AGGRESSIVE LYMPHOMA: DEMOGRAPHICS, DIAGNOSTIC PATTERNS AND OUTCOMES IN GROOTE SCHUUR HOSPITAL IN CAPE TOWN, SOUTH AFRICA
(Abstract release date: 05/19/16)
EHA Library. Levetan C. 06/09/16; 134602; PB1702
Dr. Carly Levetan
Contributions
Contributions
Abstract
Abstract: PB1702
Type: Publication Only
Background
The high rate of HIV in South Africa led to an increasing incidence of aggressive non Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL), but also of infection with Mycobacterium tuberculosis (TB) which may mimic lymphoma. We have observed in Cape Town that lymphoma patients present with advanced disease and that their route to diagnosis is often markedly delayed.
Aims
This study describes the demographic distribution of aggressive lymphomas in our Cape Town institution as well as examine survival outcomes as impacted by documented time delays along the diagnostic pathway.
Methods
We studied 163 patients diagnosed and treated for aggressive lymphoma by Radiation Oncology and Haematology at Groote Schuur Hospital Cape Town in 2013/14. We collected diagnostic and outcome data from hospital records and patient interviews. We constructed a pathway to diagnosis as previously described by Howell DA et al in BMC Hematology 2013 Oct 31;13(1):9. Delays along the diagnostic pathway were divided into three time frames. 1. Patient delay (time from first symptoms until first contact with a medical practitioner) 2. Diagnostic delay (time from first medical contact to diagnostic biopsy). 3. Treatment delay (time from biopsy to referral to our unit and initiation of therapy).
Results
NHL was diagnosed in 122 (74.8%) and HL in 41 (25.2%). In the NHL cohort 29 patients (23.8%) were HIV positive and in HL 18 patients (43.9%), p=0.014. There was no significant association between HIV status and stage at presentation and HIV positive patients did not have a significantly poorer overall survival (OS) (59.6% vs 69%, p=0.251). There was, however, a significant association of HIV with progressive disease in the alive group at time of data analysis (8 patients (28.6%) vs HIV negative 10 patients (12.5%), p=0.05). HL had better OS compared to NHL (35 (85.4%) vs 73 (59.8%), p=0.003). The HL cohort was more likely to present with high-risk disease (80.5%), lymphadenopathy (82.9% vs 56.6% p=0.001) and B-symptoms (73.2% vs 54.1% p=0.032). Despite presenting at this advanced stage, they waited significantly longer for referral from first doctor’s visit to diagnostic biopsy (125 days versus 43 days p=0.01) and from first symptoms to treatment (271 versus 97 days p=0.004). Investigations for the diagnosis of TB as well as empiric TB treatment had a major impact on this delay. Empiric TB treatment was given to 26% of the HL cohort prior to diagnosis of lymphoma, compared to 4.9% in the NHL cohort (p=0.00). Fine needle aspiration (FNA) was carried out in 63 (61%) prior to excisional biopsy and in 17 (27%) FNAs were repeated. Only 10 of 88 FNA studies (11%) suggested lymphoma. Time delay between FNA and diagnostic biopsy median 22 days (IQR 9.8-64). Longer delay from first doctors visit to referral for diagnostic biopsy was associated with an increased mortality (alive: median 40 days (IQR 23-69), dead: median 64 days (IQR 27-154), p=0.04). This is also true for time from first doctor’s visit to treatment (alive: median 59 days (IQR 29-122), dead: median 97 (51-205), p=0.03) and for time from first symptoms until treatment (alive: median 103 days (61-178), dead: median 131 (IQR 73-299), p=0.04).
Conclusion
In aggressive lymphoma diagnosis the period between first patient contact with a health professional and the diagnostic biopsy is crucial. FNA examination is often the first step in the diagnostic pathway of lymphadenopathy in South Africa due to the high rate of TB and poor access to diagnostic biopsy. This led to an inappropriately long 3-week median delay from first FNA to diagnostic biopsy. These three key areas - use of FNA, poor access to excisional biopsy and treatment with empiric TB therapy – significantly delayed diagnosis resulting in severe consequences with increased patient mortality.
