The 2011 iCMLf Forum

CML Management in Emerging Economic Regions

Presented in partnership with The Max Foundation

The 2011 iCMLf Virtual Education Program is supported by an unrestricted grant from Novartis Oncology

Management of CML in Young Patients and in Children

Dr Ximena Jordan Bruno

Bolivia

• Located in the center of South America

• Population of ~10 million

• It has a varied geography and is divided into three zones: High mountain , valleys, and tropical zones

• The tropical zone is more than the half of the country, with 4 million inhabitants

BOLIVIA

Bolivia

Map of Bolivia and Bordering Countries

Hematology in Bolivia

• There are ~35 hematologists in Bolivia

• 25 of these are working in La Paz and in the high mountain zone

• Only 5 hematologists work within the tropical zone

• All Bolivian hematologists have performed their training in other countries, such as; France, Mexico, Brazil, Argentina, and Uruguay

• The Health System is divided into: Public Health, Social Security, and Private.

• The Social Security portion provides medical care to 40 % of the population

• In Santa Cruz it counts for approximately 500,000 habitants

• The biggest Social Security hospital in Santa Cruz is the hospital Obrero with only one hematologist

Health System in Bolivia

Health System and coverture to Cancer Medication

• THERE IS NO HEALTH INSURANCE in Bolivia providing IMATINIB, or other TKIs to their CML patients

• The only way for our patients to receive proper medications is thru GIPAP and the Max Foundation

• The Hematology Society is currently working on Bolivian Senate legislation to include Imatinib as essential medication

CML patients in Bolivia

• There are approximately 200 patients with the CML disease in Bolivia

• More than 100 receive Imatinib from GIPAP

• 50 of these patients live within the tropical zone• There are still patients without proper diagnosis in some places

of our country; such as remote forest locations and populations located in the altiplano

• Unfortunately, we still have patients that do not receive proper

treatment

Diagnosis

• Bolivia as a country does not have CITOGENETIC ANALYSIS .

• There is only one center located in La Paz which can perform QUALITATIVE PCR. This helps us with confirming diagnosis, but we do not have a correct way to follow-up with these patients

• We are now trying to send samples to Argentina for CYTOGENETIC and QUANTITATIVE PCR .

CML in young adults and in children

• We have 50 patients in the Tropical Zone

• More than 50 % of them are younger than 45 years old

• Posing a challenge to us is one pediatric patient. The challenge exists since it is very rare within this age group, and there is a lack of documented research

• Age: 8 year old female

• Absolutley healthy prior to the disease

• She went to her pediatrician for having fatigue, pallor,abdominal pain, and demonstrating anormal hemorraging after a molar extraction .

• At physical examination was found: Pallor of skin mucosae, and splenomegaly

Dr. Macias , Dr Jordan

CML in a 8 year old child

Case

Labs : • WC : 275,900 Hb : 8.6 PLT : 2,897,000

Bone Marrow Aspiration: Myeloproliferative Disorder compatible with Chronic Myeloid Leukemia in its Chronic Phase .

Confirmatory diagnosis was performed by cytogenetic analysis, and PCR in both Bolivia and Chile

The patient’s only sister is not HLA compatible

Treatment

• She received Hydroxiurea and Imatinib initially, and after she was stable continued with Imatinib 300 mg day

• She achieved hematological response in 3 months

• Asintomatic and having a normal life .

• The mother states that the patient has not grown normal this year

• Patient is about to complete one year of treatment

Evolution

2011

Mar. May June Aug. Sept. Oct. Dec.

WC 4.100 6.100 5.600 4.000 5.100 4.900 3.900

HB 11.3 10.7 11.7 12 11 11.9 11

PLT 251.000 180.000 164.000 139.000 164.000 170.000 200.000

QUALITATIVE PCR IN MARCH , MAY , DECEMBER : All positive

Future

• Depending on the Cytogenetic Response :

• Continue treatment with Imatinib

• Consider the new TKIS

• Consider Bone Marrow Transplantation ( Non related )

GIPAP SANTA CRUZ

Thank you ICML foundation and Dr Cortez for an incredible and valuable experience at the MD Anderson Cancer Center