title: CHOP Chemotherapy for Aggressive Non-Hodgkin Lymphoma with and without HIV in the Antiretroviral Therapy Era in Malawi.
abstract: There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39-56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥ 2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1-31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61-244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31-57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV.
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.|Lineberger Comprehensive Cancer Center, Chapel Hill, United States of America.|University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Satish
authors.initials: S
authors.lastname: Gopal
authors.affiliation: Lineberger Comprehensive Cancer Center, Chapel Hill, United States of America.|University of North Carolina Department of Pathology and Laboratory Medicine, Chapel Hill, United States of America.
authors.forename: Yuri
authors.initials: Y
authors.lastname: Fedoriw
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Bongani
authors.initials: B
authors.lastname: Kaimila
authors.affiliation: University of North Carolina Department of Pathology and Laboratory Medicine, Chapel Hill, United States of America.
authors.forename: Nathan D
authors.initials: ND
authors.lastname: Montgomery
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Edwards
authors.initials: E
authors.lastname: Kasonkanji
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.|University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Agnes
authors.initials: A
authors.lastname: Moses
authors.affiliation: Kamuzu Central Hospital, Lilongwe, Malawi.
authors.forename: Richard
authors.initials: R
authors.lastname: Nyasosela
authors.affiliation: University of Malawi College of Medicine, Blantyre, Malawi.|Kamuzu Central Hospital, Lilongwe, Malawi.
authors.forename: Suzgo
authors.initials: S
authors.lastname: Mzumara
authors.affiliation: University of Malawi College of Medicine, Blantyre, Malawi.|Kamuzu Central Hospital, Lilongwe, Malawi.
authors.forename: Carlos
authors.initials: C
authors.lastname: Varela
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Maria
authors.initials: M
authors.lastname: Chikasema
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Victor
authors.initials: V
authors.lastname: Makwakwa
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Salama
authors.initials: S
authors.lastname: Itimu
authors.affiliation: University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Tamiwe
authors.initials: T
authors.lastname: Tomoka
authors.affiliation: University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Steve
authors.initials: S
authors.lastname: Kamiza
authors.affiliation: Kamuzu Central Hospital, Lilongwe, Malawi.
authors.forename: Bal M
authors.initials: BM
authors.lastname: Dhungel
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Fred
authors.initials: F
authors.lastname: Chimzimu
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Coxcilly
authors.initials: C
authors.lastname: Kampani
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: Robert
authors.initials: R
authors.lastname: Krysiak
authors.affiliation: Weill Cornell Medical College, Ithaca, United States of America.
authors.forename: Kristy L
authors.initials: KL
authors.lastname: Richards
authors.affiliation: Lineberger Comprehensive Cancer Center, Chapel Hill, United States of America.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Shea
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi.
authors.forename: N George
authors.initials: NG
authors.lastname: Liomba
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D003520:Cyclophosphamide / Q000627:therapeutic use; D004317:Doxorubicin / Q000627:therapeutic use; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008228:Lymphoma, Non-Hodgkin / Q000150:complications* / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use; D016019:Survival Analysis; D014750:Vincristine / Q000627:therapeutic use
chemical_list: D018501:Antirheumatic Agents; D014750:Vincristine; D004317:Doxorubicin; D003520:Cyclophosphamide; D011241:Prednisone