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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 3
| Issue : 3 | Page : 645-646 |
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Challenges in managing acute leukemia in India
Tapan Saikia
Department of Medical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
| Date of Submission | 30-Jun-2020 |
| Date of Decision | 05-Jul-2020 |
| Date of Acceptance | 09-Jul-2020 |
| Date of Web Publication | 19-Sep-2020 |
Correspondence Address:
Tapan Saikia
Prince Aly Khan Hospital, Mazgaon, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/CRST.CRST_226_20
How to cite this article:
Saikia T. Challenges in managing acute leukemia in India. Cancer Res Stat Treat 2020;3:645-6 |
How do we react when we are confronted with a Hobson's choice, especially when managing patients with acute leukemia in India? The courageous ones with a positive frame of mind always find a way. Often, the goal of treating cancers in resource-constrained settings is the improvement of the quality of life, as very intensive therapy cannot be provided to majority of the patients.[1],[2],[3] Given this scenario, two articles published by Pandey et al. in the journal, one on oral agents in patients with acute myeloid leukemia (AML) and the other on minimal residual disease (MRD) in B-cell acute lymphoblastic leukemia (ALL), are noteworthy. [4,5] At the outset, we appreciate the efforts of the young team and hope they will continue to work and publish in this area. An accompanying editorial looks at both papers, which is not an easy task.[6]
A retrospective analysis has several limitations. We will restrict our comments only to a few relevant ones and we hope that the young authors take this as constructive criticism. In the article regarding the management of patients with newly diagnosed AML with an oral combination of prednisolone, 6-mercaptopurine, and etoposide, the authors have mentioned about the cost of the chemotherapy drugs alone, but not the cost of supportive care.[4] Apparently, some of the patients were managed in private institutes at times. It is well known that supportive care contributes to a major portion of the total cost of management of AML;[7] someone pays, and this should be analyzed. In addition, a cost and cost–benefit analysis is a very complicated issue and needs insights from people involved in the field.[8] We presume that the patients required plenty of blood components and antimicrobials during the 3 months of therapy, after which the response assessment was done. Although the inclusion of corticosteroids in the treatment has somein vitro rationale, it could be deleterious as corticosteroids increase the risk of fungal infections significantly. Second, the complete remission rate of 45% at 1 year is remarkable, as is the 1 year overall survival reported by the authors;[9] I hope that the authors have included all 'intent to treat' patients. The authors have mentioned that all the patients were included; however, after treating thousands of AML patients, it is clear in our experience that several of these patients are not fit for any therapy. Upon censoring, the results look promising, but it becomes impossible to improve upon them in the subsequent studies. This is a self-created trap that young investigators fall into.
In the second study, the authors report on minimal/measurable residual disease (MRD) in a cohort of B-cell ALL.[5] At present, MRD is considered the most important prognostic factor in ALL. Equally important are the age, cytogenetics, and known molecular abnormalities.[10] The technology for detection of MRD in ALL is evolving rapidly; it includes multipanel immunophenotyping and polymerase chain reaction-based molecular techniques. Efforts are also focused on euroflow, a flow cytometry platform, to detect >5 log cell kill.[11] In this study, the authors outsourced the testing of the day-35 induction therapy marrow samples to an accredited laboratory. The authors could have divided the cohort according to age groups, such as 1–9 years and older. This would have further strengthened the results. In addition, we believe that the time has come to move beyond MCP-841 protocols. The cost of high dose cytarabine along with supportive care is not negligible. Perhaps high-dose methotrexate will cost the same, as the risk of infections following this agent is low. It is equally important to bring in other drugs incorporated in intermediate- and high-risk patients.
In conclusion, it is a pity that in Third World countries, we cannot use novel drugs that have begun to change the landscape of management of acute leukemia.[12],[13],[14]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Philip CC, Mathew A, John M J. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  [Full text] |
| 2. | Kumar K, Radhakrishnan V, Dhanushkodi M, Kalaiyarasi JP, Mehra N, Kumar AR, et al. Oral etoposide and cyclophosphamide: A low-cost palliative metronomic chemotherapy in advanced pediatric cancers. Cancer Res Stat Treat 2020;3:64-8. [Full text] |
| 3. | Amegan-Aho KH. Surviving on less. Cancer Res Stat Treat 2020;3:87-8. [Full text] |
| 4. | 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. [Full text] |
| 5. | Pandey A, Ahlawat S, Singh A, Singh S, Murari K, Aryan R. Outcomes and impact of minimal residual disease (MRD) in pediatric, adolescent and young adults (AYA) with acute lymphoblastic leukemia treated with modified MCP 841 protocol. Cancer Res Stat Treat 2020;3:183-91. [Full text] |
| 6. | Nayak L. Optimizing acute leukemia treatment in resource-constrained settings (Editorial). Cancer Res Stat Treat 2020;3:287-9. [Full text] |
| 7. | Rees JK, Gray RG, Wheatley K. Dose intensification in acute myeloid leukemia: Greater effectiveness at a lower cost. Principal report of the medical research council's AML9 study: MRC Leukemia in adults working party. Br J Haematol 1996;94:89-98. |
| 8. | Fung A, Horton S, Zabih V, Denburg A, Gupta S. Cost and cost-effectiveness of childhood cancer treatment in low-income and middle-income countries: A systematic review. BMJ Glob Health 2019;4:e001825. |
| 9. | Singh G, Mathur A, Rastogi N, Malhotra H. Low dose metronomic chemotherapy in patients of acute myeloid leukemia. Astrocyte 2017;4:64. |
| 10. | Lustosa de Sousa DW, de Almeida Ferreira FV, Cavalcante Félix FH, de Oliveira Lopes MV. Acute lymphoblastic leukemia in children and adolescents: Prognostic factors and analysis of survival. Rev Bras Hematol Hemoter 2015;37:223-9. |
| 11. | Theunissen P, Mejstrikova E, Sedek L, van der Sluijs-Gelling AJ, Gaipa G, Bartels M, et al. Standardized flow cytometry for highly sensitive MRD measurements in B-cell acute lymphoblastic leukemia. Blood 2017;129:347-57. |
| 12. | Rowe JM, Tallman MS. How I treat acute myeloid leukemia. Blood 2010;116:3147-56. |
| 13. | DiNardo CD, Wei AH. How I treat acute myeloid leukemia in the era of new drugs. Blood 2020;135:85-96. |
| 14. | Rafei H, Kantarjian HM, Jabbour EJ. Recent advances in the treatment of acute lymphoblastic leukemia. Leuk Lymphoma 2019;60:2606-21. |
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