Graft versus Host Disease Practice Updates - Episode 11
Closing out their discussion on graft-versus-host disease, participants reflect on patient prognoses and the future directions of care.
Nelson Chao, MD: We touched a little on how to manage treatment-induced damage. Dr Cutler, what’s the long-term prognosis of this patient?
Corey Cutler, MD, MPH, FRCPC: It turns out that the long-term prognosis is not bad. There definitely is mortality associated with chronic GVHD [graft-vs-host disease]. I worry more about the morbidity that’s associated with chronic GVHD rather than the mortality. We would probably quote this person [as having an increase in] annualized mortality of only a few percentage points per year. That number doesn’t go away. We know that studies of BMT [bone marrow transplant] survivors suggest annualized mortality ratios that are much higher than age-matched controls for up to 20 years beyond their transplant. Even if you go out to 15-plus years, the standardized mortality ratio for this person is 2 1/2-fold higher than it is for an age-matched control, based on some of the BMT survivors studies out of the City of Hope center. So as was just mentioned, one has to be very careful in taking care of the other potential long-term sequelae of both the GVHD itself, the transplant itself, and the therapeutics we use to treat chronic GVHD, all of which contribute to the long-term morbidity and mortality of this patient.
Nelson Chao, MD: I couldn’t agree more. I think this is where a partnership with their local provider is really important. Many times patients return to their home and don’t want to come back, and therefore come back infrequently. And so, I think knowing where the potential damage could be, or could be developing, is really important. We didn’t talk too much about secondary malignancies, but this is clearly a significant morbidity and potential mortality for these patients, where the cumulative incidence of secondary malignancies does go up significantly. This is not because they have chronic GVHD, but is rather from all the prior regimens that they had. I think these are really important points. I’m going to leave the last word for you, Dr Cutler. Can you share the summary of the field, where you are the guru of chronic GVHD? Where do you see this field going, and what can we expect next?
Corey Cutler, MD, MPH, FRCPC: I think it’s quite an exciting time to be working in the field of chronic GVHD, with 3 drugs approved in the last 5 years and likely more to come in the next few years. I think this is exciting for our patients, and it’s going to change long-term outcomes for sure. Where we need to go is a much more personalized approach to chronic GVHD therapy, finally deciphering which patients have a dominant biologic pathway driving that GVHD and targeting that pathway initially, rather than the guesswork that we currently do to choose appropriate agents. I think further prophylactic strategies or even preemptive strategies against chronic GVHD are really important, and probably are going to markedly diminish the long-term impact of chronic GVHD, both in terms of severity and incidence. And for that reason, I think transplant in the long term is going to have improved outcomes as chronic GVHD becomes less of a burden, both in terms of morbidity and mortality. So, I’m pretty bullish on the field at the moment.
Nelson Chao, MD: That’s terrific.
I wanted to close by thanking our panel for the thoughtful case presentations in the form of discussion. To our viewing audience, thank you for joining us for this Targeted Oncology™ Virtual Tumor Board® presentation. We hope today’s discussion was a valuable use of your time and that you acquired practical knowledge that can help you in your clinical practice. Thank you.
Transcript edited for clarity.