Therapy Selection for Patients with Chronic GVHD
The panel debates the various treatment options and comments on when they prefer each one.
Transcript:
Yi-Bin Chen, MD: So, I think there's going to come a time here where we have, shall we say, many toys, and not really knowing what order to play with them in. And so, how do we figure that out? What's the best way to do it?
Corey S. Cutler, MD, MPH, FRCPC: I think there are a couple of considerations. First of all, we do have to respect the label of the drugs. And at the moment, ruxolitinib and ibrutinib are labeled for use in second-line, where belumosudil has a third-line indication. I preferentially choose belumosudil for patients with bad sclerotic disease because of its mechanism of action. But one has to look at toxicity and ongoing side effects as well to help make a decision, and every now and then I will make a decision based on the prior malignancy that the patient had. So, if the patient had a JAK2-positive malignancy, I reach for ruxolitinib sooner. If they had a B-cell malignancy, I reach for ibrutinib a little bit sooner. So, all of these things come into play.
Catherine J. Lee, MD, MS: I think, realistically, the payer system plays a big role in this, I encountered a huge—and I hear from my colleagues in chronic GVHD at Hutch [Fred Hutch Cancer Center]—that oftentimes there is difficulty in gettingbelumosudil at all unless someone had failed ibrutinib prior. And so that is one consideration as well, as well assometimes the copay is, just, it's extremely cost prohibitive for patients. And going through the system of getting payer assistance in and from the companies can take a very long time. And it's a process. You don't have that time, right? So, you need to be able to grab on to something that's available.
Yi-Bin Chen, MD: Sometimes it's out of our hands and the decision is made for us by these external forces that we don't have control over. Colleen in the near future, if axatilimab is approved, we'll have 2 agents that are hypothetically specifically targeted towards fibrotic disease. There's belumosudil, which is oral and taken once or twice a day, depending on sort of the other medications that a patient is on, and then axatilimab, which will be an IV infusion, given once every 2 weeks. Can you see patients choosing based on that? What will the discussion be to figure out how to use those agents?
Colleen Danielson, NP: I think patients will have some feelings one way or the other. Some people certainly prefer an oral medicine. They can be at home, they can have it, especially if we're not seeing the patient as frequently in clinic as every 2 weeks, if they live quite a distance away. We certainly have a big cohort of patients who live 3, 4 hours away from our center. And so, for them to come in for IV medications is just more complicated. So, I think that will be a factor as we have more toys, as you put it, that the patient discussion with patient preference will play into that as well.
Catherine J. Lee, MD, MS: I don't want us to forget about the benefit of ECP, even though it is very convenient for patients. I think we can all agree that it is useful for particular forms of chronic GVHD. And so, I think it's still a realistic or reasonable choice for patients who live close by to a center who [are] willing to make that effort. I have found that most patients prefer this option, and they would rather try the oral agents first, but then when it comes down to needing it, they're willing to learn to do it.
Yi-Bin Chen, MD: I think, you bring up a good point. ECP might be the biggest example for how our patients may dictate what they get based on other factors. That based on sort of the investment of time and resources it takes to receive that therapy, absolutely.
Transcript is AI-generated and edited for clarity and readability.
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