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THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN

THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN. SHEIKHA. Professor Anwar Sheikha MD, FRCP, FRCPath., FCAP, FRCPA, FRCPI, FACP Senior Consultant Clinical & Lab. Hematologist, Kurdistan, IRAQ Professor of Hematology, HMU, Erbil, IRAQ Clinical Professor

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THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN

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  1. THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

  2. Professor Anwar Sheikha MD, FRCP, FRCPath., FCAP, FRCPA, FRCPI, FACP Senior Consultant Clinical & Lab. Hematologist, Kurdistan, IRAQ Professor of Hematology, HMU, Erbil, IRAQ Clinical Professor University of Mississippi Medical Center, Jackson, Mississippi

  3. KRG A Proud Part of Federal IRAQ IRAQ POPULATION 32 MILLIONS Erbil >1/5th of the IRAQI POPULATION Suly

  4. SULY AN ARMY OF 80 HEMATOLOGISTS & ONCOLOGISTS ERBIL Patients: 30% Erbil 25% Suly 10% Kirkuk 05% Duhok 30% Rest of IRAQ

  5. CML MANAGEMENT IN IRAQI KURDISTAN The Iraqi Economy is BOOOOMING! A Barrel of Oil is now selling for > $100!! Inshalla it will hit a thousand dollars a barrel. This will help us with our reconstruction efforts More Monicas than a Japan street! More BMW than a German City! Security For IRAQ We are seeing the effects of that economic upsurge. FCR for CLL  $45K 2 Radiation Centers Exjade 1 400-bed hospital in Suly Rituximab Countless Private Hospitals Oncology drugs - SHEIKHA

  6. ﺍﻟﺴﻴﺩ ﻨﻴﭽﻴﺭﭭﺎﻥ ﺒﺎﺭﺯﺍﻨﻰﺒﺭﻋﺎﻴﺔ ﺤﮑﻭﻤﺔ ﺃﻗﻟﻴﻡ ﮐﻭﺭﺩﺴﺘﺎﻥ ﺍﻟﻌﺭﺍﻕﺭﺌﻴﺱ ﺷﺭﮐﺔ ﺭﺍﺰﻳﺎﻧﺔﺗﻘﻮﻢ ﺒﺎﻟﻤﺮﺤﻠﻪ ﺍﻷﻮﻟﻰ ﻠﺒﻨﺎﺀ ﻤﺴﺘﺸﻔﻰ ﻮ ﻤﺭﮐﺯ ﺴﺭﻁﺎﻥ ﻤﻴﺪﻴﺎ ﺒﺴﻌﺔ ۲۰۰ ﺴﺭﻴﺭ ﻤﻊ ﺴﮑﻥ ﻠﻸﻁﺒﺎﺀ ﻭﻤﺠﻤﻊ ﻠﻠﻌﻴﺎﺩﺍﺕ SHEIKHA

  7. MYDIA DIAGNOSTIC CENTER A 50 million dollar project in Erbil SHEIKHA

  8. CML MANAGEMENT IN IRAQI KURDISTAN CML IN KURDISTAN SHEIKHA

  9. GEOGRAPHICAL DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN * Baghdad Ramadi Samara etc

  10. Hawler

  11. Sulaimaniya

  12. GEOGRAPHICAL DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN * Baghdad Ramadi Samara etc

  13. AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN

  14. AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN

  15. AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN

  16. SEX DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN

  17. SEX DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN

  18. CML MANAGEMENT IN IRAQI KURDISTAN GLIVEC HAS EXTENDED THE LIVES OF CML PATIENTS FROM YEARS TO DECADES KNOWING THAT CML USUALLY AFFECTS MIDDLE-AGED PEOPLE; THIS COULD BE CAUTIOUSLY TRANSLATED TO “cure”! ~AIDS & HAART SHEIKHA

