Question

One of the most predictable effects of the expansion of technology is that healthcare costs have increased tremendously. Select one disease case and discuss the cost of this disease in a chronic management system. Add references to support your selection.

Answer 1

CASE

Geoffrey Simpson is a 72-year-old pensioner with a history of a non-productive cough and occasional chest pain. Recently he has noticed blood in his handkerchief when he coughs and he states he has been losing weight but puts it down to his loss of appetite. Following a CT scan and bronchoscopy he has been diagnosed with Stage 4 non-small cell lung cancer and bony metastases. The treatment plan is for chemotherapy to treat the primary tumour and biphosphonate drugs and radiotherapy for the bony metastases. Mr Simpson retired from the ship-building industry 12 years ago and states he has never been a smoker, eats healthily enough and only drinks moderate alcohol.

ALL is a primary disorder of the bone marrow in which the normal marrow cells are replaced by immature or undiff erentiated blast cells. When the quantity of normal marrow is depleted to below the level necessary to maintain peripheral blood cells within normal ranges, then the following occur:
• anaemia
• neutropenia
• thrombocytopenia.

The exact cause of ALL is unknown, but the following are suspected of being involved in
the development of this disease:
• environmental causes
• infectious agents (especially viruses)
• genetic factors
• chromosomal abnormalities.
ALL is the most common malignancy in children .ALL is classifi ed according to the cell type involved. ALL results from the growth of an abnormal type of leucocyte in the bone marrow, the spleen and the lymph nodes. These abnormal cells have little cytoplasm and a round nucleus
– they resemble lymphoblasts.

Therefore, the signs and symptoms of ALL are:
   • an increase in lethargy and general malaise
• persistent fever of unknown cause
• recurrent infection

.   prolonged bleeding (e.g. after dentistry)

• bruising easily
• pallor
• enlarged lymph nodes
• pain, particularly abdominal, bone and joint
• CNS involvement leading to headache and vomiting.

Treatment
The treatment for ALL includes:
• supportive therapy, including:
• control of infections, anaemia, bleeding, etc.
• specifi c therapy, including:
• cytotoxic chemotherapy – e.g. dexamethasone, vincristine, imatinib, asparaginase,
methotrexate
• radiation therapy
  • bone marrow transplantation (BMT) to replace the damaged marrow with noncancerous
marrow

Chronic management of ALL

Acute lymphoblastic leukemia (ALL) is best treated by physicians who have significant experience in the treatment of patients with acute leukemia. In addition, these patients should receive treatment in a setting where appropriate supportive care measures (high-level blood banking and leukapheresis) are available. Patients admitted to hospitals that lack appropriate blood product support facilities, leukapheresis capabilities, or physicians and nurses familiar with the treatment of patients with leukemia should be transferred to an appropriate (generally, tertiary care) hospital.

Examples of commonly used regimens include the following

Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin [Adriamycin], and dexamethasone)[28]

CALGB 8811 regimen[29]

GRAALL-2005 regimen[30]

Linker 4-drug regimen[31]

MRC UKALLXII/ECOG2993 regimen[32]

ALL-216

Patients with ALL require hospital admission for induction chemotherapy, and they require readmission for consolidation chemotherapy or for the treatment of toxic effects of chemotherapy. Surgical intervention may be required for the placement of a central venous catheter, such as a triple lumen, Broviac, or Hickman catheter.

Induction therapy

Standard induction therapy typically involves either a four-drug regimen of vincristine, prednisone, an anthracycline, and cyclophosphamide or L-asparaginase or a five-drug regimen of vincristine, prednisone, an anthracycline, cyclophosphamide, and L -asparaginase given over the course of 4-6 weeks. Using this approach, complete remissions (CRs) are obtained in 65-85% of patients.

Consolidation chemotherapy

The use of consolidation chemotherapy in acute lymphoblastic leukemia (ALL) is supported by several studies. Fiere et al compared consolidation therapy with daunorubicin and cytosine arabinoside (Ara-C) versus no consolidation therapy in adults with ALL, demonstrating a 38% 3-year, leukemia-free survival rate for subjects receiving consolidation and maintenance therapy compared with 0% for those receiving maintenance therapy without consolidation.[34]

Maintenance therapy

The effectiveness of maintenance chemotherapy in adults with acute lymphoblastic leukemia (ALL) has not been studied in a controlled clinical trial. However, several phase II studies without maintenance therapy have shown inferior results compared with historical controls

Although maintenance appears necessary, using a more intensive versus less intensive regimen does not appear to be beneficial. Intensification of maintenance therapy from a 12-month course of a four-drug regimen compared with a 14-month course of a seven-drug regimen did not show a difference in disease-free survival between the two groups.

Treatment of mature b cell ALL

Mature B-cell acute lymphoblastic leukemia (ALL) is a special type, representing only 5% of adult patients with ALL. The hallmark of mature B-cell ALL is the presence of surface immunoglobulin on the lymphoblasts. Using conventional regimens, only 30-40% of patients enter complete remission (CR) and few patients survive long term.

Ibatinib
Nilotinib
Dasatinib . These are the drugs which are used for the treatment of ALL.

Transplantation

In current practice, most adult patients (except the most elderly and those with significant comorbidities) are offered allogeneic transplantation in first remission. The use of alternative donors (including matched unrelated donors, cord blood, and haploidentical donors) allows for most patients to have an appropriate donor.

Treatment of relapsed ALL

Patients with relapsed acute lymphoblastic leukemia (ALL) have an extremely poor prognosis. Most patients are referred for investigational therapies. Patients who have not previously undergone transplantation are referred for such therapy, preferably after obtaining a complete response to salvage therapy. Reinduction regimens include standard chemotherapy regimens (similar to the front-line setting), novel chemotherapeutic agents or immunotherapies (blinatumomab, inotuzumab ozogamicin, or tisagenlecleucel). Patients with Ph+ disease generally receive a tyrosine kinase inhibitor either alone or in combination with other therapies

The front-line regimen they received

The duration of prior remission

Whether the patient relapsed after transplantation

Cloforabine
Nilarabine
Vincristine liposomal .Theseare the drugs which are usedfor the treatment for ALL

Supportive care should be given

Total treatment cost for ALL is  $85,326 in adults and $59,899 in children