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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 644-645

Navigating the financial impasse in acute myeloid leukemia: Prednisolone, etoposide, and 6-mercaptopurine metronomic chemotherapy

Department of Haemato-Oncology, Kingston Hospital NHS Foundation Trust; Lead for Commercial Education and Training, Haematology Institute, King's College Health Partners; King's College, London, UK

Date of Submission30-Jun-2020
Date of Decision05-Jul-2020
Date of Acceptance24-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Vishal Jayakar
Kingston Hospital, Kingston upon the Thames, London KT27QB, England
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_227_20

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How to cite this article:
Jayakar V. Navigating the financial impasse in acute myeloid leukemia: Prednisolone, etoposide, and 6-mercaptopurine metronomic chemotherapy. Cancer Res Stat Treat 2020;3:644-5

How to cite this URL:
Jayakar V. Navigating the financial impasse in acute myeloid leukemia: Prednisolone, etoposide, and 6-mercaptopurine metronomic chemotherapy. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 22];3:644-5. Available from: https://www.crstonline.com/text.asp?2020/3/3/644/295555

Acute myeloid leukemia (AML) therapeutics is in the golden period of renaissance with eight new drugs approved by the Food and Drug Administration in the last two years and several others in the pipeline, after a long spell of clinical nihilism with no drug approvals over the past decade.[1] This has led to a renewed enthusiasm in this hemato-oncological domain, thus reenergizing and galvanizing the AML narrative. Unfortunately, the original article by Pandey etal. is a humble and sobering reminder of the inequity of resources across the globe and highlights the stark disparity in clinical practice in the western world vis-à-vis the deprived state in upcoming economies like India.[2]

This study alludes to the institutional practice of using the prednisolone, etoposide, and 6-mercaptopurine oral chemotherapy regimen in patients with AML aged 19–53 years.[3],[4] The most striking aspect is the resolve and resilience of this team in treating these patients despite arduous financial, infrastructural, and workforce challenges. A single faculty member with a junior resident managing an outpatient volume of 100 patients in a day is unthinkable and untenable in the western world.

The regimen in itself cannot be recommended nor established as “standard of care” for the various shortcomings mentioned by the authors: small sample size and the retrospective nature of the analysis being the primary ones. This regimen is a complete departure from the standard AML treatment for the patient cohort included in this study, i.e., a median age of 41 years. In such patients, high-dose intensive induction (cytarabine and daunorubicin [DA] or CPX-351 chemo) with targeted agents where possible (fms-like tyrosine kinase 3 and isocitrate dehydrogenase 1/2 inhibitors, antibodies such as myrelotarg, etc.) and consolidation with stem cell transplant in select cases would be the norm.[1]

However, practicing in the embittering clinical circumstances (poorest Indian state with poverty exceeding 42%) that these clinicians combat on a daily basis, a regimen that costs $18/month with an overall survival of 9–12 months and a favorable toxicity profile seems like a viable and reasonable alternative, albeit far from ideal. The role of this regimen in the small subset of patients (4 in the study) post-DA (3 + 7) chemo as maintenance is interesting and needs further investigation in the premise of a structured and randomized clinical trial.

They say,“'When life gives you lemons, make lemonade.” This team seems to have strived to achieve some of that, seeking clinical creativity amidst adversity. Both, the team and the editors, need to be lauded for their effort and permissiveness in publishing, respectively, since what this article truly harbors is an outcry against the current sociopolitical and governance failures in allocating health as a primary birth right for every citizen.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bohl SR, Bullinger L, Rücker FG. New targeted agents in acute myeloid leukemia: New hope on the rise. Int J Mol Sci 2019;20:1983.  Back to cited text no. 1
Philip CC, Mathew A, John MJ. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  Back to cited text no. 2
  [Full text]  
Pandey A, Deshpande P, Singh A, Singh S, Murari K, Aryan R. Oral prednisolone, etoposide, 6-mercaptopurine (PREM) metronomic chemotherapy in treatment naïve and partially treated acute myeloid leukemia in a resource constrained setting. Cancer Res Stat Treat 2020;3:172-82.  Back to cited text no. 3
  [Full text]  
Nayak L. Optimizing acute leukemia treatment in resource-constrained settings. Cancer Res Stat Treat 2020;3:287-9.  Back to cited text no. 4
  [Full text]  


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