1. THE DILEMMA OF CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

2. Professor Anwar Sheikha MD, FRCP, FRCPath., FCAP, FRCPA, FRCPI, FACP Senior Consultant Clinical & Lab. Hematologist, Kurdistan, IRAQ Professor of Hematology, HMU, Erbil, IRAQ Clinical Professor University of Mississippi Medical Center, Jackson, Mississippi

3. >1/5 th of the IRAQI POPULATION IRAQ POPULATION 32 MILLIONS KRG A Proud Part of Federal IRAQ Suly Erbil

4. SULY ERBIL AN ARMY OF 80 HEMATOLOGISTS & ONCOLOGISTS Patients: 30% Erbil 25%Suly 10%Kirkuk 05%Duhok 30%Rest of IRAQ

6. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA The Iraqi Economy is BOOOOMING! A Barrel of Oil is now selling for > $100!! Inshalla it will hit a thousand dollars a barrel. This will help us with our reconstruction efforts More Monicas than a Japan street! More BMW than a German City! We are seeing the effects of that economic upsurge. FCR for CLL  $45K 2 Radiation Centers Exjade 1 400-bed hospital in Suly RituximabCountless Private Hospitals Oncology drugs-  Security For IRAQ

7. SHEIKHA ﺍﻟﺴﻴﺩ ﻨﻴﭽﻴﺭﭭﺎﻥ ﺒﺎﺭﺯﺍﻨﻰ ﺒﺭﻋﺎﻴﺔ ﺤﮑﻭﻤﺔ ﺃﻗﻟﻴﻡ ﮐﻭﺭﺩﺴﺘﺎﻥ ﺍﻟﻌﺭﺍﻕ ﺭﺌﻴﺱ ﺷﺭﮐﺔ ﺭﺍﺰﻳﺎﻧﺔ ﺗﻘﻮﻢ ﺒﺎﻟﻤﺮﺤﻠﻪ ﺍﻷﻮﻟﻰ ﻠﺒﻨﺎﺀ ﻤﺴﺘﺸﻔﻰ ﻮ ﻤﺭﮐﺯ ﺴﺭﻁﺎﻥ ﻤﻴﺪﻴﺎ ﺒﺴﻌﺔ ۲۰۰ ﺴﺭﻴﺭ ﻤﻊ ﺴﮑﻥ ﻠﻸﻁﺒﺎﺀ ﻭﻤﺠﻤﻊ ﻠﻠﻌﻴﺎﺩﺍﺕ

8. SHEIKHA MYDIA DIAGNOSTIC CENTER A 50 million dollar project in Erbil

9. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA CML IN KURDISTAN

10. GEOGRAPHICAL DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN HAWLERPATIENTS “ 56 ” SULYPATIENTS “ 98 ” 30HAWLER06 05SULY51 06KIRKUK18 09DUHOK03 04MOSUL02 00DIYALA06 00TIKRIT03 02OTHERS*09 * Baghdad Ramadi Samara etc

11. Hawler

12. Sulaimaniya

13. GEOGRAPHICAL DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN HAWLER 30+06 36 SULY 05 +51 56 KIRKUK 06 +18 24 DUHOK 09 +03 12 MOSUL 04 +02 06 DIYALA 06 0606 TIKRIT 03 0303 *OTHERS 02 +09 11 TOTAL154 * Baghdad Ramadi Samara etc

14. AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN HAWLERPATIENTS “ 56 ” YEARSSULYPATIENTS “ 98 ” 0310-1901 1220-2918 1430-3922 1440-4918 0950-5920 0260-6911 0270+08

15. AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN AGE RANGE 10-19 03 +01 04 20-29 12 +18 30 30-39 14 +22 36 40-49 14 +18 32 50-59 09 +20 29 60-69 02 +11 13 70+ 02 +08 10 TOTAL 56 + 98 154

16. AGE DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN

17. SEX DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN HAWLERPATIENTS “ 56 ” SULYPATIENTS “ 98 ” 30MALE41 26FEMALE57

