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Approach to Young, High Risk AML patients with Limited Resources

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.

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Approach to Young, High Risk AML patients with Limited Resources

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  1. 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: drmalhotrahemant@gmail.com

  2. Sawai Man Singh [SMS]Medical College Hospital

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

  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. 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. Talk Outline • Some India-specific Issues • AML - Overview • AML in India • AML in resource limited setting • The Future

  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. The Cancer problem in India On the threshold of an ‘Epidemic’!! “Cancer Sunami”

  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. 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. The Economic Mismatchin resource-limited Countries!!

  12. Ratio of no. of qualified oncologists to population in millions

  13. New cancer patients per qualified oncologist

  14. Economic spectrum in India 50 % 45 % 5 % ‘ES’ 0/1 ‘ES’ 3 ‘ES’ 2

  15. Approach toHigh Risk AML in Young patients with Limited Resources

  16. Approach toHigh Risk AML in Young patients with Limited Resources

  17. Approach to High Risk AML in Young patients with Limited Resources

  18. Approach to High Risk AML in Young patients with Limited Resources

  19. Aggressive Rx of AML inLimited Resource setting!!

  20. AML PATIENT

  21. AML – Prognosis & Rx: Published Data !!

  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. Prognostic Factor in AML

  24. Prognostic Factor in AML

  25. Prognostic Factor in AML:In developing Countries FINANCIAL CONSTRAINS

  26. AML in INDIA

  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. AML published datafrom India

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

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

  34. Low-dose Metronomic Rx in AML

  35. Low-dose Metronomic Rx in AML

  36. 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

  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. 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

  39. THANK YOU

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