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Approach to Young, High Risk AML patients with Limited Resources

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  • 1. Approach to Young, High Risk AML patients with Limited Resources Dr. Hemant Malhotra, MD, FRCP (London), MNAMS, FUICC, FICP, FIMSA Professor of Medicine & Head, Division of Medical Oncologist SMS Medical College & Hospital, Jaipur. Email: drmalhotrahemant@gmail.com
  • 2. Sawai Man Singh [SMS] Medical College Hospital
  • 3. Welcome to Jaipur – The „pink‟ city of the world !!
  • 4. Disclaimer • No significant conflict of interest to declare related to this presentation • Views expressed by me in this presentation are essentially mine and my perspective of the problem
  • 5. WARNING !!!! • The following presentation may contain contents and/or issues which may be upsetting and/or disturbing to a section of the audience!! • Viewer discretion is advised while attending this session!!
  • 6. Talk Outline • Some India-specific Issues • AML - Overview • AML in India • AML in resource limited setting • The Future
  • 7. India - Population & Problems • 1.20 billion people (estimated 2011) • 15% of the world‟s population • 2nd most populous country after China • Increasing at the rate of 1.7% annually • Likely to overtake China in the middle of this century • Rapidly aging population – presently 40% younger that 15 yrs. • Senior citizens expected to increase by 274% by year 2040. India will have 20% of the world‟s senior citizens by 2040. • No social system of medicine • 10 to 15 % have access to medical insurance – 85 to 90% „out-of-pocket‟ payment
  • 8. The Cancer problem in India On the threshold of an „Epidemic‟!! “Cancer Sunami”
  • 9. Cancer in India • 1 million new cases detected every year • 3-3,50,000 die each year due to cancer • 500 % increase in cancer in India by 2025 (280% due to ageing & 220% due to tobacco use)
  • 10. Oncology Care in India: Best to the non-existent • Oncology setups in Metros - Matching best international standards • Good hospitals with trained oncologists in category A & most category B cities • Radiotherapy dept in most medical college hospitals • No/minimal presence at district/village level hospitals
  • 11. The Economic Mismatch in resource-limited Countries!!
  • 12. 8.33 15.71 25.63 0.52 0.17 1.14 0.3 0.98 15.39 50 7.95 50 6.98 14.29 50.71 14 28.79 2.46 24.4 2.63 18.41 3.64 0 10 20 30 40 50 60 Egypt LebanonPhillipines NepalMyanmar IranIndonesia India China Armenia Bosnia Moldova Georgia Serbia Belarus Ukraine Uraguay EcuadorVenezuela Peru Argentina Brazil Ratio of no. of qualified oncologists to population in millions
  • 13. 80 94 459 1329 5318 635 2878 835 110 65 398 45 386 320 61 202 133 531 51 650 165 472 0 500 1000 1500 2000 2500 3000EgyptLebanonPhillipines NepalMyanmar IranIndonesia India ChinaArmenia BosniaMoldova Georgia SerbiaBelarusUkraineUraguayEcuadorVenezuela PeruArgentina Brazil New cancer patients per qualified oncologist
  • 14. 5 % 45 % 50 % Economic spectrum in India „ES‟ 0/1 „ES‟ 2 „ES‟ 3
  • 15. Approach to High Risk AML in Young patients with Limited Resources
  • 16. Approach to High Risk AML in Young patients with Limited Resources
  • 17. Approach to High Risk AML in Young patients with Limited Resources
  • 18. Approach to High Risk AML in Young patients with Limited Resources
  • 19. Aggressive Rx of AML in Limited Resource setting!!
  • 20. AML PATIENT
  • 21. AML – Prognosis & Rx: Published Data !!
  • 22. High Risk AML in Young patients with Limited Resources Standard aggressive induction chemotherapy followed by 3/4 cycles of Consolidation chemotherapy with HD Ara-C or Allogenic HSCT in 1st remission
  • 23. Prognostic Factor in AML
  • 24. Prognostic Factor in AML
  • 25. Prognostic Factor in AML: In developing Countries
  • 26. AML in INDIA
  • 27. AML in India • Remission rates: 60 to 70% • 2 year DFS: 10 to 30% (more in children) • Total cost of Standard 3+7 Induction CT followed by 3 to 4 HD Ara-C (including supportive care): INR 3,00,000/- to 5,00,000/- (USD: 6,000/- to10,000/-) • Approximate cost of Allogenic HSCT: INR 7,00,000/- to 10,00,000/- (USD: 14,000 to 20,000)
  • 28. AML published data from India
  • 29. Leukemia Lymphoma Clinic, Birla Cancer Center, SMSMC&H, Jaipur 1992 to 2010 Data N=1348 94 366 29486 234 334 AML ALL CML CLL HD NHL
  • 30. Jaipur AML Data • N= 94 • Median age: 48 years • 22 patients less that 20 years of age • Only 16 out of 94 received standard-of-care chemotherapy • Majority not eligible for standard-of-care chemotherapy b/o: – Financial constrains – Lack of supportive care (no blood and/or platelet donors) – Logistic issues – Co-morbidities
  • 31. AML in India • Less than 30% of patients eligible for standard- of-care treatment aggressive treatment • Less than 5% of patients receive allogenic SCT • Majority not eligible for standard-of-care chemotherapy b/o: – Financial constrains – Lack of supportive care (no blood and/or platelet donors) – Logistic issues – Co-morbidities
  • 32. AML in India • Options for the patient who are not eligible for standard aggressive CT: – Best Supportive Care – Low-dose, metronomic chemotherapy – Innovative approaches (e.g. arsenic for APML) – Other novel combinations: e.g. targeted agents (FLT3 I) with chemotherapy - standard/metronomic, other combinations – Clinical trials
  • 33. Low-dose, oral metronomic Treatment for patients with AML who are not candidates for standard-Rx
  • 34. Low-dose Metronomic Rx in AML
  • 35. Low-dose Metronomic Rx in AML
  • 36. To study the efficacy and toxicity of low dose, metronomic chemotherapy in patients of AML who are not candidates for standard-aggressive chemotherapy THE METRONOMIC CHEMOTHERAPY OF AML: (PEM) Prednisolone 40 mg/m2/day, Etoposide 50 mg/m2/day and 6-MP 75 mg/m2/day Given orally on out-patient basis continuously for 21 days every month Prospective Single-arm Study at SMSH, Jaipur N= 25
  • 37. “When administered, as in the schedule published here, it is associated with minimal toxicity and is well tolerated. After remission induction, it can be administered on an outpatient basis; this, in combination with the absence of conventional toxicities of chemotherapy such as grade 3/4 neutropenia and mucositis, makes it significantly less expensive to administer. In our setting, administration of an ATRA plus chemotherapy regimen is associated with expenses of approximately $15 000 to $20 000, while this single-agent As2O3-based regimen is associated with expenses of approximately $3000 to $5000.”
  • 38. 28 May 2001
  • 39. Conclusions: • AML Rx in a resource-constrained setting is a major challenge • No easy answers • All out efforts to increase infra-structure and provide medical insurance/other funding for diagnosis & Rx (including supportive care & HSCT) at least for the young patient with AML • Role of metronomic Rx • Role of targeted agents • Region-specific clinical trials needed to address local issues
  • 40. THANK YOU