Updates in the Management of Graft-Versus-Host Disease - Episode 8

Treating Chronic Graft-vs-Host Disease

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Corey S. Cutler, MD, MPH, FRCPC: Zach, let’s move on to chronic GVHD [graft-vs-host disease]. Can you discuss the role of recognizing chronic GVHD early and getting on top of therapy?

Zachariah DeFilipp, MD: As Yi-Bin [Chen] mentioned, the onset of chronic GVHD can be clinically subtle. On the other hand, it can progress quickly. We feel that early management of the disease is preferred. We see chronic GVHD, in the more involved cases, is usually managed in a multidisciplinary manner. Most large transplant centers have specialists who help see their patients who have organ-specific chronic GVHD involvement. For example, for patients with ocular GVHD, there’s usually an ophthalmologist who sees all the GVHD cases.

For patients with oral GVHD, there’s usually a dental specialist and a dermatologist, who could see skin or myofascial GVHD. One of the other things we know is that severe chronic GVHD can significantly impact the quality of life for both the patients and their family members. Oftentimes, once our patients are diagnosed with more involved chronic GVHD, they meet with our clinic social workers to make sure we are addressing their needs to the best of our abilities.

Corey S. Cutler, MD, MPH, FRCPC: It is tricky once the patients have been sent out closer to home after their initial transplant and 100 days are done, to have them come back to the transplant center for management of chronic GVHD. How do we deal with that? How do we talk to the referring oncologists and suggest when it’s time to refer the patient back to the transplant center for expert management of chronic graft-vs-host disease if that exists?

Joseph H. Antin, MD: That’s a very complicated issue. There are some centers that at day 100 send the patient back to the community physician and say, “Look, you know, it’s up to you. The patient doesn’t have to come to the center anymore, and we need to work together. Call us, and we’ll try and guide you.” At our center we have taken a more paternalistic approach. We have a regional transplant center. And although patients tend to have quite long drives, we have felt that it’s difficult to administer this type of complex therapy remotely. We are doing some telemedicine. We do communicate with the community doctors if a patient lives 4 hours away and has a fever, dry eyes, mouth sores, diarrhea. We do our best to try to get these things under control, and if the community oncologist or hematologist feels comfortable doing it and the patient responds to therapy, then great, but very frequently they don’t. They probably wouldn’t have responded immediately even if we had been treating them, and we do have to have a significant proportion of patients transferred to our center, so we can either enroll them on an investigational study or have more heads thinking about them who are skilled in the management of graft-vs-host disease.

Transcript Edited for Clarity