Case 3: Supportive Care in Chronic GVHD

Corey Cutler, MD, MPH, FRCPC: I'm going to bring it back to you, Dan, and ask if you can go over some of the supportive care and ancillary therapies that are very important in chronic graft-versus-host disease [GVHD]?

Daniel Couriel, MD, MS: Absolutely. I think that, at the end of the day, what gives the patient the more immediate relief is adopting a lot of these ancillary and supportive care measures. I'm glad you brought it up because they're frequently forgotten. They are not very well studied. I believe that they have the potential of sparing steroids, although that hasn't been looked at systematically, in part because it's very difficult to design a study that, in a clean way, will give us that answer. There are, however, different ancillary and supportive care interventions that start with education, which needs to happen at the time of diagnosis. This is crucial because it prevents the patients from having flares or worsening of their chronic GVHD. Education has to do with things like using sun protection to avoid reflare of GVHD or worsening of GVHD.

When you continue down the different interventions, you have organ-specific interventions that have do with management of dry eye, management of sores and lesions in the mouth, dryness in the mouth, or management of mobility issues that have to do with sclerodermatous chronic GVHD, like in the case that we presented. There are gynecological issues that have to do with vaginal dryness and also strictures, gastrointestinal [GI] issues with GI strictures that can be dilated by a gastroenterologist. There are a lot of different things that can be done. Unfortunately, they are frequently forgotten, as I said, and these are the things that relieve the symptoms more immediately than systemic therapy and sometimes make life worth living for the patient because these are patients who usually live for years. And if they have severe chronic GVHD, they live those years miserably. We need to remember that these are things that will help.

Corey Cutler, MD, MPH, FRCPC: Usama, do you want to touch a little bit on the long-term complications of steroid therapy and the things we need to do from a survivorship point of view for these patients?

Usama Gergis, MD, MBA: Sure, Corey. I am from a school where I think that leaving patients on glucocorticosteroids for a long time can be as toxic as the sequelae of GVHD, whether that is acute or chronic. In the first case, you knew fairly early that the patient responded or will not respond, and you can move onto a second line or other lines of therapy. In chronic GVHD, most transplant centers do not have the expertise or the chronic GVHD-specific clinics or survivorship programs that can care for these patients. I also like to believe that 2 years after transplant both us, clinicians, and patients lose the momentum that we started with transplanting our patients. Nothing acute is happening, so sometimes we can get adjusted and accept the new norm, which is not optimal. OK, with that philosophical entrance…. I think the real problem in the transplant community is you can scale the survivorship programs because you have the volume in Boston at the Dana-Farber Cancer Institute. Wherein, most other centers where they do 50 allogeneic transplants a year, you cannot have that luxury of a survivorship program and subspecialties. In many cases, having a colonoscopy and getting the call from the gastroenterologist late at night telling you, “Corey, this looks like acute GVHD, or this looks like CMV [cytomegalovirus],” makes all the difference. Again, having all these subspecialized programs and clinicians is a great thing to have, but I think we, as a community, need to work together to have some sort of consortia to treat this as a community.

Corey Cutler, MD, MPH, FRCPC: Before we wrap up, some final thoughts of what you think the future for GVHD holds. I'll go to you first, Dan.

Daniel Couriel, MD, MS: I think you, Corey, will agree with this, we're moving to a phase of focusing more on preventive therapies and proactive intervention versus waiting until the manifestation of chronic GVHD, or any GVHD for that matter, is meaningful. I really think that new way of doing clinical research, plus the existence of agents that are a lot more active than what we've seen in the last 20 or 30 years, are a good combination. I am very hopeful and optimistic that in the next 5 or 10 years, we're going to improve outcomes even further, and not just because our supportive care is better, but because our treatments of the disease are going to be better.

Corey Cutler, MD, MPH, FRCPC: Usama, your final thoughts?

Usama Gergis, MD, MBA: I'll echo Dan's point that rates and the severity of acute GVHD are decreasing now compared to 10 years ago—better HLA [human leukocyte antigen] matching, better prophylaxis platforms, and other supportive care issues—number 1. This is good news. Number 2, I think with both the approval of ruxolitinib in steroid-refractive acute GVHD, and ibrutinib for chronic GVHD, the bar is higher. With response rates in the acute setting around 50%, and 70% in the chronic setting for ibrutinib, the bar is higher. When we design our clinical trials now, we have better agents to compare to.

Corey Cutler, MD, MPH, FRCPC: Great. I couldn't agree more. I think being in this field now for nearly 20 years, it's quite a difference. We have this embarrassment of riches of agents and pathways and strategies to test. I think we are only going to get better, and transplant outcomes are only going to improve as a result of this.

With that, I'm going to thank both of you for your thoughtful case presentations, your discussion, your candor. To our viewing audience, thank you for joining us for this Targeted Oncology™ Virtual Tumor Board®. We hope today's discussion was a valuable use of your time and that you acquired some practical knowledge that you can take back to your clinic.

With that, we'll thank you very much.

Transcript edited for clarity.