The Scenario of Myelofibrosis in Brazil in the View of a Panel of Experts: Challenges and Proposals
Authors: Fogliatto Laura Maria , Solza Cristiana , Apa Alexandre Gustavo , Magalhaes Gustavo HR , Delamain Marcia Torresan , Tavares Renato , Figueiredo-Pontes Lorena Lobo 
Published: November 2019

Introduction: Myelofibrosis (MF) is a rare and progressive myeloproliferative neoplasm (MPN), with increased risk of death due to disease complications and progression. The only curative therapy, bone marrow transplantation, is rarely feasible due to patients' age and comorbidities. Genetic study for prognostication and JAK inhibitors drugs are not available for all patients. Thus, patients with MF, especially those with poor prognosis (int-2 and high-risk IPSS), present decreased quality of life and survival. In Brazil, there is a lack of information regarding the epidemiology and management of the disease.
Aims and methods: An expert panel was conducted in June 2019 with seven hematologists from different centers to identify limitations to MF care in Brazil and address pertinent recommendations. The experts received the questions in advance, conducted a literature review, and then discussed results and proposals for MF management in Brazil.
Results: Diagnosis of MF, including hematologic, morphologic, and molecular findings, is challenging. In Brazil, patients are often diagnosed in advanced phases of MF what may suggest a late referral for specialized centers. The specialists concluded that awareness about the clinical findings of MF requires attention. An effort also needs to be made regarding morphological diagnosis according to the WHO revised criteria for MPN differential diagnosis. Although the mutational profile is essential for diagnosis and risk stratification, in Brazil, most of the centers have no access to driver mutations tests. The risk stratification relies on clinical scores such as IPSS or DIPSS, which leads to a lower identification of patients with a higher risk of disease that should be considered for transplantation. Regarding the quality of life, there is a sense of low perception about symptomatic severity of patients and physicians. Symptomatic scores, not yet available in Portuguese, are not applied routinely: patients have difficulties in understanding the questions without supervision. Finally, even though the Brazilian public healthcare system is based on the principles of universal coverage, the integrality of care and equity, most patients have limited access to drugs that improve symptoms and survival, like the JAK1/2 inhibitor ruxolitinib. Availability of medications is greater in the private system. However, there is a mandatory list of drugs approved by the insurance companies and updated every two years. Thus, new drugs are not readily available even in this setting. Of note, the majority of the Brazilian population is covered by the public system, while the private system covers 24% of the entire population. Therefore, disparities in health care between public and private systems can affect MF assistance.
Based on these findings, the expert panel made the following suggestions:
1) A Brazilian registry, with a representative coverage of the national territory, to better understand the MF patient journey.
2) In order to improve diagnosis, investment in hematopathologist training and molecular testing for JAK2, CALR, and MLP mutations should be encouraged.
3) New prognostic classifications, such as MIPSS70+ version 2.0, that combine genetic and clinical variables, reinforce the need for adopting molecular tests as routine risk assessment.
4) Urgent need to develop a specific instrument to assess the impact of symptoms on the quality of life. Therefore, translation and validation of MPN-SAF TSS have been recently accomplished and will be used by MF reference centers when published. 5) Lack of equity in access to treatment options between public and private system was a consensus among experts. Measures that could address this issue include the establishment of MPN reference centers according to geographic distribution and centralization of the drugs purchasing system. A recently elaborated guideline endorsed by the Brazilian Society of Hematology is being used to circumvent the lack of a national protocol.
In conclusion, the identification of limiting factors for MF management leads us to propose recommendations for the Brazilian healthcare system in an attempt to improve patient care. Urgent actions should be taken to improve the unmet needs for these patients, especially in the public system where diagnostic, prognostic, and therapeutic approaches deserve special attention.

Disclosures
Solza: Novartis: Honoraria. Apa:Novartis: Honoraria. Magalhaes:Novartis: Honoraria. Delamain:Novartis: Honoraria. Tavares:Novartis: Honoraria. Figueiredo-Pontes:Novartis: Honoraria.