila B, Nyasosela R, Nyirenda R, Tomoka T, Mulenga M, Chikasema M, Tewete B, Mtangwanika A, Chiyoyola S, Chimzimu F, Kampani C, Mhango W, Nicholas S, Randall C, Montgomery ND, Fedoriw G, Westmoreland KD, Painschab MS, Gopal S. Modified EPOCH for high-risk non-Hodgkin lymphoma in sub-Saharan Africa. Cancer Med 2020; 9:77-83. [PMID: 31705618 PMCID: PMC6943163 DOI: 10.1002/cam4.2631] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/30/2019] [Accepted: 10/09/2019] [Indexed: 12/21/2022] Open
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.
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Affiliation(s)
| | | | | | - Bongani Kaimila
- UNC Project‐MalawiLilongweMalawi
- University of Malawi College of MedicineBlantyreMalawi
| | | | | | - Tamiwe Tomoka
- UNC Project‐MalawiLilongweMalawi
- University of Malawi College of MedicineBlantyreMalawi
- University of North CarolinaChapel HillNCUSA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Satish Gopal
- UNC Project‐MalawiLilongweMalawi
- University of Malawi College of MedicineBlantyreMalawi
- University of North CarolinaChapel HillNCUSA
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