Ideal induction regimen for AML in adolescents and young adults
Approach to Young, High Risk AML patients with Limited Resources
description
Transcript of Approach to Young, High Risk AML patients with Limited Resources
![Page 1: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/1.jpg)
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]
![Page 2: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/2.jpg)
Sawai Man Singh [SMS]Medical College
Hospital
![Page 3: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/3.jpg)
![Page 4: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/4.jpg)
Welcome to Jaipur – The ‘pink’ city of the world !!
![Page 5: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/5.jpg)
![Page 6: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/6.jpg)
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
![Page 7: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/7.jpg)
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!!
![Page 8: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/8.jpg)
Talk Outline• Some India-specific Issues• AML - Overview• AML in India• AML in resource limited setting• The Future
![Page 9: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/9.jpg)
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
![Page 10: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/10.jpg)
The Cancer problem in India
On the threshold of an ‘Epidemic’!!
“Cancer Sunami”
![Page 11: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/11.jpg)
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)
![Page 12: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/12.jpg)
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
![Page 13: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/13.jpg)
The Economic Mismatchin resource-limited Countries!!
![Page 14: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/14.jpg)
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
![Page 15: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/15.jpg)
0
500
1000
1500
2000
2500
3000
New cancer patients per qualified oncologist
![Page 16: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/16.jpg)
5 %
45 % 50 %
Economic spectrum in India
‘ES’ 0/1 ‘ES’ 2 ‘ES’ 3
![Page 17: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/17.jpg)
Approach toHigh Risk AML in
Young patients with Limited Resources
![Page 18: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/18.jpg)
Approach toHigh Risk AML in
Young patients with Limited Resources
![Page 19: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/19.jpg)
Approach to High Risk AML in
Young patients with Limited Resources
![Page 20: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/20.jpg)
Approach to High Risk AML in
Young patients with Limited Resources
![Page 21: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/21.jpg)
Aggressive Rx of AML in Limited Resource setting!!
![Page 22: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/22.jpg)
AML
PATIENT
![Page 23: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/23.jpg)
AML – Prognosis & Rx: Published Data !!
![Page 24: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/24.jpg)
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
![Page 25: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/25.jpg)
Prognostic Factor in AML
![Page 26: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/26.jpg)
Prognostic Factor in AML
![Page 27: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/27.jpg)
Prognostic Factor in AML:In developing Countries
FINANCIAL CONSTRAINS
![Page 28: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/28.jpg)
AML in INDIA
![Page 29: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/29.jpg)
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)
![Page 30: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/30.jpg)
AML published datafrom India
![Page 31: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/31.jpg)
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
![Page 32: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/32.jpg)
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
![Page 33: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/33.jpg)
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
![Page 34: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/34.jpg)
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
![Page 35: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/35.jpg)
Low-dose, oral metronomic Treatment for patients with
AML who are not candidates for standard-Rx
![Page 36: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/36.jpg)
Low-dose Metronomic Rx in AML
![Page 37: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/37.jpg)
Low-dose Metronomic Rx in AML
![Page 38: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/38.jpg)
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
![Page 39: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/39.jpg)
“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.”
![Page 40: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/40.jpg)
![Page 41: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/41.jpg)
28 May2001
![Page 42: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/42.jpg)
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
![Page 43: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/43.jpg)
![Page 44: Approach to Young, High Risk AML patients with Limited Resources](https://reader036.fdocuments.in/reader036/viewer/2022062323/568166b3550346895ddab87c/html5/thumbnails/44.jpg)
THANK YOU