Treatment Recommendations for Patients with NHL at the Uganda Cancer Institute
Authors: Menon Manoj P , Coghill Anna , Mutyaba Innocent , Okuku Fred , Phipps Warren , Harlan John M. , Orem Jackson , Casper Corey 
Published: October 2019

Abstract

Introduction
It is estimated that nearly half a million people will die of cancer in sub-Saharan Africa (SSA) in 2020, and that the incidence of cancer will increase more than 40% between now and then. Unfortunately, treatment options in SSA are often hampered by a sub-optimal health care infrastructure resulting in advanced disease at presentation and the limited availability of effective, but cost prohibitive, chemotherapy. Consequently patient outcomes are typically poor and there is an unmet need to identify those cancer patients who would benefit most from the limited resources available.
In resource-abundant areas, low hemoglobin [hgb], advanced disease stage, and poor patient performance status (PS) are associated with a poor prognosis and often serve to direct cancer care towards palliation instead of cure. Similarly, the international prognostic index (IPI) provides prognostic information among patients with non-Hodgkin lymphoma (NHL). However, the utility of such measures in therapeutic decision making in resource-poor areas is less studied. Here we describe characteristics of patients with a new diagnosis of NHL presenting for care in Uganda and identify factors associated with those patients recommended to receive cancer-directed therapy.

Methods
We conducted a retrospective analysis of all patients > 18 at the time of diagnosis of NHL between 2003 and 2010 who were residents of Kyandondo County (Uganda). Cases were identified from the Kampala Cancer Registry (KCR), a national population-based cancer registry. Patient lists from the KCR were transferred to the Uganda Cancer Institute (UCI), the nation's sole cancer center and Mulago Hospital, a university teaching hospital located in Kampala. Additionally, eligible patients who had not yet been recorded in the KCR were identified from patient records at the UCI or Mulago Hospital. Medical records were reviewed for all eligible patients. Patients determined to have a prior malignancy were excluded from this analysis.
Demographic, clinical, and laboratory data were abstracted from the medical record. PS data were not routinely recorded in the medical record. The outcome measure was whether chemotherapy was recommended by clinical staff.
We assessed whether demographic, clinical, and laboratory measurements were associated with the recommendation for treatment with chemotherapy. Those variable which were associated with the recommendation for chemotherapy (p <0.20) were included in the multivariate analysis.

Results
A total of 134 patients met our inclusion criteria. 48% of the patients were female with a median age of all patients of 40.7 years (range 19-82 years). Over half of the patients (57.5%) were HIV positive. Nearly 90% of the patients presented with stage 3 or stage 4 disease. The vast majority of patients (97.0%) reported at least 1 symptom. Fever (55.8%), a palpable mass (79.7%), and wasting (52.3%) were the most common symptoms reported at presentation. Approximately three-fourths of the patients had at least 1 comorbidity. The median baseline hgb level was 10.8 g/dl; 10% had a hgb <7g/dl. The median LDH level was elevated at 416 IU/L, however data were only obtained for 66 (49%) patients.
Chemotherapy was recommended to 91.2% of the patients. In the multivariate logistic regression model, older age (p=.02), lower stage of disease (p <.001), and fewer comorbidities (p=.01) were associated with the failure to recommend for cancer-directed therapy.

Conclusion
Given their independent effect on response to therapy and overall survival, clinical prognostic indices are often used in resource-abundant countries to identify which patients will derive a benefit from cancer-directed therapy and which patients are better served by supportive measures. In our analysis, the recommendation for cancer-directed therapy was nearly universal. Collecting complete prospective data on IPI variables and follow-up data can validate the IPI in Uganda, allow Ugandan clinicians to determine whether such measures inform survival, and potentially optimize treatment decisions among patients with NHL.
In resource-poor areas, the allocation of scarce health care resources to those patients that will be most likely to derive a meaningful benefit is imperative. Targeting therapy will not only save limited resources, it will also prevent harm in those patients unlikely to realize an effect of cancer-directed therapy.

Disclosures:
Casper: Janssen Research & Development: Research Funding.