Dr. Myo Myint Maw Senior Consultant Physician Medical Oncology Unit Yangon General Hospital

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1 Dr. Myo Myint Maw Senior Consultant Physician Medical Oncology Unit Yangon General Hospital

2 *Sarcoma constitutes 2% of cancer patients attended at medical oncology unit of Yangon General Hospital.( ) *Osteogenic sarcoma mainly affect adolescents and common cause of functional disability in our instituition.

3 *22 osteosarcoma patients attended at Medical Oncology Unit of Yangon General Hospital. ( ) *Male - 10 people Female- 12 people *Majority are adolescents. ( Between 10 and 20 years of age)

4 *Regions of involvement Areas Femur 12 Tibia 8 Humerus 2 *Staging Localized disease 10 Metastasis ( Lung metastasis) No. of people 12 *CT/ MRI were done in 10 cases.

5 Soft Tissue Sarcoma *60 patients attended at Medical Oncology unit of Yangon General hospital. ( ) * Male - 33 cases Female - 27 cases *Common in middle aged group ( 26 patients are between years of age)

6 Distribution of Soft Tissue Sarcoma 3.30% 3.30% 3.30% 3.30% 5% 5% 23.30% Fibrosarcoma Rhabdomyosarcoma leiomyosarcoma liposarcoma Dermatofibrosarcoma MFH 6.70% 10% 11.70% 11.70% 13.30% Uterine Sarcoma Undifferentiated sarcoma Haemangiopericytoma Kapossi Sarcoma Chondrosarcoma Ewing Sarcoma

7 *X ray/ Ultrasound of affected region is the major investigation. *CT/ MRI was done in 22 cases. *Bone Scan was done only in 7 cases. *Haematoxylin & Eosin ( H & E ) stain is mainly used for biospy. *Immunohistochemistry (IHC) testing was performed only in 7 cases.

8 GIST Tumour *Total - 9 cases * Male 5 cases Female 4 cases *CT scan 5 cases *IHC 7 cases *Majority are above 40 years of age.

9 Surgery Management *Mainly done by general surgeon/orthopedic surgeons. *Amputation, disarticulation and debulking surgery are usually performed. *According to the collected data, limb saving surgery was done only in 4 cases. *Reason is that 1) late stage at the time of diagnosis 2) limited number of specialized surgeons

10 * Localized disease Surgery followed by adjuvant chemotherapy Metastatic disease Neo-adjuvant chemotherapy Followed by surgery Followed by adjuvant chemotherapy

11 First line chemo Cisplatin + adriamycin Second line chemo Ifosfamide Ifosfamide + etoposide Methotrexate (high dose)

12 Chemotherapy of Soft Tissue Sarcoma No standard guideline for specific histological sub-types. Only general guideline for soft tissue sarcoma. Preference of choosing of chemo in certain histological sub-type. Eg-choosing of taxol in angiosarcoma and leiomyosarcoma of uterus.

13 Localized disease Surgery followed by adjuvant RT +/ chemo Metastatic disease Chemotherapy + / - Palliative RT + / - Palliative surgery

14 First line chemo Doxorubicin + / - ifosfamide Second line chemo Ifosfamide + etoposide Gemcitabine +docetaxel Dacarbazine combination MAID CYVADIC Temozolamide

15 Chemotherapy of Gastrointestinal stroma Tumour *Localized disease Surgery followed by adjuvant chemo *Metastatic disease Neo-adjuvant chemo Followed by surgery Followed by adjuvant chemo

16 First line chemo Imatinib Second line chemo Sorafinib Sunitinib is not available in our country

17 Chemo Medicine *Previously, patients needed to buy chemodrugs on their own due to limited health budget (<3% of Government budget) *Nowadays, government tries to reduce the medical expense of patients own pocket by expanding the health budget. *But still, no health insurance system is established in our institution.

18 Availability of chemotherapy drugs Drugs Cisplatin Doxorubicin Vincristine Methotrexate Gemcitabine Docetaxel Ifosfamide Temozolomide Imatinib Availability Fully supplied by government Limited supplied Available but not supplied by government Tyrosine kinase inhibitor(tki) Pazopanib Trabectedin Not available in Myanmar

19 There are two sources of chemomedicine. 1. Original Products 2. Generic Products Original Products are approximately 10 times more expensive than generic ones. The majority of our patients rely on generic medicine for their treatment.

20 Adverse effects of chemotheraphy Common Uncommon Leucopenia Neurotoxicity Anaemia Nephrotoxicity

21 Management of Toxicity *Anaemia Erythropoietin injection S.C Blood transfusion *Neutropenia Grastim(GCSF) injection S.C *Freely supplied for OPD and in-patients at Yangon General Hospital.

22 Weakness in toxicity management *Lack of isolation rooms for neutropenic patients. *Blood drug level measurement is not available for monitoring of drug toxicity. *Limited dialysis machine for some drug toxicity.

23 Adjuvant RT Palliative RT Radiotherapy *Cobalt medicine is mainly used for RT. *LA with conformal RT is only used in small number of cases. *For adjuvant RT 60 Gray 30# *For palliative RT- 30 Gray 10#

24 Weakness in Radiotherapy *Now, two linear accelerator machine have been installed. *But, still using cobalt machine due to specialized training for radiation oncologists is still taking. Limited number of radio physicists.

25 There is no data regarding the response to treatment (efficacy) and survival analysis due to Limited medical staffs Weakness in data entry Limited facilities of computer and internet network

26 Palliative Care *No proper integrated palliative care services. *Palliative care management runs in hopsitals, hospices and homes. *Services are run by Genearal practitioners, general physicians, oncologists and nurses. *Palliative care training was started in 2012 supervised by Prof. Cyntia Goh ( SGH), funded by LIAN foundation. ( Asia Pacific Hospice Network) *Integrated palliative care service will start in next year ( Janauary/2016)

27 Pain Management *Available Medicines 1. Paracetamol/ NSAID 2. Weak opioid codeine Tramadol (oral/ injection) 3. Sedative Diazepam Lorazepam 4. Adjuvant Gabapentin Pregabalin

28 Strong Opoids Available Injection morphine Injection Fentanyl Unavailable Oral morphine Fentanyl patch

29 Accessibility of upstream and downstream care of primary care services GP/ Township or station MO (Initial assessment) Orthosurgeon/ General surgeon (Investigations/ Biopsy/ Surgery) Clinical Oncologist/ Tertiary centre Chemotherapy and/or Radiotherapy Medical Oncologist ( Divisional Hospital) (Chemotherapy)

30 Challenging Issues *Drop out cases and follow up cases due to 1) financial problem 2) lack of educational background *Limited accessibility to some imaging procedures. *IHC testing is not available in public hospital. *Late stages of the disease at the time of diagnosis. *Some difficulties in toxicity management. *Lack of 1) availability of TKI. 2) skilled staffs for operation of RT machine 3) clinical pharmacist *MDT tumor board meetings not established. *Integrated palliative care services are not available. *Limited pain control due to lack of oral morphine.

31 General weaknesses *Absence of chemo chamber or incubator and chemo preparation room. *Not enough bed and building for patients. *Weakness in research and audit. *Overwork load of doctors and nurses.

32 Inspiration for successful achievement *Development of MDT meeting. *Establishment of palliative care services. *Upgrading of imaging machines and laboratory services. *Training of medical oncologists, radiation oncologists and Radio physicists. *Creation of jobs for clinical pharmacists. *Recruitment of more nurses and doctors.

33 General *Expanding National research budget. *Inviting international grant for training and service development. *Strengthening collaboration with oversea cancer centers.

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