THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA.

THE DILEMMA OF

CML MANAGEMENT

IN IRAQI KURDISTAN

SHEIKHA

ProfessorAnwar SheikhaAnwar 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

>1/5th of theIRAQI

POPULATION

IRAQPOPULATION

32 MILLIONS

KRGA Proud Partof FederalIRAQ

Suly

Erbil

SULY

ERBIL

AN ARMYOF 80

HEMATOLOGISTS & ONCOLOGISTS

Patients:

30% Erbil25% Suly10% Kirkuk05% Duhok30% Rest of IRAQ

CML MANAGEMENT IN IRAQI KURDISTAN

SHEIKHA

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 effortsMore Monicas than a Japan street! More BMW than a German City!

We are seeing the effects of that economic upsurge.

FCR for CLL $45K 2 Radiation CentersExjade 1 400-bed hospital in SulyRituximab Countless Private HospitalsOncology drugs -

SecurityFor

IRAQ

SHEIKHA

برعاية بارزانى نيچيرڤان السيدالعراق حکومة کوردستان رئيس أقليم

رازيانة تقوم شرکةمرکز و مستشفى لبناء األولى ميديا بالمرحله سرطان

للعيادات ۲۰۰بسعة ومجمع لألطباء سکن مع سرير

SHEIKHA

MYDIA DIAGNOSTIC CENTER

A 50 million dollar project in Erbil


SHEIKHA

CML IN KURDISTAN

GEOGRAPHICAL DISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN

HAWLERHAWLERPATIENTSPATIENTS

““5656””

SULYSULYPATIENTSPATIENTS

““9898””

3030 HAWLERHAWLER 0606

0505 SULYSULY 5151

0606 KIRKUKKIRKUK 1818

0909 DUHOKDUHOK 0303

0404 MOSULMOSUL 0202

0000 DIYALADIYALA 0606

0000 TIKRITTIKRIT 0303

0202 OTHERS*OTHERS* 0909

*BaghdadRamadiSamaraetc

HawlerHawler

SulaimaniyaSulaimaniya

GEOGRAPHICAL DISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN

HAWLERHAWLER 30+30+0606 3636

SULYSULY 0505 +51 +51 5656

KIRKUKKIRKUK 0606 +18 +18 2424

DUHOKDUHOK 0909 +03 +03 1212

MOSULMOSUL 0404 +02 +02 0606

DIYALADIYALA 0606 0606

TIKRITTIKRIT 0303 0303

*OTHERS*OTHERS 0202 +09 +09 1111

TOTALTOTAL 154154

*BaghdadRamadiSamaraetc

AGE DISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN


““5656”” YEARSYEARS


““9898””

0303 10-1910-19 0101

1212 20-2920-29 1818

1414 30-3930-39 2222

1414 40-4940-49 1818

0909 50-5950-59 2020

0202 60-6960-69 1111

0202 70+70+ 0808

AGE DISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN

AGE RANGEAGE RANGE

10-1910-19 0303 +01 +01 0404

20-2920-29 1212 +18 +18 3030

30-3930-39 1414 +22 +22 3636

40-4940-49 1414 +18 +18 3232

50-5950-59 0909 +20 +20 2929

60-6960-69 0202 +11 +11 1313

70+70+ 0202 +08 +08 1010

TOTALTOTAL 56 + 9856 + 98 154154

AGE DISTRIBUTION OF CML PATIENTS IN AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTANIRAQI KURDISTAN

SEXDISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN


““5656””


““9898””

3030 MALEMALE 4141

2626 FEMALEFEMALE 5757

SEXDISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN

MALEMALE 30+30+4141 71 71 46%46%

FEMALEFEMALE 2626 +57 +57 8383 54% 54%

TOTALTOTAL 154154 100%100%


SHEIKHA

GLIVEC HAS EXTENDED THE LIVES OF CML PATIENTSFROM

YEARS TO DECADES

KNOWING THAT CML USUALLY AFFECTSMIDDLE-AGED PEOPLE; THIS COULD BE

CAUTIOUSLY TRANSLATED TO “cure”!

~AIDS & HAART


SHEIKHA

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 Imatinibis 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

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 Imatinibis 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


SHEIKHA

CHR 1 log reductionCCR 2 log reductionMMR 3 log reduction

4 log reduction>4 log reduction

CRKL

pho

spho

ryla

tion

(IC50

)

WT1 Expression

OKT-1 Activity


SHEIKHA

WBC/uL 100,000

CHR 1 log reduction 10,000CCR 2 log reduction 1,000MMR 3 log reduction 100

4 log reduction 10>4 log reudction ?


SHEIKHA

3 Abl Kinase Inhibitors:

Imatinib 2001

Dasatinib 2006

Nilotinib 2007


SHEIKHA

CHRONIC CHRONIC PHASEPHASE

ACCELERATEACCELERATED PHASED PHASE

BLAST BLAST CRISISCRISIS

Classical Classical TeachingTeaching

3-4 Years3-4 Years 6 months6 months Few Few Months Months

? ?WeeksWeeks


SHEIKHA

CHRONIC CHRONIC PHASEPHASE

ACCELERATEACCELERATED PHASED PHASE

BLAST BLAST CRISISCRISIS

Classical Classical TeachingTeaching

3-4 Years3-4 Years 6 months6 months Few Few Months Months ? ?WeeksWeeks

Middle Middle EastEast

> 6 Years> 6 Years 2 Years2 Years > 6 > 6 MonthsMonths


SHEIKHA


SHEIKHA

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

Are we justified to start Glivec without cytogentic analysis?


SHEIKHA


Are we justified to continue Glivec without proper molecular follow up?


SHEIKHA



Can we count on response to Glivec to predict Ph positivity?


SHEIKHA




Until we stand on our feet, what is wrong with blind use of Glivecas long as the patient responds?


SHEIKHA





When in crisis, seek the alternative.


SHEIKHA





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 involvedin flooding the Iraqi market with the Indian Glivec? How effective isthe Indian Imatinib?


SHEIKHA

THANKS FROMIRAQ & KRG


SHEIKHA

THANK YOUTHANK YOU


SHEIKHA

THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA.

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