Approach to Young, High Risk AML patients with Limited Resources

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Approach to Young, High Risk AML patients with Limited Resources

  1. 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. 2. Sawai Man Singh [SMS] Medical College Hospital
  3. 3. Welcome to Jaipur – The „pink‟ city of the world !!
  4. 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. 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. 6. Talk Outline • Some India-specific Issues • AML - Overview • AML in India • AML in resource limited setting • The Future
  7. 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. 8. The Cancer problem in India On the threshold of an „Epidemic‟!! “Cancer Sunami”
  9. 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. 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. 11. The Economic Mismatch in resource-limited Countries!!
  12. 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. 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. 14. 5 % 45 % 50 % Economic spectrum in India „ES‟ 0/1 „ES‟ 2 „ES‟ 3
  15. 15. Approach to High Risk AML in Young patients with Limited Resources
  16. 16. Approach to High Risk AML in Young patients with Limited Resources
  17. 17. Approach to High Risk AML in Young patients with Limited Resources
  18. 18. Approach to High Risk AML in Young patients with Limited Resources
  19. 19. Aggressive Rx of AML in Limited Resource setting!!
  20. 20. AML PATIENT
  21. 21. AML – Prognosis & Rx: Published Data !!
  22. 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. 23. Prognostic Factor in AML
  24. 24. Prognostic Factor in AML
  25. 25. Prognostic Factor in AML: In developing Countries
  26. 26. AML in INDIA
  27. 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. 28. AML published data from India
  29. 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. 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. 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. 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. 33. Low-dose, oral metronomic Treatment for patients with AML who are not candidates for standard-Rx
  34. 34. Low-dose Metronomic Rx in AML
  35. 35. Low-dose Metronomic Rx in AML
  36. 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. 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. 38. 28 May 2001
  39. 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. 40. THANK YOU

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