Advances in the Management of Graft Versus Host Disease - Episode 5

Impact of GVHD on Patient Outcomes

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Yi-Bin Chen, MD, and Nelson J. Chao, MD, MBA, comment on the changing landscape of GVHD and the effect on patient outcomes.

Yi-Bin Chen, MD: As we think more about acute graft-vs-host disease [GVHD] and where we’ve come from and where we’re going, it helps to think about how it has changed over time. We’ve published our own experience, as have others, on different patterns of graft-vs-host disease. I’ve been doing this for about 14 years, and I’ve read about the experience of the past, and I’ll ask people to confirm what I think are patterns that have changed. Patients live more now when they get acute graft-vs-host disease. We tend to see a different pattern. We don’t see hyperacute graft-vs-host disease much anymore. A lot of that is because of much better methods of typing and maybe prophylaxis. We tend to not see grade 4 skin acute graft-vs-host disease compared with what we used to read about. Those are 2 big changes.

As patients live longer and live through acute graft-vs-host disease because of better supportive care and treatment, we probably have more patients with chronic graft-vs-host disease because preexisting acute GVHD is the biggest risk factor to develop chronic. We’ll have more patients with chronic and maybe with more severe chronic. We’ll touch on this later as we talk about chronic GVHD, how newer treatments may be influencing that. Nelson, do you have any other comments on how it’s changed over time?

Nelson J. Chao, MD, MBA: Yes, since I’m the grandfather here.

Yi-Bin Chen, MD: The elder statesman, if you will.

Nelson J. Chao, MD, MBA: I’m old. What’s really changed since I started is that if you were age 45½, you wouldn’t get an allogeneic transplant. It was a hard cutoff, because we didn’t know exactly what we were doing. A lot of the data we have historically are based on a myeloablative regimen in a matched sibling who’s healthy. Today—I do this mentally—you can put these columns as age, and the range of the age; prep regimen; ablative, reduced intensity; nonablative; source of cells, meaning marrow, peripheral blood, or cord blood; and the type of GVHD prophylaxis. And you can go across these columns and mix and match.

We accumulate all these data as 1 set, but they really aren’t. These are different patient categories, and we accumulate them all together. If you look at ablative matched siblings for AML [acute myeloid leukemia], which is probably the cleanest group, I agree with you that there has been a lot less of these horrible cases of GVHD we used to see in the past. It’s because we’ve gotten better at patient selection and GVHD prophylaxis, and our supportive care has been much better. When I started this, people got CMV [cytomegalovirus] and died a week later of CMV pneumonia, so we’ve come a long way.

Transcript Edited for Clarity