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Treatment of Hodgkin Lymphoma With ABVD Chemotherapy in Rural Rwanda: A Model for Cancer Care Delivery Implementation

Abstract

Purpose

Hodgkin lymphoma (HL) is highly curable in high-income countries (HICs), yet many patients around the world do not have access to therapy. In 2012, cancer care was established at a rural district hospital in Rwanda through international collaboration, and a treatment protocol using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiotherapy was implemented.

Methods

We conducted a retrospective cohort study of all patients with confirmed HL seen at Butaro Hospital from 2012 to 2018 to evaluate quality indicators and clinical outcomes.

Results

Eighty-five patients were included (median age, 16.8 years; interquartile range, 11.0-30.5 years). Ten (12%) were HIV positive. Most had B symptoms (70%) and advanced stage (56%) on examination and limited imaging. Of 21 specimens evaluated for Epstein-Barr virus, 14 (67%) were positive. Median time from biopsy to treatment was 6.0 weeks. Of 73 patients who started ABVD, 54 (74%) completed 6 cycles; the leading reasons for discontinuation were treatment abandonment and death. Median dose intensity of ABVD was 92%. Of 77 evaluable patients, 33 (43%) are in clinical remission, 27 (36%) are deceased, and 17 (22%) were lost to follow-up; 3-year survival estimate is 63% (95% CI, 50% to 74%). Poorer performance status, advanced stage, B symptoms, anemia, dose intensity < 85%, and treatment discontinuation were associated with worse survival.

Conclusion

Treating HL with standard chemotherapy in a low-resource setting is feasible. Most patients who completed treatment experienced a clinically significant remission with this approach. Late presentation, treatment abandonment, and loss to follow-up contribute to the discrepancy in survival compared with HICs. A strikingly younger age distribution in our cohort compared with HICs suggests biologic differences and warrants further investigation.

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Support

R.J.D. was supported by the Fogarty International Center and the National Cancer Institute of the National Institutes of Health under award no.D43TW009343, the Global Cancer Program at UCSF Helen Diller Family Comprehensive Cancer Center, and the University of California Global Health Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding sources. The funding sources were not involved in the design of the study; collection, analysis, and interpretation of data; or writing of the manuscript.

Authors' Disclosures of Potential Conflicts of Interest

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/site/misc/authors.html.
Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Temidayo A. Fadelu

Research Funding: Celgene (Inst), Cepheid (Inst)

Lawrence N. Shulman

Research Funding: Celgene
No other potential conflicts of interest were reported.

Information & Authors

Information

Published In

JCO Global Oncology
Pages: 1093 - 1102
PubMed: 32678711

History

Published online: July 17, 2020

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Authors

Affiliations

Rebecca J. DeBoer, MD, MA [email protected]
Department of Medicine, University of California, San Francisco, San Francisco, CA
Cyprien Shyirambere, MD
Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
Caitlin D. Driscoll, MD
Duke University, Durham, NC
Yvan Butera, MD
Republic of Rwanda Ministry of Health, Kigali, Rwanda
Alan Paciorek, BS
Department of Medicine, University of California, San Francisco, San Francisco, CA
Deogratias Ruhangaza, MD
Republic of Rwanda Ministry of Health, Burera District, Rwanda
Temidayo A. Fadelu, MD, MPH
Dana-Farber Cancer Institute, Boston, MA
Aline Umwizerwa, RN
Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
Jean Bosco Bigirimana, BSN
Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
Clemence Muhayimana, BSN
Republic of Rwanda Ministry of Health, Butare, Rwanda
Cam Nguyen, MSPH
Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
Paul H. Park, MD, MSc
Brigham and Women’s Hospital, Boston, MA
Tharcisse Mpunga, MD
Republic of Rwanda Ministry of Health, Burera District, Rwanda
Leslie Lehmann, MD
Dana-Farber/Boston Children’s Hospital Cancer Center, Boston, MA
Lawrence N. Shulman, MD
Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA

Notes

Rebecca J. DeBoer, MD, MA, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143-1270; e-mail: [email protected].

Author Contributions

Conception and design: Rebecca J. DeBoer, Cyprien Shyirambere, Deogratias Ruhangaza, Temidayo A. Fadelu, Clemence Muhayimana, Paul H. Park, Tharcisse Mpunga, Leslie Lehmann, Lawrence N. Shulman
Financial support: Lawrence N. Shulman
Administrative support: Cyprien Shyirambere, Cam Nguyen, Lawrence N. Shulman
Provision of study material or patients: Temidayo A. Fadelu, Aline Umwizerwa, Tharcisse Mpunga
Collection and assembly of data: Rebecca J. DeBoer, Caitlin D. Driscoll, Yvan Butera, Aline Umwizerwa, Jean Bosco Bigirimana, Clemence Muhayimana, Cam Nguyen
Data analysis and interpretation: Rebecca J. DeBoer, Cyprien Shyirambere, Caitlin D. Driscoll, Alan Paciorek, Temidayo A. Fadelu, Clemence Muhayimana, Tharcisse Mpunga, Leslie Lehmann, Lawrence N. Shulman
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors

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Rebecca J. DeBoer, Cyprien Shyirambere, Caitlin D. Driscoll, Yvan Butera, Alan Paciorek, Deogratias Ruhangaza, Temidayo A. Fadelu, Aline Umwizerwa, Jean Bosco Bigirimana, Clemence Muhayimana, Cam Nguyen, Paul H. Park, Tharcisse Mpunga, Leslie Lehmann, Lawrence N. Shulman
JCO Global Oncology 2020 :6, 1093-1102

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