Session topic: E-poster
Keyword(s): AIDS/HIV, Diagnosis, Lymphoma
Type: Publication Only
Background
The high rate of HIV in South Africa led to an increasing incidence of aggressive non Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL), but also of infection with Mycobacterium tuberculosis (TB) which may mimic lymphoma. We have observed in Cape Town that lymphoma patients present with advanced disease and that their route to diagnosis is often markedly delayed.
Aims
This study describes the demographic distribution of aggressive lymphomas in our Cape Town institution as well as examine survival outcomes as impacted by documented time delays along the diagnostic pathway.
Methods
We studied 163 patients diagnosed and treated for aggressive lymphoma by Radiation Oncology and Haematology at Groote Schuur Hospital Cape Town in 2013/14. We collected diagnostic and outcome data from hospital records and patient interviews. We constructed a pathway to diagnosis as previously described by Howell DA et al in BMC Hematology 2013 Oct 31;13(1):9. Delays along the diagnostic pathway were divided into three time frames. 1. Patient delay (time from first symptoms until first contact with a medical practitioner) 2. Diagnostic delay (time from first medical contact to diagnostic biopsy). 3. Treatment delay (time from biopsy to referral to our unit and initiation of therapy).
Results
NHL was diagnosed in 122 (74.8%) and HL in 41 (25.2%). In the NHL cohort 29 patients (23.8%) were HIV positive and in HL 18 patients (43.9%), p=0.014. There was no significant association between HIV status and stage at presentation and HIV positive patients did not have a significantly poorer overall survival (OS) (59.6% vs 69%, p=0.251). There was, however, a significant association of HIV with progressive disease in the alive group at time of data analysis (8 patients (28.6%) vs HIV negative 10 patients (12.5%), p=0.05). HL had better OS compared to NHL (35 (85.4%) vs 73 (59.8%), p=0.003). The HL cohort was more likely to present with high-risk disease (80.5%), lymphadenopathy (82.9% vs 56.6% p=0.001) and B-symptoms (73.2% vs 54.1% p=0.032). Despite presenting at this advanced stage, they waited significantly longer for referral from first doctor’s visit to diagnostic biopsy (125 days versus 43 days p=0.01) and from first symptoms to treatment (271 versus 97 days p=0.004). Investigations for the diagnosis of TB as well as empiric TB treatment had a major impact on this delay. Empiric TB treatment was given to 26% of the HL cohort prior to diagnosis of lymphoma, compared to 4.9% in the NHL cohort (p=0.00). Fine needle aspiration (FNA) was carried out in 63 (61%) prior to excisional biopsy and in 17 (27%) FNAs were repeated. Only 10 of 88 FNA studies (11%) suggested lymphoma. Time delay between FNA and diagnostic biopsy median 22 days (IQR 9.8-64). Longer delay from first doctors visit to referral for diagnostic biopsy was associated with an increased mortality (alive: median 40 days (IQR 23-69), dead: median 64 days (IQR 27-154), p=0.04). This is also true for time from first doctor’s visit to treatment (alive: median 59 days (IQR 29-122), dead: median 97 (51-205), p=0.03) and for time from first symptoms until treatment (alive: median 103 days (61-178), dead: median 131 (IQR 73-299), p=0.04).
Conclusion
In aggressive lymphoma diagnosis the period between first patient contact with a health professional and the diagnostic biopsy is crucial. FNA examination is often the first step in the diagnostic pathway of lymphadenopathy in South Africa due to the high rate of TB and poor access to diagnostic biopsy. This led to an inappropriately long 3-week median delay from first FNA to diagnostic biopsy. These three key areas - use of FNA, poor access to excisional biopsy and treatment with empiric TB therapy – significantly delayed diagnosis resulting in severe consequences with increased patient mortality.
