Abstract
Introduction
Despite the improvement in management of diffuse large B-cell lymphoma (DLBCL) in recent years, the outcome of patients in low and low-middle income countries remains suboptimal. Considering the Brazilian heterogeneous population and the usual lack of access to novel therapies, there is a clear need to understand the outcome of these patients in the real world. The Brazilian Health System has a unique composition, divided into Public Health Services (Public Services, historically underfunded, and available to all citizens and maintained by the Brazilian Government) and Complementary Health Services (Private Services, available to those with private health insurance either by their own or by the employer). In the latter, access to approved novel therapies, including antibody drug conjugates, biespecifics antibodies and others, is usually facilitated. The current study aimed to compare outcome of newly diagnosed DLBCL patients treated at Public and Private centers in Brazil.
Methods
BRA-DLBCL is a Brazilian multicenter retrospective observational study aimed at generating real-world data (RWD) in patients with newly diagnosed DLBCL and high-grade B-cell lymphoma. Patients registered from 2017 to 2023 at Private and Public Centers located in the Southeast and Northeast regions of Brazil, which account for more than two-thirds of the Brazilian population, were included. The primary outcome was progression-free survival, and secondary outcomes included overall survival, relapse, and non-relapse mortality. analyses were conducted using Kaplan-Meier and cumulative incidence curves and compared with the log-rank and Gray tests, respectively.
Results
A total of 237 patients were treated in Private Centers and 325, in Public Centers. The median follow-up was 40 months. The median age was 64 years, and 46% were female. ECOG performance status 0-1 was slightly higher in Private Services (77% vs 63%). Disease Staging was not different. B-symptoms were more frequent in Public Services (57% vs 17%), possibly reflecting longer times between symptoms and diagnosis (median 31 days in Public vs 21 days in Private Services, p<0.001). Longer time between diagnosis and first treatment was also noted in the Public Services (median 22 vs 15 days, p=0.02). Other baseline patient characteristics were well balanced. In both scenarios, most patients were treated with R-CHOP regimens (79%), but R-DA-EPOCH was more frequent in Private Services (12%), compared with 5% in Public Services.
Three-year progression-free survival was 61% (95%CI 55-67%) at Public Services, compared with 58% (95%CI 52-65%) in Private Services (p=0.80). Three-year Overall survivals were not different either (Public 70%, 95%CI 65-76%, compared with 66%, 95%CI 65-76% in Private Services, p=0.90). Patterns of treatment failures were not different (3-y relapse 29% and 32% for Public and Private Services, respectively, and 3-y non-relapse mortality 11% and 9%).
Discussion
In this multicenter study of over 500 Brazilian patients, we found no difference in outcomes in patients treated in Public or Private Services. Although our results were quite unexpected, we must keep in mind that R-CHOP had been the standard treatment for DLBCL for decades, and only recently novel therapies have been approved for DLBCL, including CAR-T cell, novel monoclonal and biespecifics antibodies. Due to the time window and late approval of these drugs in Brazil, our study might not have captured the impact of access to novel therapies. 42% of patients were treated on Private Centers, and since it is estimated that 40% of patients have some form of Private Health coverage, our study accurately captures the Brazilian socioeconomic demographics, which is a strong point of our study. However, we should notice that most patients treated in Public System were treated in highly especialized Centers, and that may implicate better outcomes in the Public System, especially a low non-relapse mortality. We noticed that both time from symptoms to diagnosis and time from diagnosis to treatment were longer in Public Services, compared with Private Services. This may have led to some survival bias but, most importantly, is an area of potential improvement in Public Health Care.
