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Thursday, July 19, 2012
ONLINE FIRST: SECOND THOUGHTS FROM SEKERES: How Good We Have It

By Mikkael A. Sekeres, MD, MS

 

I had the chance recently to participate in the Highlights of ASH in Latin America, which took place in Foz do Iguaçu, Brazil. This city borders Argentina and Paraguay at the Southern tip of Brazil.

 

Going into the meeting, I was convinced their motto must be, “Getting there is half the fun”--our flight from Cleveland to our connecting flight in Washington, DC, was cancelled at the last minute, so a colleague and I piled into a car, drove two hours to Pittsburgh, and barely made the only flight left to DC, which promptly had mechanical difficulty. As we deplaned, a maintenance man stood watching us with a box of light bulbs in his hands--surely not a good sign. Our flight took off 45 minutes late, leaving us 20 minutes to run from Terminal A in Dulles (which is conveniently located somewhere in western Maryland) to Terminal C, where we barely caught our flight to Sao Paulo, the last passengers to board.

 

After landing and a six-hour layover, we then calmly boarded the plane to Foz do Iguaçu, arriving approximately 24 hours after starting our journey, not exactly looking like experts in anything, other than perhaps grime.

 

This is the fourth time ASH has partnered with hematology associations from a variety of countries in Latin America, including Brazil, Argentina, Colombia, Bolivia, Chile, Uruguay, Paraguay, Peru, and Venezuela. This initiative has been supported by the Wallace H. Coulter Foundation, which gives ASH the resources to “think globally and act locally” by collaborating with local hematology organizations outside of the United States.

 

One goal is to produce innovative programs for resource-limited countries, providing the latest in hematology knowledge and education; another is to strengthen the bond among the societies. Sounded pretty lofty to me, and I have to admit I was a bit dubious that we’d accomplish this mission.

 

Little did I know how wrong I was.

 

The meeting started the following day, and followed the basic format of the North America “Highlights” meetings, albeit with strict instructions to the speakers to avoid idioms and to speak slowly enough so the Portuguese and Spanish translators could keep up. We heard a lot from a variety of presenters about the latest in molecular diagnostics and prognosticators, combination therapies and monoclonal antibodies, and bone marrow transplantation strategies. Built into the meeting was a lunch for speakers and attendees.

 

This was really the highlight for me, where the Latin American hematologists could ask specific questions about managing their patients, and I got to ask about life as a hematologist outside the U.S. One woman from Uruguay, who ran the only laboratory that performed flow cytometry and cytogenetic testing for the entire country, asked a question about cytogenetic testing in myelodysplastic syndromes. I asked if she felt that her lab lost some test accuracy because samples from around the country all had to be sent to her.

 

“Oh, that’s not a problem for us. The mail isn’t reliable, so we long ago realized that the best container for these samples are the patients themselves, so we have them travel to the lab to collect their samples.”

 

Really? Can you imagine telling your patient that she had to get in a car and drive to Mayo Medical Laboratories in Minnesota or to LabCorp in North Carolina to have appropriate disease testing?

 

The conversation turned to transfusion needs. A doctor from Argentina commented that, prior to elective surgeries, they have patients donate a unit of blood for the potential use during the surgery itself. But they hope the patient doesn’t need it, so they can redirect the unit to their blood bank for use in another patient, as this is how they obtain the majority of their blood supply. No consent required.

 

Imagine that. Putting public health necessities before individual rights.

 

Then we talked about the role of bone marrow transplantation in myelodysplastic syndromes, a topic that occupied about 25 percent of the talk I had just given. I asked if these were performed in the attendees’ countries. A doctor from Chile responded.

 

“We can perform bone marrow transplants. But only in people under 40 years old. The government won’t pay for them in anyone older, for any indication--myelodysplasia, acute leukemia, lymphoma, even if you are six months beyond 40 years.”

 

Gulp. That one hit close to home. I’d be screwed. He went on.

 

“But even if we were allowed to transplant older patients, we can’t.”

 

“Why not?”

 

"There are no donors. We don’t have the support for HLA typing.”

 

As the day went on, I came to two major realizations. First, as hard as we worked on our talks and tried to make them logical and reflective of the incredible research presented at ASH, a good deal was only tangentially relevant to hematologists in countries so constrained by resources.

 

Second, as much as it is a monumental pain to justify what we do to insurance companies and resource utilization reviews, we are very, very lucky to practice oncology and hematology with the latest technology for diagnostics, prognostics, and therapeutics, and to have choices in how we practice.

 

And we shouldn’t forget it.

 

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MIKKAEL A. SEKERES, MD, MS,  OT’S Clinical Advisory Editor for Hematology/Oncology and a member of the FDA’s Oncologic Drugs Advisory Committee, is Director of the Leukemia Program at the Cleveland Clinic Taussig Cancer Institute and Chair of the Hematology/Oncology Pharmacy & Therapeutics Committee. He is a staff member in the Department of Hematologic Oncology and Blood Disorders and holds a joint appointment in the Departments of Translational Hematology and Oncology Research.

 

 

More ‘Second Thoughts’!

Check out all the previous articles in Mikkael Sekeres’ award-winning column in this collection on the OT website: http://bit.ly/OT-SekeresCollection