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THE DILEMMA OF
CML MANAGEMENT
IN IRAQI KURDISTAN
SHEIKHA
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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
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>1/5th of theIRAQI
POPULATION
IRAQPOPULATION
32 MILLIONS
KRGA Proud Partof FederalIRAQ
Suly
Erbil
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SULY
ERBIL
AN ARMYOF 80
HEMATOLOGISTS & ONCOLOGISTS
Patients:
30% Erbil25% Suly10% Kirkuk05% Duhok30% Rest of IRAQ
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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
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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
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SHEIKHA
MYDIA DIAGNOSTIC CENTER
A 50 million dollar project in Erbil
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CML IN KURDISTAN
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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
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HawlerHawler
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SulaimaniyaSulaimaniya
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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
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AGE DISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN
HAWLERHAWLERPATIENTSPATIENTS
““5656”” YEARSYEARS
SULYSULYPATIENTSPATIENTS
““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
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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
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AGE DISTRIBUTION OF CML PATIENTS IN AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTANIRAQI KURDISTAN
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SEXDISTRIBUTION OF CML PATIENTSIN IRAQI KURDISTAN
HAWLERHAWLERPATIENTSPATIENTS
““5656””
SULYSULYPATIENTSPATIENTS
““9898””
3030 MALEMALE 4141
2626 FEMALEFEMALE 5757
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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%
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CML MANAGEMENT IN IRAQI KURDISTAN
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
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CML MANAGEMENT IN IRAQI KURDISTAN
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.
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CML MANAGEMENT IN IRAQI KURDISTAN
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
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
CHR 1 log reductionCCR 2 log reductionMMR 3 log reduction
4 log reduction>4 log reduction
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CRKL
pho
spho
ryla
tion
(IC50
)
WT1 Expression
OKT-1 Activity
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CML MANAGEMENT IN IRAQI KURDISTAN
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 ?
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
3 Abl Kinase Inhibitors:
Imatinib 2001
Dasatinib 2006
Nilotinib 2007
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CML MANAGEMENT IN IRAQI KURDISTAN
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
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CML MANAGEMENT IN IRAQI KURDISTAN
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
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
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
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
Are we justified to start Glivec without cytogentic analysis?
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
Are we justified to start Glivec without cytogentic analysis?
Are we justified to continue Glivec without proper molecular follow up?
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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?
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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 Glivecas long as the patient responds?
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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 Glivecas long as the patient responds?
When in crisis, seek the alternative.
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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 Glivecas 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 involvedin flooding the Iraqi market with the Indian Glivec? How effective isthe Indian Imatinib?
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
THANKS FROMIRAQ & KRG
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
THANK YOUTHANK YOU
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
THANK YOUTHANK YOU
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA
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CML MANAGEMENT IN IRAQI KURDISTAN
SHEIKHA