Session topic: E-poster
Keyword(s): AIDS/HIV, Diagnosis, Lymphoma
Abstract: PB1702
Type: Publication Only
Background
The high rate of HIV in South Africa led to an increasing incidence of aggressive non Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL), but also of infection with Mycobacterium tuberculosis (TB) which may mimic lymphoma. We have observed in Cape Town that lymphoma patients present with advanced disease and that their route to diagnosis is often markedly delayed.
Aims
This study describes the demographic distribution of aggressive lymphomas in our Cape Town institution as well as examine survival outcomes as impacted by documented time delays along the diagnostic pathway.
Methods
We studied 163 patients diagnosed and treated for aggressive lymphoma by Radiation Oncology and Haematology at Groote Schuur Hospital Cape Town in 2013/14. We collected diagnostic and outcome data from hospital records and patient interviews. We constructed a pathway to diagnosis as previously described by Howell DA et al in BMC Hematology 2013 Oct 31;13(1):9. Delays along the diagnostic pathway were divided into three time frames. 1. Patient delay (time from first symptoms until first contact with a medical practitioner) 2. Diagnostic delay (time from first medical contact to diagnostic biopsy). 3. Treatment delay (time from biopsy to referral to our unit and initiation of therapy).
Results
NHL was diagnosed in 122 (74.8%) and HL in 41 (25.2%). In the NHL cohort 29 patients (23.8%) were HIV positive and in HL 18 patients (43.9%), p=0.014. There was no significant association between HIV status and stage at presentation and HIV positive patients did not have a significantly poorer overall survival (OS) (59.6% vs 69%, p=0.251). There was, however, a significant association of HIV with progressive disease in the alive group at time of data analysis (8 patients (28.6%) vs HIV negative 10 patients (12.5%), p=0.05). HL had better OS compared to NHL (35 (85.4%) vs 73 (59.8%), p=0.003). The HL cohort was more likely to present with high-risk disease (80.5%), lymphadenopathy (82.9% vs 56.6% p=0.001) and B-symptoms (73.2% vs 54.1% p=0.032). Despite presenting at this advanced stage, they waited significantly longer for referral from first doctor’s visit to diagnostic biopsy (125 days versus 43 days p=0.01) and from first symptoms to treatment (271 versus 97 days p=0.004). Investigations for the diagnosis of TB as well as empiric TB treatment had a major impact on this delay. Empiric TB treatment was given to 26% of the HL cohort prior to diagnosis of lymphoma, compared to 4.9% in the NHL cohort (p=0.00). Fine needle aspiration (FNA) was carried out in 63 (61%) prior to excisional biopsy and in 17 (27%) FNAs were repeated. Only 10 of 88 FNA studies (11%) suggested lymphoma. Time delay between FNA and diagnostic biopsy median 22 days (IQR 9.8-64). Longer delay from first doctors visit to referral for diagnostic biopsy was associated with an increased mortality (alive: median 40 days (IQR 23-69), dead: median 64 days (IQR 27-154), p=0.04). This is also true for time from first doctor’s visit to treatment (alive: median 59 days (IQR 29-122), dead: median 97 (51-205), p=0.03) and for time from first symptoms until treatment (alive: median 103 days (61-178), dead: median 131 (IQR 73-299), p=0.04).
Conclusion
In aggressive lymphoma diagnosis the period between first patient contact with a health professional and the diagnostic biopsy is crucial. FNA examination is often the first step in the diagnostic pathway of lymphadenopathy in South Africa due to the high rate of TB and poor access to diagnostic biopsy. This led to an inappropriately long 3-week median delay from first FNA to diagnostic biopsy. These three key areas - use of FNA, poor access to excisional biopsy and treatment with empiric TB therapy – significantly delayed diagnosis resulting in severe consequences with increased patient mortality.
