Accessibility to Rituximab and its impact on treatment outcomes in major Non-Hodgkin Lymphoma subtypes: Insights from a resource-limited setting

Objective: Non- Hodgkin’s lymphoma is a relatively uncommon cancer and outcome data in Indian setting is scarce. This study aimed to evaluate the accessibility to rituximab and its impact on treatment outcomes in major non-Hodgkin's lymphoma (NHL) subtypes at a tertiary care cancer hospital in South India.

Methods: This was a single-centre, hospital-based retrospective study of all newly diagnosed NHL patients between April 2015 and March 2020, at Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka. Case files of the patients were retrieved, relevant data was collected and analysed.

Results: In total, 929 patients were diagnosed with NHL [diffuse large B-cell lymphoma =478(51.4%), follicular lymphoma =82(8.8%), mantle cell lymphoma=65(6.9%), peripheral T-cell lymphoma=50(5.4%), and high-grade B-cell lymphoma=49(5.2%) and rest others]. Diffuse large B cell lymphoma patients mostly presented with stage IV disease (n=162(33.5%)). More than one-third (188(39.3%)) of the patients had extra-nodal disease with gastrointestinal tract involvement being the most common. The median progression free survival and overall survival of diffuse large B cell lymphoma patients were 15.2 and 23 months respectively. Only 37% of these patients had access to rituximab, and those who received rituximab-based chemotherapy demonstrated significantly better overall survival (HR=0.64, p=0.001). Follicular lymphoma patients also presented primarily with stage IV (n=40(49%)) disease, with 31(37.8%) and 58(70%) patients showing bone marrow involvement and extra-nodal involvement respectively. The median progression free survival and overall survival for these patients were not reached, however, the 2-year median progression free survival was 75%. Only 58% of the follicular lymphoma patients had access to rituximab. Response rates were higher with rituximab-based therapy, with complete response rates of 62% with rituximab vs 49% without rituximab. The progression free survival of patients who received rituximab was 61 months vs 41 months for those who did not (p=0.012).

Conclusion: There is significant gap in treatment outcomes of NHL patients between richer and poorer countries. There is an urgent need for framing of policies and public health interventions to improve access to newer therapies in resource constrained countries to further enhance cancer treatment outcomes.