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Approach to Young, High Risk AML patients with Limited Resources
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
6. 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
7. 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!!
8. Talk Outline
• Some India-specific Issues
• AML - Overview
• AML in India
• AML in resource limited setting
• The Future
9. 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
11. 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)
12. 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
24. 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
29. 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)
31. 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
32. 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
33. 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
34. 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
38. 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
39. “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.”
42. 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