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.
Highlights
Aggressive non‐Hodgkin lymphoma (NHL) subtypes predominate in sub‐Saharan Africa (SSA),[1] reflecting a young population and high prevalence of HIV and oncogenic viruses, including Epstein‐Barr virus (EBV) and Kaposi sarcoma‐associated herpesvirus (KSHV).[2]Diffuse large B‐cell lymphoma (DLBCL) is the most common aggressive NHL worldwide,[1] for which rituximab plus CHOP is the international standard of care.[3,4] Treatment intensification has not improved DLBCL outcomes, individualized approaches based on molecular characterization are being investigated
Seventeen patients were treated with modified EPOCH (8 Burkitt lymphoma (BL), 8 plasmablastic lymphoma (PBL), and 1 primary effusion lymphoma (PEL))
International standards of care for high‐risk NHL are associated with significant toxicities and require robust support, making them impractical for many SSA settings.[12,13]
Summary
Diffuse large B‐cell lymphoma (DLBCL) is the most common aggressive NHL worldwide,[1] for which rituximab plus CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) is the international standard of care.[3,4] Treatment intensification has not improved DLBCL outcomes, individualized approaches based on molecular characterization are being investigated. Lower‐intensity infusional regimens, notably dose‐adjusted EPOCH (etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin), have been developed as an alternative to reduce treatment‐related toxicities while maintaining excellent outcomes.[7,8] Cytotoxicity in proliferative lymphoma cells may be enhanced by prolonged chemotherapy exposure, and EPOCH has gained acceptance as a standard option for BL, plasmablastic lymphoma (PBL), and primary effusion lymphoma (PEL) in high‐income countries.[8,9,10,11]
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