1. The 2011 iCMLf Forum
CML Management in
Emerging Economic Regions
Presented in partnership with
The Max Foundation
The 2011 iCMLf Virtual Education Program is supported by an unrestricted grant from
Novartis Oncology

2. Management of CML in Young Patients and
in Children
Dr Ximena Jordan Bruno
Bolivia

3. • Located in the center of South America
• Population of ~10 million
• It has a varied geography and is divided into three
zones: High mountain , valleys, and tropical zones
• The tropical zone is more than the half of the country,
with 4 million inhabitants
BOLIVIA

4. Bolivia
Map of Bolivia and
Bordering Countries

5. Hematology in Bolivia
• There are ~35 hematologists in Bolivia
• 25 of these are working in La Paz and in the high mountain
zone
• Only 5 hematologists work within the tropical zone
• All Bolivian hematologists have performed their training in
other countries, such as; France, Mexico, Brazil, Argentina,
and Uruguay

6. • The Health System is divided into: Public Health, Social
Security, and Private.
• The Social Security portion provides medical care to 40 %
of the population
• In Santa Cruz it counts for approximately 500,000 habitants
• The biggest Social Security hospital in Santa Cruz is the
hospital Obrero with only one hematologist
Health System in Bolivia

7. Health System and coverture to Cancer
Medication
• THERE IS NO HEALTH INSURANCE in Bolivia providing
IMATINIB, or other TKIs to their CML patients
• The only way for our patients to receive proper medications
is thru GIPAP and the Max Foundation
• The Hematology Society is currently working on Bolivian
Senate legislation to include Imatinib as essential
medication

8. CML patients in Bolivia
• There are approximately 200 patients with the CML disease
in Bolivia
• More than 100 receive Imatinib from GIPAP
• 50 of these patients live within the tropical zone
• There are still patients without proper diagnosis in some
places of our country; such as remote forest locations and
populations located in the altiplano
• Unfortunately, we still have patients that do not receive
proper treatment

9. Diagnosis
• Bolivia as a country does not have CITOGENETIC
ANALYSIS .
• There is only one center located in La Paz which can
perform QUALITATIVE PCR. This helps us with confirming
diagnosis, but we do not have a correct way to follow-up
with these patients
• We are now trying to send samples to Argentina for
CYTOGENETIC and QUANTITATIVE PCR .

10. CML in young adults and in children
• We have 50 patients in the Tropical Zone
• More than 50 % of them are younger than 45 years old
• Posing a challenge to us is one pediatric patient. The
challenge exists since it is very rare within this age group,
and there is a lack of documented research

11. • Age: 8 year old female
• Absolutley healthy prior to the disease
• She went to her pediatrician for having fatigue,
pallor,abdominal pain, and demonstrating anormal
hemorraging after a molar extraction .
• At physical examination was found: Pallor of skin
mucosae, and splenomegaly
Dr. Macias , Dr Jordan
CML in a 8 year old child

12. Case
Labs :
• WC : 275,900 Hb : 8.6 PLT : 2,897,000
Bone Marrow Aspiration: Myeloproliferative Disorder
compatible with Chronic Myeloid Leukemia in its Chronic
Phase .
Confirmatory diagnosis was performed by cytogenetic
analysis, and PCR in both Bolivia and Chile
The patient’s only sister is not HLA compatible

13. Treatment
• She received Hydroxiurea and Imatinib initially, and after
she was stable continued with Imatinib 300 mg day
• She achieved hematological response in 3 months
• Asintomatic and having a normal life .
• The mother states that the patient has not grown normal
this year
• Patient is about to complete one year of treatment

14. Evolution
2011
Mar. May June Aug. Sept. Oct. Dec.
WC 4.100 6.100 5.600 4.000 5.100 4.900 3.900
HB 11.3 10.7 11.7 12 11 11.9 11
PLT 251.000 180.000 164.000 139.000 164.000 170.000 200.000
QUALITATIVE PCR IN
MARCH , MAY , DECEMBER :
All positive

15. Future
• Depending on the Cytogenetic Response :
• Continue treatment with Imatinib
• Consider the new TKIS
• Consider Bone Marrow Transplantation ( Non related )

16. GIPAP SANTA CRUZ
Thank you ICML
foundation and
Dr Cortez for an
incredible and
valuable
experience at the MD
Anderson
Cancer Center