Management and Outcomes of Low-Grade Lymphomas in a Prospective Lymphoma Cohort in Malawi

PURPOSE To outline the baseline characteristics, treatment, and outcomes of adults with low-grade lymphomas in Malawi. METHODS We describe a prospective, observational cohort of newly diagnosed low grade lymphomas at a national teaching hospital in Lilongwe, Malawi June 2013--December 2021; follow up was censored December 2022. Diagnoses were supported by histopathology and immunohistochemistry during weekly telepathology conferences between Malawi and U.S. Treatment guidelines were standardized and generally only started if patients met GELF criteria. Simple descriptive statistics and Kaplan Meier methods were used. RESULTS We enrolled 55 patients with low grade lymphoma. Median age was 58 (range 28-82), 35 (64%) were male, and three (9%) HIV-positive. Of 42 patients who required treatment, 37 received CVP (cyclophosphamide, vincristine, and prednisone) and 3 received CHOP (CVP plus doxorubicin), 1 received Mini-CHOP and 1 Received R-CHOP. Median chemotherapy cycles received was six (range 1-8). Of 39 evaluable patients, response was: seven (18%) complete response, 4 (10%) stable disease, 26 (67%) partial response, and 2 (5%) progressive disease. Median follow-up was 34 months (range 5-49 months) among those alive. One- and two-year overall survival were 60% (95% CI 48-75%) and 44% (95% CI 33-60%), respectively. One- and two-year progression free survival were 44% (95% CI 32-59%) and 28% (95% CI 18-43%), respectively. There were a total of four non-hematologic grade 3/4 adverse events and 44 deaths, 29 attributed to disease progression. CONCLUSION This is among the first prospective cohorts of low-grade lymphoma from sub-Saharan Africa. Patients with low grade lymphomas in Malawi have poor progression-free and overall survival compared to high income countries and all deaths in our cohort were from disease progression. Thus, increased resources (e.g., rituximab and other novel therapies) and investigation of the underlying biology of low-grade lymphoma in Malawi and similar contexts are needed to improve patient outcomes.