Baseline characteristics, treatment, and outcomes of indolent lymphoma in Malawi: a prospective, observational cohort

• Of 55 patients with indolent lymphoma enrolled 2013-2021 in Malawi, only eleven survived to Dec. 2022; median overall survival 15 months. • Survival outcomes are poor, likely due to limited access to novel therapies, late-stage diagnosis, and social determinants of health. The literature is sparse on the characteristics, treatment, and outcomes of patients with indolent lymphomas in sub-Saharan Africa. We conducted a prospective observational cohort of indolent lymphoma cases in Lilongwe, Malawi (June 2013-December 2021), censored December 2022. Diagnoses were confirmed via histopathology and immunohistochemistry in telepathology conferences between Malawi and U.S. Treatment was standardized per Groupe d’Etude des Lymphomes Folliculaires criteria. Descriptive statistics and Kaplan Meier methods were used. Fifty-five patients were enrolled with median age 58 years (range 28-82), 64% male, and 13% HIV-infected. Among 42 patients who required treatment, 37 (88%) received CVP, four (10%) received CHOP, and one (2%) received R-CHOP. Of 39 evaluable patients, seven (18%) had complete response, 26 (67%) partial response, four (10%) stable disease, and two (5%) progressive disease. Median follow-up was 34 months (range 5-49) 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 four non-hematologic grade 3/4 adverse events and 44 deaths, 29 attributed to disease progression, five possibly due to treatment, and ten to other causes. This is among the first prospective cohorts of indolent lymphoma from sub-Saharan Africa. Survival outcomes are worse than in high income countries, likely due to limited access to rituximab and novel therapies, late-stage diagnosis, and social determinants of health. Increased access to targeted therapies and care implementation strategies are needed to reduce these disparities.