Haematological malignanices in Adults in Malawi

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Haematological malignanices in Adults in Malawi

• What can we do now?

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Introduction
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How common are haematological malignancies in
Malawi?
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Leukaemia in Malawi

• QECH 1994-1998
• 95 leukaemia patients
• child- 27 adult- 68
• ALL 14
• AML 25
• CML 32
• CLL 22

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Lymphoma in Malawi

• Undoubtedly under-diagnosed
• -not biopsied-unable to biopsy-not suspected
  (eg. abdominal disease)-late presentation

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My experience

• 1 year- morphology proven diagnoses at QECH
• Non Hodgkins lymphoma 11
• Hodgkins lymphoma 3
• CLL 12
• CML 4
• Acute leukaemias 9
• Myeloma 10
• Other 3

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Barriers to treatment

• Diagnosis
• Cost of drugs?- not necessarily(1 course CVP
  1730 MWK)
• Procurement of drugs
• Supportive care/ investigation facilities
• Staff training/experience/time

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Barriers to treatment

• Patient location transport
• Emergency care arrangements
• Patient understanding

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What treatments are feasible
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Levels of treatment intensity

• Neutropenia is most important limiting factor.
• 0Regimens where neutropenia not expected
• 1Regimens where neutropenia expected but brief
  duration (4-5 days)
• 2 Regimens causing prolonged neutropenia/ marrow
  suppression (2-3 weeks)

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Level 0 neutropenia unexpected

• Examples-Myeloma-Chronic lymphocytic
  leukaemia-Low grade (follicular) lymphoma
  -Chronic myeloid leukaemia-ALL maintenance
• Generally can obtain remission but not cure
  disease

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Case history

• 55 y/o lady from Chiradzulu
• L tibia pathological fracture, lytic lesions
  typical of myeloma, bony pain
• Anaemic symptoms, Hb5.6
• Rx weekly oral cyclophosphamide 400mg/m2, monthly
  o/p review
• 4/12 later pain control better (still pain at
  healing fracture site). Hb improved-

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Summary

• This level of treatment can be safely provided
  with existing facilities
• General physicians could provide this level of
  care with appropriate training and support
• Treatment may be months/indefinite, it can be
  difficult to persuade patients to come for follow
  up.

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Level 1 brief neutropenia

• Examples-High grade non-Hodgkin's
  lymphoma-Hodgkin's disease
• Combination chemotherapy regimens
• Normally can be given as outpatient treatment

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BCSH Level 1 requirements

• Staffing-24 h availability of junior staff on
  site
• -Protocols for common emergencies-Consultant
  haematologist available for advice at all
  times-Nurse has experience of haematology-Enough
  nursing staff to give medication at correct times

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BCSH Level 1 requirements

• Facilities-Haematology, transfusion,
  biochemistry on site-Cytotoxic drug handling
  facility and experienced pharmacist on
  site-Access to necessary antimicrobials,
  antiemetics etc.
• Protocols-cytotoxic drug handling, transfusion,
  pyrexia, infection control

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Case history 1

• 22 year old HIV student- 8cm node mass L groin,
  3 cm R groin. Hodgkins disease
• Staging CT showed no disease elsewhere
• 2 cycles OPA, 4 cycles COP, 2 weekly O/P
  attendance.
• Obtained complete remission
• Difficulties nausea, treatment delay
  (unavailable drugs), dystonic reaction
  (metoclopramide)
• Has probably got 80 chance of cure now

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Case history 2

• 37 y/o with massive neck swelling
• Friday morning- distressed, difficulty
  maintaining airway
• Tracheostomy. Reduced dose CVP
• Good partial remission
• Tracheostomy became infected
• Died 2 weeks after treatment

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Case history 3

• 36 year old lady
• 2cm neck node- "high grade NHL" Stage IA
• HIV presenting illness
• Commenced ARV, started CVP chemotherapy complete
  remission
• d13- admitted with neutropenic sepsis
• severely unwell
• died 1 month after starting treatment

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Lower intensity treatments for high grade
lymphomas

• Data from early 1970s
• CHOP- 60CR
• CVP- 44 CR
• Cyclo- 14CR (71 overall response)
• Vincristine- 9CR (35 overall response)
• CEPP- 40 CR (relapsed patients)

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Level 1 treatment

• Conditions are not ideal yet for this level of
  treatment.
• Patient selection according to prognosis is
  important here- trade off between theoretical
  efficacy and toxicity.
• Performance status, CD4 count, extent of disease
  and ability to comply with treatment are
  important factors to consider.

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Level 2 prolonged neutropenia

• Induction treatment for acute leukaemias
• AML consolidation treatment
• Mostly inpatient treatment
• Severe emesis
• Expected neutropenic sepsis
• Risk of opportunistic infections
• Intensive transfusion support (RBC, platelets
  almost daily)

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Any hope for acute leukaemias?
Low dose ara-C in elderly patients
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Newer approaches?

• Some non-cytotoxic drugs are attractive options
• Drug costs and supply are limiting here
• Imatinib for CML (free donation programme but
  needs molecular diagnosis)
• Thalidomide for myeloma
• Retinoic acid for promyelocytic leukaemia

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What I am offering at QECH

• I'm always happy to discuss patients
• New patients should be admitted under dept. of
  Medicine for initial workup
• Patients must be able to attend subsequent follow
  up
• There must be a named contact in local healthcare
  facility for patients from distant regions for
  liaison/ emergency care

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What I am offering at QECH

• Currently-Hodgkins disease "definitive
  treatment"-NHL Intravenous treatment x 1 to
  acheive rapid disease control then oral
  chemotherapy. This should be explained to
  patients as "palliative care"-Myeloma/CML/CLL
  oral chemotherapy, which is acceptable
  treatment.-AML palliative care only at present,
  study of LD ara C is being designed.

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Who should be referred abroad

• Lymphoma with localised disease good prognosis
  with localised radiotherapy plus chemotherapy.
• High grade lymphomas if possible, especially if
  good prognostic features
• Acute leukaemia (but will be very expensive)
• Important that referral is for whole treatment
  not just 1 course chemotherapy

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Ethical questions

• Haematological malignancy is important disease
  burden but not the largest public health problem
• Important not to take resources away from more
  prevalent concerns
• What should be strategy? concentrate on curable
  patients? offering some treatment to maximum
  number? improving general healthcare environment
  and supportive/palliative care

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Summary

• Haematological malignancies are an important
  disease burden in adults and are underdiagnosed.
• Many patients can receive useful treatment with
  current resources and a small investment would
  greatly expand this.

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Summary

• Organisation and human resources are the most
  important limiting factors.
• Cancer care will always need more resources, a
  clear and realistic strategic policy is needed.
• "Primum non nocere" is an important guiding
  principle this applies to patients but also
  healthcare systems.

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