Management of multiple myeloma in a resource-constrained setting
Dr Henry Ddungu - Uganda Cancer Institute, Kampala, Uganda
Can you tell us about your presentation today on Management of Multiple Myeloma in a Resource Constrained Setting?
We were talking about how to manage patients with multiple myeloma given the limited resources and to emphasise the fact that multiple myeloma is a common condition, especially in our setting of Sub-Saharan Africa. Also to tell them that it’s very, very important to make a diagnosis early enough, to start treatment early enough and to be able to risk stratify the disease into favourable risk and unfavourable risk so that we are able to choose the best treatment options.
We are discussing the challenges associated with all of these because in health systems like those of Sub-Saharan Africa, there are a number of limitations, for example, diagnostics. We talk about doing molecular studies to stratify patients into different risk groups, but many centres in Sub-Saharan Africa are not able to do that. Yet, evidence shows that if you are able to stratify someone into those groups, you treat them differently and probably get a better outcome. So those are challenges.
Other things like imaging – in most centres you talk about a total body CT-scan or MRI or PET scans, but I can assure you many centres don’t have that. So the message is, much as we don’t have these, what can we use that we have to help improve? But also not to forget that we need to advocate with our governments, with our funders, to move a step ahead towards achieving that. We don’t want to lay back and relax that, for us, we don’t have resources, we are going to continue like this. The goal is to move towards better myeloma outcomes despite restricted resources.
What message would you give to your colleagues working with Multiple Myeloma in Africa?
I want to emphasise the fact that we need to make a diagnosis early. I don’t believe we should wait for when someone has the so-called CRAB criteria. By this I mean when someone has developed broken bones, their kidneys are not working, they have anaemia. There is growing evidence that if you start early, before someone gets all those complications, the outcome is better.
So the message to all the people treating patients, especially in Sub-Saharan Africa, is to really look out for the disease as soon as possible and start treatment. Also to emphasise to everyone that the treatment should be the best available. If we can afford to give three combinations of drugs at a minimum we should do that. If we are able to add more medicines then we can do that. But we cannot afford not to treat patients because of fear of complications, because of fear of these few medicines that we have. Many people can access, for example, a cheap medicine called thalidomide, it’s not used in other countries. We can all afford to get dexamethasone, which is a steroid, and bortezomib which is a proteasome inhibitor. So, at a minimum, all centres should be able to access those and treat patients accordingly.
Is there anything else you would like to add?
What I want to emphasise is that if we work through collaborations with the limited resources we might be able to achieve even more because standard of care for multiple myeloma includes starting someone on treatment, what we call induction, and then giving them a transplant, an autologous transplant, followed by maintenance treatment. Of course, many centres here in Africa we cannot do transplants, even the simple autologous transplants. So if we have collaborators that can help us get affordable but effective treatments, that would be great.
I think within Africa we can identify centres of excellence that we can work with to be able to start somewhere. Because it may be cheaper, for example, if I’m from the East African region and we have a bone marrow transplant centre in the region, we can work together to utilise that service and get the best outcome out of it. It would be cheaper than moving to other countries.