Transcript Z._CML_IRAQI_KURDISTAN_EXPERIENCE_Istanbul

THE DILEMMA OF
CML
MANAGEMENT
IN
IRAQI KURDISTAN
SHEIKHA
Professor
Anwar 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
KRG
A Proud
Part
of Federal
IRAQ
IRAQ
POPULATION
32 MILLIONS
Erbil
>1/5th
of the
IRAQI
POPULATION
Suly
SULY
AN ARMY
OF 80
HEMATOLOGISTS
& ONCOLOGISTS
ERBIL
Patients:
30%
25%
10%
05%
30%
Erbil
Suly
Kirkuk
Duhok
Rest of IRAQ
CML MANAGEMENT IN IRAQI KURDISTAN
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 efforts
More Monicas than a Japan street!
More BMW than a German City!
Security
For
IRAQ
We are seeing the effects of that economic upsurge.
FCR for CLL  $45K
Exjade
Rituximab
Oncology drugs
2 Radiation Centers
1 400-bed hospital in Suly
Countless Private Hospitals
-
SHEIKHA
‫ﺒﺭﻋﺎﻴﺔ ﺍﻟﺴﻴﺩ ﻨﻴﭽﻴﺭﭭﺎﻥ ﺒﺎﺭﺯﺍﻨﻰ‬
‫ﺭﺌﻴﺱ ﺤﮑﻭﻤﺔ ﺃﻗﻟﻴﻡ ﮐﻭﺭﺩﺴﺘﺎﻥ ﺍﻟﻌﺭﺍﻕ‬
‫ﺗﻘﻮﻢ ﺷﺭﮐﺔ ﺭﺍﺰﻳﺎﻧﺔ‬
‫ﺒﺎﻟﻤﺮﺤﻠﻪ ﺍﻷﻮﻟﻰ ﻠﺒﻨﺎﺀ ﻤﺴﺘﺸﻔﻰ ﻮ ﻤﺭﮐﺯ ﺴﺭﻁﺎﻥ ﻤﻴﺪﻴﺎ‬
‫ﺒﺴﻌﺔ ‪ ۲۰۰‬ﺴﺭﻴﺭ ﻤﻊ ﺴﮑﻥ ﻠﻸﻁﺒﺎﺀ ﻭﻤﺠﻤﻊ ﻠﻠﻌﻴﺎﺩﺍﺕ‬
‫‪SHEIKHA‬‬
MYDIA DIAGNOSTIC CENTER
A 50 million dollar project in Erbil
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
CML
IN KURDISTAN
SHEIKHA
GEOGRAPHICAL
DISTRIBUTION
OF
CML PATIENTS
IN
IRAQI
KURDISTAN
*
Baghdad
Ramadi
Samara
etc
HAWLER
SULY
PATIENTS
PATIENTS
“56”
“98”
30
HAWLER
06
05
SULY
51
06
KIRKUK
18
09
DUHOK
03
04
MOSUL
02
00
DIYALA
06
00
TIKRIT
03
02
OTHERS*
09
Hawler
Sulaimaniya
GEOGRAPHICAL
DISTRIBUTION
OF
CML PATIENTS
IN
IRAQI
KURDISTAN
*
Baghdad
Ramadi
Samara
etc
HAWLER
30+06
36
SULY
05 +51
56
KIRKUK
06 +18
24
DUHOK
09 +03
12
MOSUL
04 +02
06
DIYALA
06
06
TIKRIT
03
03
02 +09
11
*OTHERS
TOTAL
154
AGE
DISTRIBUTION
OF
CML PATIENTS
IN
IRAQI
KURDISTAN
HAWLER
SULY
PATIENTS
PATIENTS
“56”
YEARS
“98”
03
10-19
01
12
20-29
18
14
30-39
22
14
40-49
18
09
50-59
20
02
60-69
11
02
70+
08
AGE
DISTRIBUTION
OF
CML PATIENTS
IN
IRAQI
KURDISTAN
AGE RANGE
10-19
03 +01
04
20-29
12 +18
30
30-39
14 +22
36
40-49
14 +18
32
50-59
09 +20
29
60-69
02 +11
13
70+
02 +08
10
TOTAL
56 + 98
154
AGE DISTRIBUTION OF CML PATIENTS IN
IRAQI KURDISTAN
SEX
DISTRIBUTION
OF
CML PATIENTS
IN
IRAQI
KURDISTAN
HAWLER
SULY
PATIENTS
PATIENTS
“56”
“98”
30
MALE
41
26
FEMALE
57
SEX
DISTRIBUTION
OF
CML PATIENTS
IN
IRAQI
KURDISTAN
MALE
30+41
71
46%
FEMALE
26 +57
83
54%
154
100%
TOTAL
CML MANAGEMENT IN IRAQI KURDISTAN
GLIVEC HAS EXTENDED THE LIVES OF CML PATIENTS
FROM
YEARS TO DECADES
KNOWING THAT CML USUALLY AFFECTS
MIDDLE-AGED PEOPLE; THIS COULD BE
CAUTIOUSLY TRANSLATED TO
“cure”!
~AIDS & HAART
SHEIKHA
CML MANAGEMENT IN
IRAQI KURDISTAN
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 Imatinib
is 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
CML MANAGEMENT IN
IRAQI KURDISTAN
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 Imatinib
is 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.
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
CHR 1 log reduction
CCR 2 log reduction
MMR 3 log reduction
