Approach to young high risk aml patients with limited resources
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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: [email protected]

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Approach to Young, High Risk AML patients with Limited Resources

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Approach to young high risk aml patients with limited resources

Approachto Young, HighRisk AML patientswithLimitedResources

Dr. HemantMalhotra,

MD, FRCP (London), MNAMS, FUICC, FICP, FIMSA

Professor of Medicine &

Head, Division of Medical Oncologist

SMS Medical College & Hospital, Jaipur.

Email: [email protected]


Sawai man singh sms medical college hospital

Sawai Man Singh [SMS]Medical College Hospital


Welcome to jaipur the pink city of the world

Welcome to Jaipur – The ‘pink’ city of the world !!


Disclaimer

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


Warning

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!!


Talk outline

Talk Outline

  • Some India-specific Issues

  • AML - Overview

  • AML in India

  • AML in resource limited setting

  • The Future


India population problems

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


The cancer problem in india

The Cancer problem in India

On the threshold of an ‘Epidemic’!!

“Cancer Sunami”


Cancer in india

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)


Oncology care in india best to the non existent

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


The economic mismatch in resource limited countries

The Economic Mismatchin resource-limited Countries!!


Approach to young high risk aml patients with limited resources

Ratio of no. of qualified oncologists

to population in millions


Approach to young high risk aml patients with limited resources

New cancer patients per qualified oncologist


Economic spectrum in india

Economic spectrum in India

50 %

45 %

5 %

‘ES’ 0/1

‘ES’ 3

‘ES’ 2


Approach to high risk aml in young patients with limited resources

Approach toHigh Risk AML in Young patients with Limited Resources


Approach to high risk aml in young patients with limited resources1

Approach toHigh Risk AML in Young patients with Limited Resources


Approach to high risk aml in young patients with limited resources2

Approach to High Risk AML in Young patients with Limited Resources


Approach to high risk aml in young patients with limited resources3

Approach to High Risk AML in Young patients with Limited Resources


Aggressive rx of aml in limited resource setting

Aggressive Rx of AML inLimited Resource setting!!


Approach to young high risk aml patients with limited resources

AML

PATIENT


Aml prognosis rx published data

AML – Prognosis & Rx: Published Data !!


High risk aml in young patients with limited resources

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


Prognostic factor in aml

Prognostic Factor in AML


Prognostic factor in aml1

Prognostic Factor in AML


Prognostic factor in aml in developing countries

Prognostic Factor in AML:In developing Countries

FINANCIAL CONSTRAINS


Aml in india

AML in INDIA


Aml in india1

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)


Aml published data from india

AML published datafrom India


Leukemia lymphoma clinic birla cancer center smsmc h jaipur 1992 to 2010 data n 1348

Leukemia Lymphoma Clinic,Birla Cancer Center, SMSMC&H, Jaipur1992 to 2010 Data N=1348


Jaipur aml data

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


Aml in india2

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


Aml in india3

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


Low dose oral metronomic treatment for patients with aml who are not candidates for standard rx

Low-dose, oral metronomic Treatment for patients with AML who are not candidates for standard-Rx


Low dose metronomic rx in aml

Low-dose Metronomic Rx in AML


Low dose metronomic rx in aml1

Low-dose Metronomic Rx in AML


Approach to young high risk aml patients with limited resources

To study the efficacy and toxicity of low dose, metronomic chemotherapy in patients of AML who are not candidates for standard-aggressive chemotherapy

Prospective Single-arm Study at SMSH, Jaipur

N= 25

THE METRONOMIC CHEMOTHERAPY OF AML: (PEM)

  • Prednisolone 40 mg/m2/day,

  • Etoposide50 mg/m2/day and

  • 6-MP 75 mg/m2/day

    Given orally on out-patientbasis continuously for 21 days every month


Approach to young high risk aml patients with limited resources

“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.”


Conclusions

Conclusions:

  • AML Rx in a resource-constrained setting is a major challenge

  • No easy answers

  • All out efforts to increase infra-structure and providemedical 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


Approach to young high risk aml patients with limited resources

THANK YOU


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