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

2. Sawai Man Singh [SMS]
Medical College Hospital

4. Welcome to Jaipur –
The „pink‟ city of the world !!

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

10. The Cancer problem
in India
On the threshold of an „Epidemic‟!!
“Cancer Sunami”

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

13. The Economic Mismatch
in resource-limited Countries!!

14. 8.33
15.71
25.63
0.52
0.17
1.14
0.3
0.98
15.39
50
7.95
50
6.98
14.29
50.71
14
28.79
2.46
24.4
2.63
18.41
3.64
0
10
20
30
40
50
60
Egypt
LebanonPhillipines
NepalMyanmar
IranIndonesia
India
China
Armenia
Bosnia
Moldova
Georgia
Serbia
Belarus
Ukraine
Uraguay
EcuadorVenezuela
Peru
Argentina
Brazil
Ratio of no. of qualified oncologists
to population in millions

15. 80 94
459
1329
5318
635
2878
835
110
65
398
45
386
320
61
202
133
531
51
650
165
472
0
500
1000
1500
2000
2500
3000EgyptLebanonPhillipines
NepalMyanmar
IranIndonesia
India
ChinaArmenia
BosniaMoldova
Georgia
SerbiaBelarusUkraineUraguayEcuadorVenezuela
PeruArgentina
Brazil
New cancer patients per qualified oncologist

16. 5 %
45 % 50 %
Economic spectrum in India
„ES‟ 0/1 „ES‟ 2 „ES‟ 3

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

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

21. Aggressive Rx of AML in
Limited Resource setting!!

22. AML
PATIENT

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

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

25. Prognostic Factor in AML

26. Prognostic Factor in AML

27. Prognostic Factor in AML:
In developing Countries

28. AML in INDIA

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)

30. AML published data
from India

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

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

36. Low-dose Metronomic
Rx in AML

37. Low-dose Metronomic
Rx in AML

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.”

41. 28 May
2001

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

44. THANK YOU