Session topic: E-poster
Keyword(s): AIDS/HIV, Diagnosis, Lymphoma
Type: Publication Only
Background
The high rate of HIV in South Africa led to an increasing incidence of aggressive non Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL), but also of infection with Mycobacterium tuberculosis (TB) which may mimic lymphoma. We have observed in Cape Town that lymphoma patients present with advanced disease and that their route to diagnosis is often markedly delayed.
Aims
This study describes the demographic distribution of aggressive lymphomas in our Cape Town institution as well as examine survival outcomes as impacted by documented time delays along the diagnostic pathway.
Methods
We studied 163 patients diagnosed and treated for aggressive lymphoma by Radiation Oncology and Haematology at Groote Schuur Hospital Cape Town in 2013/14. We collected diagnostic and outcome data from hospital records and patient interviews. We constructed a pathway to diagnosis as previously described by Howell DA et al in BMC Hematology 2013 Oct 31;13(1):9. Delays along the diagnostic pathway were divided into three time frames. 1. Patient delay (time from first symptoms until first contact with a medical practitioner) 2. Diagnostic delay (time from first medical contact to diagnostic biopsy). 3. Treatment delay (time from biopsy to referral to our unit and initiation of therapy).
Results
NHL was diagnosed in 122 (74.8%) and HL in 41 (25.2%). In the NHL cohort 29 patients (23.8%) were HIV positive and in HL 18 patients (43.9%), p=0.014. There was no significant association between HIV status and stage at presentation and HIV positive patients did not have a significantly poorer overall survival (OS) (59.6% vs 69%, p=0.251). There was, however, a significant association of HIV with progressive disease in the alive group at time of data analysis (8 patients (28.6%) vs HIV negative 10 patients (12.5%), p=0.05). HL had better OS compared to NHL (35 (85.4%) vs 73 (59.8%), p=0.003). The HL cohort was more likely to present with high-risk disease (80.5%), lymphadenopathy (82.9% vs 56.6% p=0.001) and B-symptoms (73.2% vs 54.1% p=0.032). Despite presenting at this advanced stage, they waited significantly longer for referral from first doctor’s visit to diagnostic biopsy (125 days versus 43 days p=0.01) and from first symptoms to treatment (271 versus 97 days p=0.004). Investigations for the diagnosis of TB as well as empiric TB treatment had a major impact on this delay. Empiric TB treatment was given to 26% of the HL cohort prior to diagnosis of lymphoma, compared to 4.9% in the NHL cohort (p=0.00). Fine needle aspiration (FNA) was carried out in 63 (61%) prior to excisional biopsy and in 17 (27%) FNAs were repeated. Only 10 of 88 FNA studies (11%) suggested lymphoma. Time delay between FNA and diagnostic biopsy median 22 days (IQR 9.8-64). Longer delay from first doctors visit to referral for diagnostic biopsy was associated with an increased mortality (alive: median 40 days (IQR 23-69), dead: median 64 days (IQR 27-154), p=0.04). This is also true for time from first doctor’s visit to treatment (alive: median 59 days (IQR 29-122), dead: median 97 (51-205), p=0.03) and for time from first symptoms until treatment (alive: median 103 days (61-178), dead: median 131 (IQR 73-299), p=0.04).
Conclusion
In aggressive lymphoma diagnosis the period between first patient contact with a health professional and the diagnostic biopsy is crucial. FNA examination is often the first step in the diagnostic pathway of lymphadenopathy in South Africa due to the high rate of TB and poor access to diagnostic biopsy. This led to an inappropriately long 3-week median delay from first FNA to diagnostic biopsy. These three key areas - use of FNA, poor access to excisional biopsy and treatment with empiric TB therapy – significantly delayed diagnosis resulting in severe consequences with increased patient mortality.
Session topic: E-poster
Keyword(s): AIDS/HIV, Diagnosis, Lymphoma
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