4 log reduction
>4 log reduction
SHEIKHA
WT1 Expression
OKT-1 Activity
CML MANAGEMENT IN IRAQI KURDISTAN
WBC/uL
100,000
CHR 1 log reduction
CCR 2 log reduction
MMR 3 log reduction
4 log reduction
>4 log reudction
10,000
1,000
100
10
?
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
3 Abl Kinase Inhibitors:
Imatinib
2001
Dasatinib
2006
Nilotinib
2007
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
CHRONIC
PHASE
Classical
Teaching
3-4 Years
ACCELERATED BLAST
PHASE
CRISIS
6 months
Few
Months
?Weeks
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
Classical
Teaching
CHRONIC
PHASE
ACCELERATED BLAST
PHASE
CRISIS
3-4 Years
6 months
Middle East > 6 Years
2 Years
Few
Months
?Weeks
>6
Months
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN
IRAQI KURDISTAN
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
CML MANAGEMENT IN IRAQI KURDISTAN
Are we justified to start Glivec without cytogentic analysis?
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
Are we justified to start Glivec without cytogentic analysis?
Are we justified to continue Glivec without proper molecular follow up?
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
Are we justified to start Glivec without cytogentic analysis?
Are we justified to continue Glivec without proper molecular follow up?
Can we count on response to Glivec to predict Ph positivity?
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
Are we justified to start Glivec without cytogentic analysis?
Are we justified to continue Glivec without proper molecular follow up?
Can we count on response to Glivec to predict Ph positivity?
Until we stand on our feet, what is wrong with blind use of Glivec
as long as the patient responds?
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
Are we justified to start Glivec without cytogentic analysis?
Are we justified to continue Glivec without proper molecular follow up?
Can we count on response to Glivec to predict Ph positivity?
Until we stand on our feet, what is wrong with blind use of Glivec
as long as the patient responds?
When in crisis, seek the alternative.
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
Are we justified to start Glivec without cytogentic analysis?
Are we justified to continue Glivec without proper molecular follow up?
Can we count on response to Glivec to predict Ph positivity?
Until we stand on our feet, what is wrong with blind use of Glivec
as long as the patient responds?
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 involved
in flooding the Iraqi market with the Indian Glivec? How effective is
the Indian Imatinib?
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
THANKS FROM
IRAQ & KRG
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
THANK YOU
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
THANK YOU
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA