Yi-Bin Chen, MD: Caring for a transplant patient is a team sport, and we have many providers who help coordinate the care and serve different roles. These roles are not explicit, and they’re overlapping along the way from the journey of meeting the transplant through the actual transplant admission, with a very important follow-up period afterward. When a patient comes after transplant for follow-up visits, they often see 1 of our practice nurses and then 1 of our nurse practitioners or their BMT [blood and marrow transplant] physician, all of whom work together. Along the way they’ve met a social worker, a nutritionist, and a physical therapist, and they may have met our research team as well if they’re involved in our clinical trials.
When a patient develops acute graft-vs-host disease, he or she will often call our clinic because they’re home when this happens, and they will report the symptoms to their care team, generally the practice nurse, a nurse practitioner, or a physician. We’re all in open communication with one another because we all work together for the good of the patient and we’ll be on an e-mail chain, oftentimes with the patient, to figure these things out. The symptoms of acute graft-vs-host disease include rash…so we need to figure out what’s what. If there’s a rash, we’ll often ask the patient to take a picture. We have that technology these days, oftentimes with smartphones, and they’re able to send the picture in so we can do a real-time assessment without having the patient make the physical trip all the way to our center.
We often involve local providers as well, as needed, but generally if these symptoms arise and we believe it is serious enough, then we’ll have the patient come in and be assessed at our center to figure out if they have graft-vs-host disease. When they come in, they’ll meet members of their care team and may meet our research team as well, depending on if we feel a research trial is in their best interest.
Zachariah DeFilipp, MD: The management of patients diagnosed with graft-vs-host disease is truly a team effort, and we care for patients with GVHD in both the inpatient and the outpatient setting. In the inpatient setting there are daily rounds in which attending physicians, residents, nurse practitioners, nurses, pharmacists, dietitians, social workers, and case managers review every BMT in the hospital. Patients with GVHD usually require more extensive conversations on rounds considering their more complex care.
In the outpatient setting physicians, nurse practitioners, nurses, and social workers work together to monitor the response of patients, making sure patients and their caregivers have the appropriate level of support while receiving treatment at home.
At MGH [Massachusetts General Hospital], our research team is also heavily involved in the care of our graft-vs-host disease patients, as many are enrolled in clinical studies for their treatment.
When a patient is diagnosed with graft-vs-host disease, the first thing we need to do is assess the severity of their symptoms and which organs are involved. The initial questions we need to answer are, 1) Does this patient require systemic therapy? And 2) Should this patient be treated in the outpatient or inpatient setting?
Additionally, if patients require systemic therapy, we also assess whether the patient is eligible to participate in a clinical trial.
Yi-Bin Chen, MD: At diagnosis, if someone has a skin rash, there may be utility in doing skin biopsies. Different providers have different opinions about the importance and the utility of a skin biopsy. Certainly, if patients have a lot of diarrhea or other GI [gastrointestinal] symptoms, we tend to ask for an endoscopic biopsy from our GI colleagues, whether it’s through an upper endoscopy or through a flexible sigmoidoscopy to get mucosal biopsies of their intestines. There is no gold standard pathological diagnosis of graft-vs-host disease. It remains a clinical diagnosis, but the pathology can be quite supportive. More important, it can rule out other etiologies. Oftentimes, the most important other etiologies to rule out is CMV [cytomegalovirus] enteritis for patients at risk for that complication.
Also, at diagnosis, you can make decisions about treatment, and I’m sure we’ll dive into treatment in a second. At that point, we tend to think about if a patient is eligible…and what we may have open at our site. At diagnosis we may present the opportunity to enroll in certain clinical trials at that point. At our site, we take acute graft-vs-host disease very seriously, and we’re quite involved academically in trying to improve its care and experimental efforts, both in sample collection to study biomarkers as well as in novel treatment.
Our site actually has a research infrastructure about graft-vs-host disease for any patient who presents with new grades 3 through 4 acute graft-vs-host disease. We are on a big email chain, including our research group, to let everybody know that that’s happening. There may be end points for certain trials that patients are already on. There may be samples that have to get collected, and there may be new-treatment trials the patient may be eligible for.
Transcript Edited for Clarity