Inequities in Access to Rituximab and Survival in Non-Hodgkin Lymphoma: A 20-Year Cohort Study from Nigeria

Background: Outcomes for non-Hodgkin lymphoma (NHL) in sub-Saharan Africa remain constrained by delayed diagnosis, incomplete diagnosis, limited access to guideline-concordant treatment, and high out-of-pocket expenditure. Rituximab transforms outcomes in CD20-positive B-cell lymphomas, but its real-world penetration in many African oncology settings remains poorly described. We analyzed adults with NHL to assess treatment access, rituximab uptake, and survival outcomes. Methods: This was a retrospective cohort study of adult NHL patients between 2005 and 2025 at two tertiary hospitals in Port Harcourt, Nigeria. Demographic, clinical, laboratory, immunophenotypic, treatment, and follow-up data were retrieved from the case notes. Data was analyzed using SPSS version 26. Results: A total of 86 patients were included. Median age was 52 years (IQR 40 - 62); 53 (61.6%) were male. Median symptom duration before presentation was 5.0 months (IQR 3.0-10.0). Among 76 (88.4%) staged patients, 40 (52.6%) had stage III/IV disease. Seventy-two (83.7%) received treatment, but only 22 (25.6%) received any rituximab-containing regimen. Among 39 patients with available CD20 testing, 37 (94.9%) were CD20-positive, of whom 21 (58.3%) received rituximab. CHOP was the most common regimen (n=41, 47.7%), followed by R-CHOP (n=18, 20.9%). Among 55 response-evaluable treated patients, objective response rate was 65.5% and complete response rate 3.6%. At last contact, 48 (56.5%) had died, 33 (38.8%) were lost to follow-up, and four (4.7%) were alive. Median OS for the full cohort was 12.0 months; 12-month and 24-month OS were 49.9% and 25.6%, respectively. Rituximab treatment was associated with superior survival (median OS 45.0 vs 11.0 months; log-rank p=0.002) and lower mortality (HR 0.32, 95% CI 0.14-0.70; p=0.005). Conclusion: Restricted access to rituximab was associated with inferior survival, highlighting treatment inequities as a key driver of avoidable mortality in NHL in LMICs. Expanding access to immunochemotherapy and strengthening care systems are essential to improve outcomes.