CHAPEL HILL, North Carolina – Researchers at the UNC Lineberger Comprehensive Cancer Center showed in a clinical study in Malawi that five-drug combination chemotherapy had curative benefits compared to current standard therapy in patients diagnosed with lymphoma, and now they have they found that this option is inexpensive too. The economic result appeared on July 22, 2021 in Lancet Global Health.

The results of the clinical study, published May 19, 2021, in Lancet Global Health 37 people with diffuse large B-cell lymphoma (DLBCL) were involved. The majority of patients were also HIV positive, which greatly increased their risk of DLBCL; all HIV-positive patients were treated with antiviral drugs. Study participants received a standard chemotherapy combination of four drugs known as CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) along with rituximab, an antibody therapy. After two years of follow-up, 55 percent of patients were still alive, a result that is higher than with CHOP alone based on previous studies.

With the available study results, the researchers wanted to know whether CHOP or CHOP plus rituximab are cost-effective treatments in an environment with limited resources. Demographically, Malawi is a country south of the Sahara in Africa with around 19 million inhabitants. The health resources available for Malawi in the 2017-2018 state budget were $ 170 million (about $ 9 per person); external donors contribute approximately an additional $ 350 million to healthcare spending annually.

Matthew Painschab, MD of UNC Lineberger, lead author of the economic analysis and co-lead author of the study on treatment efficacy, said cost-benefit analyzes allow comparisons across diseases so that limited resources can be optimally allocated.

“Without such analysis, relatively expensive up-front cancer drug costs often seem prohibitive to a relatively small number of patients compared to other public health interventions available,” said Painschab, assistant professor in the UNC School of Medicine Department of Hematology and a member of the UNC Malawi Project . “We have shown that a time-limited upfront payment followed by decades of healthy life can be a wise investment compared to other accepted interventions such as daily, lifelong antiretroviral treatment for HIV.”

When comparing supportive treatment (no chemotherapy) with chemotherapy with CHOP per patient, chemotherapy prevented more than seven disability-adjusted life years (DALYs) at a cost of $ 193 per prevented DALY. A DALY is a year of life in perfect health, and therefore losses represent both years lost through premature death and years of life lost qualitatively through disability. The addition of rituximab to CHOP prevented about three DALYs at a price of $ 1,145 per DALY.

“Our analysis has important implications for saving lives,” said Painschab. “Although accurate cancer incidence estimates are lacking, we estimate that treating all cases of DLBCL in Malawi with CHOP would cost about a million dollars annually and save an estimated 252 lives. For an extra two million dollars a year, we could add rituximab, which costs about $ 500 a dose in Malawi, and the five-drug therapy could save an additional 100 lives. “

In addition to the recently published studies, researchers are conducting some of the world’s first molecular profiling studies for HIV-associated lymphomas. They hope that a better biological understanding of DLBCL in Malawi can lead to more targeted, safe, and effective treatment strategies. They find that there is still much to be done in this area in both the US and Malawi.

“Demonstrating that treating DLBCL in Malawi can be cost-effective has not been particularly intuitive, as the upfront costs of treating cancer patients often seem daunting for countries with many competing health priorities,” noted Stephen Kimani, MD, Hematology / Oncology Fellow at UNC -Chapel Hill and research associate at the UNC project Malawi and first author of the study that determined the effectiveness of combination therapy. “Investing in high quality, potentially curative cancer treatment can be very prudent when short-term costs result in normal life expectancy. Hopefully these types of demonstrations will spark a movement for cancer access that is analogous to what has happened with HIV. “

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Authors and information

Economic research

Besides Painschab, the other authors of the paper are Stephanie Wheeler, PhD, UNC Lineberger, and UNC Gillings School of Global Public Health; Wilberforce Mhango, Bongani Kaimila, MBBS, MSc, Takondwa Zuze, MBBS, Victor Mithi, MBBS, Edwards Kasonkanji, MPH and Noel Mumba, UNC Project Malawi, Lilongwe; Racquel E. Kohler, PhD, Rutgers Cancer Institute of New Jersey, New Brunswick; Richard Nyasosela, MBBS, Kamuzu Central Hospital, Lilongwe, Malawi; and Satish Gopal, MD, formerly Center for Global Health, National Cancer Institute, Bethesda, MD.

The research was supported by NIH grants K01TW011470, U54CA190152, D43TW009340, UM1CA121947, P30CA233709, R25CA057711, and T32CA11633911.

Effectiveness of treatment research

Besides Kimani and Painschab, the other authors of the paper are Bongani Kaimila, MBBS, UNC Project Malawi, and University of Malawi College of Medicine; Tamiwe Tomoka, MMed, UNC Project Malawi, University of Malawi College of Medicine, and UNC School of Medicine; Edwards Kasonkanji, Takondwa Zuze, MBBS, Maria Chikasema, Asekanadziwa Mtangwanika, Mena Chawinga, Wilberforce Mhango, Simon Nicholas, Fred Chimzimu, Coxcilly Kampani, Robert Krysiak, MS, Ryan Seguin, MPH, UNC Project Malawi, Lilongwe; Maurice Mulenga, MMed, Richard Nyasoselam, MMed, Ministry of Health of Malawi; Amy Lilly, MD, UNC Medical School; Cara Randall, MD, West Virginia University; Katherine D. Westmoreland, MD, UNC Project-Malawi and UNC Lineberger; Nathan D. Montgomery, MD, Yuri Fedoriw, MD, UNC Project-Malawi, and UNC School of Medicine; and Satish Gopal, MD, Center for Global Health, National Cancer Institute.

The research was funded in part by a UNC Lineberger Developmental Research Award and NIH grants D43TW009340, K01TW011470, and UM1CA121947.

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