In a clinical trial conducted in Malawi, researchers found that combination chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) provided curative benefit compared to current standard-of-care therapy in people diagnosed with diffuse large B-cell lymphoma (DLBCL)—and that this option is cost-effective. These findings were published by Matthew Painschab, MD, and colleagues in The Lancet Global Health.
Matthew Painschab, MD
Stephen Kimani, MD
In another analysis published by Stephen Kimani, MD, and colleagues in the same journal, researchers gathered data on 37 people with DLBCL; the majority of patients were also human immunodeficiency virus (HIV)-positive, which greatly increased their risk of DLBCL. All HIV-positive patients were treated with antiviral drugs. The trial participants received CHOP along with rituximab, an antibody therapy. After 2 years of follow-up, 55% of the patients were still alive, an survival rate that is higher than what is seen with CHOP alone based on earlier studies.
With these trial results in hand, the researchers wanted to know if CHOP or CHOP plus rituximab (R-CHOP) were cost-effective treatments in a resource-limited setting.
Treating Lymphoma in Sub-Saharan Africa
Demographically, Malawi is a sub-Saharan country in Africa with roughly 19 million residents. The health-care resources available in the 2017–2018 government budget for Malawi were $170 million dollars (about $9 per person); external donors contribute approximately another $350 million annually to health expenditures.
Dr. Painschab, of UNC Lineberger Comprehensive Cancer Center, said cost-effectiveness analyses allow comparisons across diverse diseases so that limited resources can be optimally allocated.
"Without such analyses, relatively expensive upfront costs for cancer medicines will often seem prohibitively costly for a relatively small number of patients compared to other available public health interventions," said Dr. Painschab, Assistant Professor in the Division of Hematology at UNC School of Medicine and a member of UNC Project Malawi. "We demonstrated that an upfront, time-limited expense followed by decades of healthy life may be a prudent investment, relative to other accepted interventions such as daily lifelong antiretroviral treatment for HIV."
Cost of Care
On a per-patient basis, comparing supportive care (no chemotherapy) to chemotherapy with CHOP, chemotherapy prevented more than 7 disability-adjusted life-years (DALYs), at a cost of $193 per DALY prevented. Adding rituximab to CHOP prevented about 3 DALYs at a cost of $1,145 per DALY.
"Our analysis has important implications for saving lives," said Dr. Painschab. "Though precise estimates of cancer incidence are lacking, we estimate it would cost about $1 million annually to treat all cases of DLBCL in Malawi with CHOP, saving an estimated 252 lives. For $2 million more annually, we could add rituximab, which costs about $500 a dose in Malawi, and the five-drug regimen could save an additional 100 lives."
In addition to the recently published work, the researchers are conducting some of the first molecular profiling studies for HIV-associated lymphoma in the world. They hope that greater biologic understanding of DLBCL in Malawi may lead to more targeted, safe, and effective treatment strategies. They note there is still much work to be done in this area, both in the United States and Malawi.
"Proving that treating DLBCL in Malawi can be cost-effective was not necessarily intuitive, as upfront costs of treating patients [with cancer] often seem daunting for countries facing many competing health priorities," noted Dr. Kimani, a fellow in Hematology/Oncology at UNC Chapel Hill and research fellow at UNC Project Malawi. "Investments in high-quality, potentially curative cancer care may be very prudent when short-term costs result in a normal life expectancy thereafter. These sorts of demonstrations will hopefully spur a treatment access movement for cancer that is analogous to what has occurred for HIV."
Disclosure: For full disclosures of the authors of both studies, visit thelancet.com/journals/langlo.
