GvHD: Advice for Patients

EP: 1.An Overview of Graft vs Host Disease (GvHD)

EP: 2.Regimens Used for GvHD Prevention

EP: 3.Clinical Implications of the Phase III BMT CTN 1703 Trial

EP: 4.Future of Acute GvHD Prevention

EP: 5.Acute GvHD: Clinical Presentation, Risk Factors and Treatment Options

EP: 6.Steroid Refractory Acute GvHD and REACH Trials

EP: 7.Novel Agents in Acute GvHD

EP: 8.Defining Chronic Graft vs Host Disease (GvHD)

EP: 9.Treatment Options for Chronic GvHD

EP: 10.Treatment Options: Steroid-Refractory GvHD

EP: 11.Future of Chronic GvHD

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EP: 12.GvHD: Advice for Patients

Transcript:

Corey Cutler, MD, MPH, FRCPC: Chronic GVHD [graft-vs-host disease] is hard on our patients emotionally and psychosocially. How do you counsel your patients who are developing chronic GVHD about what’s in store for them in the next 6 to 12 months, and 12 to 24 months? What do you tell your patients in this scenario?

Hannah K. Choe, MD: On the 1 hand, obviously, a difficult part of chronic GVHD is [that this is a] lifelong disease. The positive side is that as of 2 years ago, we have new drugs emerging and more clinical trials and interests brewing to develop more clinical trials [and find] more durable responses. The patients on the ROCKstar trial stayed on for a median of 54 weeks. That’s incredible compared with the previous lines of therapies that we’re offering. It’s an optimistic outlook that I try to leave them with.

At the same time, there are a lot of good things happening, particularly with the [Meredith A.] Cowden Foundation, which is an incredible nonprofit group that’s essential for GVHD research and support. They’re doing a lot more with GVHD patient advocacy, and BMT InfoNet [Blood and Marrow Transplant Information Network] now has GVHD support groups. Those things are emerging to be better resources for our patients as well. The counseling is that, unfortunately, this is a long-term disease. If we can identify it earlier, which we’re trying to do, we can hopefully prevent the more severe outcomes. At the same time, even for those outcomes, we have better treatment options available for you and more clinical trials in the pipeline.

Corey Cutler, MD, MPH, FRCPC: Doris, what do you tell patients about multidisciplinary approaches to therapy, using more than 1 physician to treat these patients?

Doris M. Ponce, MD: We’re very supportive of this approach. As we learned, graft-vs-host disease is a multiorgan problem, and sometimes we can benefit from additional input. For example, if they go to a specialized ophthalmologist, we work with them. They can provide Tears Plus and scleral lenses, which will enhance and improve their quality of life. At [Memorial] Sloan Kettering [Cancer Center], we have a multidisciplinary team, and we work with a nutritionist and a rehab physician to incorporate physical therapy and OT [occupational therapy]. We also have a dermatologist who can assist with patients that could develop severe ulcers and they need additional care. We also work with a dentist. We have an endocrinologist for patients on steroids, who can get diabetes as well. We have a pulmonologist and other professionals as needed. We believe that comprehensive multidisciplinary care can help our patients get better. If they engage in physical therapy and physical activity, they have a better quality of life.

At our practice, we’ve been monitoring quality of life with PROMIS [Patient-Reported Outcomes Measurement Information System], and we see an improvement. It’s not only about offering the drug. It’s also about taking care of our patients and spending time with them, explaining what’s expected and how can we try to make their condition better. If they want to know what to eat, we say, “These are the foods we recommend.” If you have a GI symptom, we could customize it better for you. Having a nutritionist in hand is important because they give a very customized answer and guidance. There are a lot of resources for patients. Connecting with groups is important, whether they’re in Spanish or English. Having that connection and telling our patients where to go is important because they feel they’re part of the community.

Corey Cutler, MD, MPH, FRCPC: We’ve covered a fair amount of ground today. I want to thank all 3 of you for this rich, informative discussion. Yi-Bin, tell us what you think will be the greatest thing to come in GVHD in the next few years. What are you looking forward to the most?

Yi-Bin Chen, MD: We’ve made a lot of progress, but we’re not close to being done. We can’t rest on our laurels and claim victory. It’s gratifying to see that for acute GVHD, we’re doing risk-stratified studies. We now have 2 successful studies of steroid-free treatment for low-risk GVHD. For high-risk GVHD, we need to figure out how to treat high-risk disease. Is it going to be steroids plus another drug, whether it’s a drug for stem cell preservation, organ resiliency, or something else? We have to figure that part out. That’s the No. 1 priority. Up-front treatment of high-risk disease is probably the biggest thing going forward in acute care. In chronic [GVHD], as I talked about before, we must figure out who’s responding to what. That’s a task for the whole community to collaborate, to collect samples, and to do discovery of chronic GVHD biomarkers, to help risk stratify but also to predict patient response to certain treatments.

Corey Cutler, MD, MPH, FRCPC: Doris, what are your final thoughts?

Doris M. Ponce, MD: In the future, we’ll be trying to fulfill the unmet needs that we currently have, with more customized treatment for our patients. We’re aiming to raise the bar for what to achieve. What if we aim for a higher CR rate in our patients and a better quality of life? Definitely, we love and hate corticosteroids. That can be part of the armamentarium, but we want to minimize exposure to steroids if it’s needed. A steroid-free treatment for certain customized patients who we could identify is something that I hope we can achieve in the future.

Corey Cutler, MD, MPH, FRCPC: Hannah, what are your final thoughts?

Hannah K. Choe, MD: As we look into identifying these biomarkers, we’re going to find new targets, and that’s going to open the landscape for new therapies. I’m excited about understanding the science a little more and the immunology of the disease, which we’re admittedly a little naïve to.

Corey Cutler, MD, MPH, FRCPC: I’m looking forward to seeing a reduction in the overall incidence of acute chronic graft-vs-host disease. We didn’t discuss other methods of chronic GVHD prevention, which are going to come into play in the coming years, and getting rid of steroids as the mainstay of therapy in chronic GVHD. That will be our next major hurdle.

With that, I want to thank you all again and thank our viewing audience. We sincerely hope you found this OncLive® Peer Exchange® discussion to be useful and informative.

Transcript edited for clarity.