(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Dr. Chiragbhai, thank you very much for helping us summarize this complex topic. In last 2 parts we covered treatment advances including some very exciting news for CML, CLL, Hodgkin’s, Non Hodgkin’s lymphoma and Myeloma. 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. 208 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 to obtain a copy of the book?
Ans: Thank you. Yes the book is written in Gujarati, covering many general aspects of cancer, plus details of Breast, Gastrointestinal, and Blood cancers. It is available through publisher at 07926620472/09879500179.
Let us continue with treatment advances in Acute Leukemias:
ACUTE MYELOID LEUKEMIA: In this field, initial treatment i.e. induction chemotherapy has remained same for last several decades i.e. daunorubicin and Ara-C. However, overall long term survival has improved remarkably from 10% to 50%, due to a combination of two main reasons: FIRST is the significant advances in supportive care, resulting in much better survival from initial therapy. This includes better understanding of risks of treatment, antibiotics, antifungals, nursing care, isolation precautions like rooms with HEPA filter etc. SECOND big reason is addition of upfront transplant, in patients with medium or high risk cytogenetics. Survival in these groups increased from average 40% (medium risk) and 10% (high risk) to now 70% and 40% respectively by adding upfront transplant i.e. right after induction. Transplant has also seen a lot of improvements in last few decades, resulting in much better safety and efficacy both. Plus now there are more sources for stem cells i.e. if a 6/6 sibling match is not available, voluntary donor registry or 3/6 family match transplants are also feasible. Also, due to increasing safety, transplant is now possible for even older patients, such as over 60 years age as well. ALL NEWLY DIAGNOSED AML PATIENTS SHOULD BE EVALUATED ONCE AT A TRANSPLANT CENTER TO MAKE SURE RELEVANT PLANNING IS DONE WELL IN ADVANCE, IN CASE A TRANSPLANT MAY BE REQUIRED LATER. SOME IMPORTANT TESTS MUST BE COLLECTED AT DIAGNOSIS FOR THIS PLANNING, otherwise this critical piece of information is lost forever. For example, if FLT 3 or cytogenetics is not sent at diagnosis, these tests cannot be sent after induction. Patients with FLT 3 positive OR with high risk cytogenetics, have a 90% chance of relapse with standard treatment, hence they should be transplanted whenever feasible, immediately after induction.
Acute promyelocytic leukemia (M3 type AML) however has seen some major advances in initial therapy with use of ATRA and Arsenic. This leukemia can now be cured in some patients without chemotherapy, and better cure rates in other patients by adding these new agents.
Similarly, now for patients with relapsed leukemia, there are better salvage therapies available, to be followed by transplant. Hence relapsed leukemia also can now be cured in a significant proportion of patients, where earlier it was nearly impossible. For elderly patients with AML, now azacitidine or decitabine can be used in place of standard chemotherapy to provide control for few months to years.
ACUTE LYMPHOID LEUKEMIA: Pediatric ALL results have improved remarkably over last few decades, with cure rates of 60-90% frequently possible, with new regimens.
Children with ALL must be treated as the cure rates are so high.
Adult ALL cure rates however are still in the range of about 40%. But those with Philadelphia chromosome positive can be controlled for many years with addition of imatinib or dasatinib. Earlier this group survival was very poor. Relapsed ALL or those with high risk prognostic markers should be offered transplant.
September 10th, 2014.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001.
Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com