|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 364-365
Treating lymphomas in low- and middle-income countries
Hemant Malhotra, Naveen Gupta, Sandeep Bairwa
Department of Medical Oncology, Sri Ram Cancer Center, Mahatma Gandhi Medical College Hospital, Jaipur, Rajasthan, India
|Date of Submission||17-Mar-2020|
|Date of Decision||19-Mar-2020|
|Date of Acceptance||22-Mar-2020|
|Date of Web Publication||19-Jun-2020|
C-70, Ram Marg, Vijay Path, Tilak Nagar, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Malhotra H, Gupta N, Bairwa S. Treating lymphomas in low- and middle-income countries. Cancer Res Stat Treat 2020;3:364-5
We read with great interest the article by Kesana et al. Large data sets on the epidemiology and outcomes in less commonly diagnosed lymphomas such as T-cell lymphomas from India are scant, and this publication will serve to fill the gap. A pertinent issue we would like to point out is the high dropout rates and lost to follow-up rates seen in this study and from many retrospective as well as prospective studies from India and other low- and middle-income countries (LMICs). This is due to a combination of social and financial factors that often prove to be a hindrance in not only providing the standard of care but also diluting the value of any research study. It would be of interest to note how many of the total diagnosed patients ended up receiving the full course of treatment and also the number of grade III/IV toxic events during the course of therapy.
One of the downsides of the present study is the lack of uniformity in diagnostic criteria and treatment protocols, but this is understandable and acceptable due to the retrospective nature of the study over a long period of time. It is high time that large centers across the country join hands to create a dedicated registry for lymphomas, especially the less common ones, where standard-of-care treatment is not clearly defined. The Indian guidelines on the diagnosis and management of lymphomas  have had to rely on Western data for most of their recommendations. We hope that, in the future, we can have good-quality Indian data to guide management and lay down Indian-specific guidelines.
In the setting of inadequate finances, it is imperative that we are able to choose regimens which have less toxicity without compromising on efficacy. This is even more important in the relapsed/refractory setting where the patient may feel extremely demoralized and even question the rationale for continuing treatment. The work done by Manuprasad et al. on the utility of Gemcitabine-Dexamethasone-Platinum (GDP)-based salvage regimen is impressive in this regard. There is a paucity of Indian data on salvage regimens in relapsed/refractory lymphomas. In our practice, we have a reluctance to use ifosfamide-carboplatin-etoposide, dexamethasone-high-dose cytarabine-cisplatin, and mesna-ifosfamide-mitoxantrone-etoposide-based regimens when the financial and social support is compromised owing to increased toxicities and supportive care requirements of these regimens. These data on the GDP regimen along with the one on Gemcitabine-Vinorelbine-Dexamethasone (GVD) are reassuring for all oncologists practicing in LMICs. In addition to the usual chemotherapy regimens, can we think of and test innovative, low-cost interventions in this subgroup of patients – like the addition of pioglitazone to imatinib in patients of chronic myeloid leukemia who show a suboptimal response to only imatinib?
In the editorial, Dr. Jayakar rightly points out that more needs to be done to provide the benefits of novel agents and autologous stem cell transplants in Indian patients with T-cell lymphomas. The last two decades have seen an increase in the number of centers performing stem cell transplants in India. However, still, the number of transplants performed in the first remission in both myeloma and T-cell lymphoma is disappointingly low. Lack of patient motivation, fear of complications, and financial issues all contribute to this low number.
To conclude, we would like to state that replicating standard-of-care treatment protocols, especially those adopted from Western guidelines in LMICs, is a huge challenge. While we must push ahead to make these treatment modalities available to our patients, our immediate focus must be to devise our own evidence-based treatment guidelines and protocols to provide effective, cost-efficient, and less toxic therapy to our patients, both in the first-line setting, and after relapse.
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Conflicts of interest
There are no conflicts of interest.
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