Risk Factors for Early Mortality in Fragile Patients with Non-Hodgkin Lymphoma at Diagnosis Who Need Hospitalization in a Developing Country
Authors: Barbosa Ivan de Carvalho Valente , Bellesso Marcelo , Levy Debora , Pereira Juliana , Rocha Vanderson 
Published: October 2019

Abstract
Background
Not infrequently, doctors face a major challenge concerning how to choose the best treatment for fragile patients with cancer, especially for those who need inpatient care. Usually these patients present exclusion criteria to be treated in a curative intention at diagnosis with performance status > 2. In the other hand these patients are not included in clinical trials. In our institution it is not uncommon to receive patients with poor performance status.
Objective
With the aim to individualize the best approach for fragile adults with non-Hodgkin lymphoma (NHL) at diagnosis, we conducted a retrospective study that could identify risk factors for early mortality who needed inpatient care.
Methodology
Early death was considered up to 120 days after the biopsy date. Inclusion criteria were untreated NHL patient ≥ 18 years with indication to start a curative treatment. Exclusion criteria were patient with intention to palliative care, salvage therapy, diagnosis investigation and late death after 120 days. All patients were analyzed for clinical features and laboratory data.
Results
We hospitalized 204 patients with NHL at diagnosis from January 2014 to January 2015 in our cancer center. Sixty four patients (31.3%) met the eligibility criteria. The median age was 56 (20-80 years) years and 39 (60.9%) were male. The subtype of diffuse large B cell lymphoma represented 37 (57.8%) of cases. Forty seven (73.4%) patients had Ann Arbor Stage III or IV, twenty six (40.6%) presented with Performance Status > 2, fifty (78.1%) had elevated serum LDH, forty seven (73.4%) had extranodal involvement and forty three (67.2%) had an International Prognostic Index > 2. Twenty six (40.6%) patients had serum albumin < 3g/dL, twenty one (32.8%) were admitted at the hospital by emergency serve or intensive care unit and twenty three (35.9%) had a time of hospitalization > 20 days. The early mortality was seen in 16 (25%) patients and only two of them occurred before the chemotherapy.
The multivariate analysis identified as significant risk factors for early mortality the albumin < 3g/dL with an odds ratio (OR) 4.84 and a confidence interval (CI) (1.43-16.41), p=0.0169; time of hospitalization > 20 days OR 4.48, CI (1.35- 14.84), p=0.0016 and patients that were admitted at hospital by emergence service or intensive care unit OR 8.36, CI (2.35-29.66), p=0.0013.
Conclusion
In this study we observed high early mortality in NHL patients that needed hospitalization at diagnosis. The main risk factors were albumin < 3g/dL, time of inpatient > 20 days and the admission via emergence or intensive care unit. Therefore, we may suggest that NHL patients who need to be hospitalized and who present at least one of those findings at diagnosis should not be treated with a full dose of chemotherapy. If possible, improvement of their clinical condition should be aimed before starting curative intention treatment.

Disclosures
No relevant conflicts of interest to declare.