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,
Feb 24, 2016
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]
Sawai Man Singh [SMS]Medical College
Hospital
Welcome to Jaipur – The ‘pink’ city of the world !!
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 !!!!
• 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• Some India-specific Issues• AML - Overview• AML in India• AML in resource limited setting• The Future
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
On the threshold of an ‘Epidemic’!!
“Cancer Sunami”
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 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 Mismatchin resource-limited Countries!!
8.33
15.7
1 25.6
30.
520.
171.
140.
30.
9815
.39
507.
9550
6.98
14.2
950
.71
1428
.79
2.46
24.4
2.63
18.4
13.
64
0
10
20
30
40
50
60
Ratio of no. of qualified oncologists to population in millions
0
500
1000
1500
2000
2500
3000
New cancer patients per qualified oncologist
5 %
45 % 50 %
Economic spectrum in India
‘ES’ 0/1 ‘ES’ 2 ‘ES’ 3
Approach toHigh 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 Resources
Approach to High Risk AML in
Young patients with Limited Resources
Aggressive Rx of AML in Limited Resource setting!!
AML
PATIENT
AML – Prognosis & Rx: Published Data !!
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 AML:In developing Countries
FINANCIAL CONSTRAINS
AML in INDIA
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 datafrom India
Leukemia Lymphoma Clinic,Birla Cancer Center, SMSMC&H, Jaipur
1992 to 2010 Data N=1348
94
366
29486234
334
AML ALL CML CLL HD NHL
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 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 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 Metronomic Rx in AML
Low-dose Metronomic Rx in AML
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, JaipurN= 25
“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 lessexpensive 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.”
28 May2001
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
THANK YOU