Defining Chronic Graft vs Host Disease (GvHD)

Panel of oncologists define in chronic GvHD and review the typical presentation of a patient.


Corey Cutler, MD, MPH, FRCPC: Doris, tell us about a typical presentation of chronic graft-vs-host disease. When does it happen? What organs are involved? What do you see?

Doris M. Ponce, MD: In general, we see our patients that have passed day 100 even though sometimes we can see it sooner, but usually, patients between 100 to 1 year is when we see like 90% of our patients presenting with chronic graft-vs-host disease. Typically, we have this battle where we are tapering the primary immune suppression, the CNI where we start seeing symptoms of chronic graft-vs-host disease. Their involvement is usually at least 2 organs when they present as the typical presentation. The most common organs where I see, and the data has been shown, is the skin, the eyes, and the mouth are the organs that are typically effective with chronic graft-vs-host disease.

Corey Cutler, MD, MPH, FRCPC: Hannah, since you did such a great job staging acute GvHD, do you want to tell us about the staging of chronic graft-vs-host disease?

Hannah K. Choe, MD: That's a much bigger concern than acute GvHD. We'll use the 2014 NIH consensus guidelines. In the consensus guidelines, they outline each organ system. How I describe it is what organ is not involved in chronic GvHD. Literally, every organ can be involved in GvHD, but may not be in chronic, but may not be on the scoring guidelines. It involves similar to how you would stage acute staging of each organ. With eyes, it’s the level of dryness and how much it interferes with their daily life. With skin, it’s the amount of tightness, and if there's sclerodermas changes. There's 11 different types of chronic GvHD alone. Then oral, again, involves the same thing. How much are they able to chew? Is it interfering with their ability to swallow? Then, with the lungs, it’s how much has their forced expiratory volume in the first, second, decreased? How much has their ability to walk a few minutes decreased? Liver involvement, the transaminase, and the measurements. In that composite then, each one of those gets put into a composite of how severe each one is to define as mild, moderate, or severe. The other thing that we're incorporating more, which is being taken more seriously, too, as it's become clearly validated, is the patient-reported outcomes with these 2. We're seeing on the physician or the health care provider side what we think is an improvement based off of our physical exam is on 1 visit every 3 months or so. The patient-reported outcome at how much their daily life has actually improved or worsened from X, Y, Z intervention. It's becoming so much so that the PRO [patient reported outcomes] is equivalent now to what we are examining on the patient and documenting as a score.

Yi-Bin Chen, MD: We should emphasize this point because the chronic GvHD is such a heterogeneous and subjectively assessed disease. As you're saying, you have all of these organs and they have scores and a lot of the assessments for those of us who do them on trials, and even in taking care of patients, a lot of it's based on you asking the patients, “How do you feel? Does this feel better?” A lot of that is subjective. They're very few things that have an actual number, or a metric, that you can feel confident about over and over again. The problem with that is that it's very easy to perhaps achieve a partial response by those criteria. This is not a critique of the NIH consensus. It's better than anything we had before, but because of the disease itself, inherently it's a very difficult disease to assess. There are partial responses by the NIH criteria that are life changing and then, there are partial responses that don't mean anything. That's why this incorporation of patient-reported outcomes is super vital to trials going forward.

Transcript edited for clarity.

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