Burkitt lymphoma treatment: the Malawi experience

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The objective of the Malawi Burkitt lymphoma (BL) studies was to develop effective and affordable treatment in a setting of limited resources. In the Malawi Pilot Study 44 BL patients with St Jude stages I, II and III were treated with medium intensity chemotherapy based on the sequence and drugs used in the LMB 89 protocol. The 57% overall survival rate was however associated with treatment toxicity related deaths in 32% of patients. Forty of ninety two patients with confirmed BL discharged from hospital alive and treated with cyclophosphamide (CPM) only, were found alive on home visit 29–104 months later. In the Malawi 2002 (146 patients) and 2003 (149 patients) studies i.v or oral CPM 40 mg/kg was given at 7-day intervals × 3 together with intrathecal methotrexate (MTX), followed in stages III and IV by 3 more doses of CPM at 14-day intervals. The projected Kaplan-Meier survival ranged from 45–52%. In the Malawi 2006 study (40 patients) all stages were treated with CPM 40 mg/kg on day 1, followed by CPM 60 mg/kg on days 8, 18 and 28 together with intrathecal MTX. Nineteen (48%) patients remained in continuous remission after median 454 days. The chemotherapy drug cost was inferior 50 US dollars. Twenty eight patients with an incomplete response to primary chemotherapy or who had a relapse, were offered a BL Rescue Protocol consisting of CPM 60 mg/kg, vincristine 1.5 mg/m2 and intrathecal MTX 12.5 mg plus hydrocortisone 12.5 mg on days 1, 8, 18 and 28. Twenty achieved a remission and 10 (36%) remained in remission for median 487 days. An overall cure rate of about 65% can thus be achieved by treatment with the Malawi 2003 BL protocol followed by the Malawi rescue protocol when needed.