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Question: Dr. Chiragbhai, thank you very much for helping us summarize this complex topic. In last 2 parts we covered some very interesting facts about AML and ALL treatment. BEFORE WE PROCEED, LET ME CONGRATULATE YOU FOR YOUR BOOK ON CANCER AWARENESS. What I liked most is the fact that it is in Gujarati language, and is very easy to read. This will certainly help many of our readers and patients both, and even medical students, to understand complexities of cancer evaluation and management. Book also has many pictures and tables, and colour coded pages, making it even more interesting. Over 200 pages of knowledge and a message from Hon. Narendrabhai Modi, is certainly worth a lot of congratulations. If someone is interested, who can they contact for a copy of the book?
Ans: Yes the book is in Gujarati, covering many general aspects of cancer, plus details of Breast, Gastrointestinal, and Blood cancers. It is available through publisher at 7926620472/09879500179.
Let us continue our discussion to cover Myelodysplastic syndrome treatment advances. This is a condition with many subtypes and variable prognosis. IPSS and other scoring systems help in determining prognosis. Overall, low risk patients who are likely to live several years should be treated with low intensity therapies. LOW intensity therapies include erythropoietin, G-CSF, cyclosporine, anabolic steroids, blood transfusions, azacytidine, decitabine, lenalidomide, ATG. For patients with intermediate to HIGH risk state, TRANSPLANT should be seriously considered if feasible, as these patients are likely to live few years to few months only, and have a high risk of dying from conversion to acute leukemia or from sepsis or bleeding. Transplant should preferably be done when these patients have not developed serious complications like sepsis or fungal or other infections or leukemia. Once patient has blast count over 10%, immediate transplant is much less successful in long term. First they need treatment to try and reduce blast count below preferably 5%, before proceeding for transplant. TRANSPLANT is the only curative option and for patients below 60 years, it should be seriously considered. For patients above 60 years, and reasonable fitness, RIC or reduced intensity transplant is an option in many cases. For patients without a full match from family, there are newer options like MUD or Haplo. It is important to remember that new treatments azacytidine or decitabine have improved results, but both are palliative, non curative, work in about 50-60% patients only, and that too for several months to few years, and stop working once drug is stopped. Cost is substantial, especially considering the need to continue long term. For example, even with current Indian brands available, cost is about Rs 6 lac per year plus investigations and other supportive care which may add substantial amount. On other hand, transplant from a matched sibling would cost about Rs 12-15 lac, and is not a recurring cost, plus there is potential for cure in about 40-50% patients.
For a number of patients where transplant is not feasible due to serious comorbidities, or frail state, or who do not wish to undergo transplant, these new medicines have created a very important option. A small number of patients have significant side effects, hence caution should be exercised in first cycle. On the other hand, majority tolerate it fairly well, and some can continue for long term with minimal side effects and a good quality of life.
Lenalidomide is an oral agent, which works extremely well in MDS patients with 5q deletion cytogenetic abnormality, in about 70% cases. In other cases, response is limited about 20%. Hypoplastic variant of MDS may respond to ATG and cyclosporine, as in aplastic anemia.
Risks and benefits of both low intensity therapies and transplant should be clearly discussed with patient and they should have the opportunity to meet a transplant specialist once for clear understanding.
It is important to provide good supportive care along with definitive therapies, as needed, such as erythropoietin (require much higher doses than used for renal failure patients, such as 40,000 to 80,000 units per week) or darbepoietin, G-CSF, transfusion support as needed etc. Iron chelation for patients with high ferritin is not a standard of care, but increasingly being considered. October 12th, 2014.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001.                                                                                                            Diplomate American Board of Oncology and Hematology. Ahmedabad.                                                                                                                                                                                                                                                                               Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad.                    

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