18. SEX DISTRIBUTION OF CML PATIENTS IN IRAQI KURDISTAN MALE 30+41 71 46% 46% FEMALE 26 +57 8354% TOTAL154100%

19. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA GLIVEC HAS EXTENDED THE LIVES OF CML PATIENTS FROM YEARS TO DECADES KNOWING THAT CML USUALLY AFFECTS MIDDLE-AGED PEOPLE; THIS COULD BE CAUTIOUSLY TRANSLATED TO “cure”! ~AIDS & HAART

20. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA The Ideal Scenario: A 55 year, 90 kg fresh symptomless CML Kurdish patient with incidental leukocytosis and moderate splenomegaly. 18 Sibs; all the facilities for HSCT is available now! Order Cytogenetic and Molecular analysis. Both Ph & BCR-ABL +ve. Thanks to Novartis’ relentless efforts, barrels of Imatinib is available in both Suly Hewa & Hawler Blood Hospitals. Start the patient on Glivec and follow his response Hematologically, Cytogenetically for Ph chromosome and Molecularly for BCR-ABL transcript gene Within a year patient gets >4.5 log reduction in BCR-ABL transcript gene. For years the patient is progression free and prefers continuation of therapy.

21. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA The Typical Scenario: A 55 year, 90 kg fresh symptomless CML Kurdish patient with incidental leukocytosis and moderate splenomegaly. 18 Sibs; all the facilities for HSCT is available now! Order Cytogenetic and Molecular analysis. Both Ph & QT-PCR +ve. Thanks to Novartis’ relentless propaganda, barrels of Imatinib is available in both Suly Hewa & Hawler Blood Hospitals. Start the patient on Glivec and follow his response hematologically, cytogenetically and molecularly for BCR-ABL transcript gene Within a year you get >4.5 log reduction in BCR-ABL transcript gene. For years the patient is progression free and prefers continuation of therapy. WISHFUL THINKING

22. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

23. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA CHR 1 log reduction CCR 2 log reduction MMR 3 log reduction 4 log reduction >4 log reduction

24. CRKL phosphorylation (IC50) WT1 Expression OKT-1 Activity

25. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA WBC/uL 100,000 CHR 1 log reduction 10,000 CCR 2 log reduction 1,000 MMR 3 log reduction 100 4 log reduction 10 >4 log reudction ?

26. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA 3 Abl Kinase Inhibitors: Imatinib2001 Dasatinib2006 Nilotinib2007

27. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA CHRONIC PHASE ACCELERATED PHASE BLAST CRISIS Classical Teaching 3-4 Years 6 months Few Months ?Weeks

28. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA CHRONIC PHASE ACCELERATED PHASE BLAST CRISIS Classical Teaching 3-4 Years 6 months Few Months ?Weeks Middle East > 6 Years 2 Years > 6 Months

29. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA

30. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA The Real Scenario: A 55 year, 90 kg Fresh symptomless CML Kurdish patient with incidental Leukocytosis and moderate splenomegaly. Cannot afford medical expenses and is entirely dependent on Hospital resources! No Cytogenetics; No PCR; No HSCT; NO nothing! Patient cannot travel to Jordan, Iran or Turkey for Ph Chromosome or BCR-ABL Transcript analysis! Thanks to Novartis’ efforts, Glivec is available in both Suly Hewa & Hawler Blood Hospitals

31. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA Are we justified to start Glivec without cytogentic analysis?

32. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up?

33. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity?

34. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? Until we stand on our feet, what is wrong with blind use of Glivec as long as the patient responds?

35. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? Until we stand on our feet, what is wrong with blind use of Glivec as long as the patient responds? When in crisis, seek the alternative.

36. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA Are we justified to start Glivec without cytogentic analysis? Are we justified to continue Glivec without proper molecular follow up? Can we count on response to Glivec to predict Ph positivity? Until we stand on our feet, what is wrong with blind use of Glivec as long as the patient responds? When in crisis, seek the alternative. Half of our patients are on the Indian Glivec “Cipla”, especially when patients buy their medications; what are the recommendations and reactions of Novartis to that? Is there any legal issue involved in flooding the Iraqi market with the Indian Glivec? How effective is the Indian Imatinib?

37. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA THANKS FROM IRAQ & KRG

38. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA THANK YOU

39. CML MANAGEMENT IN IRAQI KURDISTAN SHEIKHA THANK YOU

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