  19. CML MANAGEMENT IN IRAQI KURDISTAN The Ideal Scenario: A 55 year, 90 kg fresh symptomless CML Kurdish patient with incidental leukocytosis and moderate splenomegaly. 18 Sibs; all the facilities for HSCT is available now! Order Cytogenetic and Molecular analysis. Both Ph & BCR-ABL +ve. Thanks to Novartis’ relentless efforts, barrels of Imatinib is available in both Suly Hewa & Hawler Blood Hospitals. Start the patient on Glivec and follow his response Hematologically, Cytogenetically for Ph chromosome and Molecularly for BCR-ABL transcript gene Within a year patient gets >4.5 log reduction in BCR-ABL transcript gene. For years the patient is progression free and prefers continuation of therapy. SHEIKHA

  20. CML MANAGEMENT IN IRAQI KURDISTAN The Typical Scenario: A 55 year, 90 kg fresh symptomless CML Kurdish patient with incidental leukocytosis and moderate splenomegaly. 18 Sibs; all the facilities for HSCT is available now! Order Cytogenetic and Molecular analysis. Both Ph & QT-PCR +ve. Thanks to Novartis’ relentless propaganda, barrels of Imatinib is available in both Suly Hewa & Hawler Blood Hospitals. Start the patient on Glivec and follow his response hematologically, cytogenetically and molecularly for BCR-ABL transcript gene Within a year you get >4.5 log reduction in BCR-ABL transcript gene. For years the patient is progression free and prefers continuation of therapy. WISHFUL THINKING SHEIKHA

  21. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

  22. CML MANAGEMENT IN IRAQI KURDISTAN CHR 1 log reduction CCR 2 log reduction MMR 3 log reduction 4 log reduction >4 log reduction SHEIKHA

  23. CRKL phosphorylation (IC50) WT1 Expression OKT-1 Activity

  24. CML MANAGEMENT IN IRAQI KURDISTAN WBC/uL 100,000 CHR 1 log reduction 10,000 CCR 2 log reduction 1,000 MMR 3 log reduction 100 4 log reduction 10 >4 log reudction ? SHEIKHA

  25. CML MANAGEMENT IN IRAQI KURDISTAN 3 Abl Kinase Inhibitors: Imatinib 2001 Dasatinib 2006 Nilotinib 2007 SHEIKHA

  26. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

  27. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

  28. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

  29. CML MANAGEMENT IN IRAQI KURDISTAN The Real Scenario: A 55 year, 90 kg Fresh symptomless CML Kurdish patient with incidental Leukocytosis and moderate splenomegaly. Cannot afford medical expenses and is entirely dependent on Hospital resources! No Cytogenetics; No PCR; No HSCT; NO nothing! Patient cannot travel to Jordan, Iran or Turkey for Ph Chromosome or BCR-ABL Transcript analysis! Thanks to Novartis’ efforts, Glivec is available in both Suly Hewa & Hawler Blood Hospitals SHEIKHA

  30. CML MANAGEMENT IN IRAQI KURDISTAN Are we justified to start Glivec without cytogentic analysis? SHEIKHA

  31. CML MANAGEMENT IN IRAQI KURDISTAN Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? SHEIKHA

  32. CML MANAGEMENT IN IRAQI KURDISTAN Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? SHEIKHA

  33. CML MANAGEMENT IN IRAQI KURDISTAN Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? Until we stand on our feet, what is wrong with blind use of Glivec as long as the patient responds? SHEIKHA

  34. CML MANAGEMENT IN IRAQI KURDISTAN Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? Until we stand on our feet, what is wrong with blind use of Glivec as long as the patient responds? When in crisis, seek the alternative. SHEIKHA

  35. CML MANAGEMENT IN IRAQI KURDISTAN Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? Until we stand on our feet, what is wrong with blind use of Glivec as long as the patient responds? When in crisis, seek the alternative. Half of our patients are on the Indian Glivec “Cipla”, especially when patients buy their medications; what are the recommendations and reactions of Novartis to that? Is there any legal issue involved in flooding the Iraqi market with the Indian Glivec? How effective is the Indian Imatinib? SHEIKHA

  36. CML MANAGEMENT IN IRAQI KURDISTAN THANKS FROM IRAQ & KRG SHEIKHA

  37. CML MANAGEMENT IN IRAQI KURDISTAN THANK YOU THANK YOU SHEIKHA

  38. CML MANAGEMENT IN IRAQI KURDISTAN THANK YOU THANK YOU SHEIKHA

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  41. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

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