Graft versus Host Disease Practice Updates - Episode 6

Scenario 2: Identifying Chronic GVHD and Risk Status

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Shared insight on how to distinguish chronic GVHD from acute GVHD, as well as utilize appropriate methods to risk stratify disease.


Nelson Chao, MD: So what percentage of patients with acute GVHD progressed to chronic, Dr Cutler?

Corey Cutler, MD, MPH, FRCPC: It’s variable. You know, we used to say that acute GVHD [graft-versus-host disease] was the most important risk factor for chronic GVHD. I don’t think that’s necessarily true any longer. And so, acute GVHD is certainly not a prerequisite for chronic GVHD. The 2 processes might arise out of the same immunologic phenomena, but 1 doesn’t necessarily lead to the other. And certainly, there are many patients who develop no clinical acute graft-versus-host disease, but who develop chronic GVHD. So I do think about them as entirely separate entities, but still recognize that the development of acute GVHD is a risk factor for chronic GVHD.

Nelson Chao, MD: I would agree with that. Although I think if you have acute, the chances you’re going to get chronic are clearly much higher than if you’ve not had acute. You know, they’re clearly in over chronic, which we see frequently. How is a management of chronic GVHD different from acute?

Kerry King Minor, MSN, ANP-BC: Well, for chronic, it can include a wide range of organs versus with acute just being mostly liver, gut, and skin. So, with that, I feel like we find ourselves pulling from several different specialists to make it more of a multidisciplinary approach to these patients. Like for this patient with the drop in the FEV [forced expiratory volume] 1, are we going ahead and reaching out to our pulmonary colleagues with the sclerodermatous changes? Are we reaching out to our derm [dermatology] colleagues for thoughts on if there’s a role for light therapy, or ophthalmologists for something other than just the basic usual topicals that we may use? And then, on top of that, these are not managements that I feel like are going to go away as quick as the acute side of things. So I’m usually getting social work and our pharmacy techs involved to help with patient assistance. Because these patients will be on more than likely their prophylaxis, and some of these drugs for a very long period of time, and they may at this point have run out of funds. They’re well into this transplant course and are struggling. Not to mention the counseling support too from social work, because they again will tell you, “I don’t remember hearing about this. You know, I knew there was the first 200 days, but here we are, 2 years in and now I’m debilitated from these symptoms.” Plus, they have moved back home, and they don’t want to come as often. You know, sometimes management includes ECP [extracorporeal photopheresis], which requires a special center and requires frequent visits. They just did not have this on their radar, and they’ll tell you so. Also, I feel like they don’t want to come as often, so they want you to involve their local oncologists. A lot of local oncologists don’t feel comfortable, which is rightfully so. Therefore, the follow-up is much harder versus when they’re in your day hospital for the first 100 days and you’re already seeing them every day.

Nelson Chao, MD: I think that’s a really important point, which is that their psychosocial well-being and the quality of life becomes even more important in the chronic setting with chronic GVHD.

Corey Cutler, MD, MPH, FRCPC: So we talked a little bit about this. This is a chronic GVHD assessment. It has 10 points plus performance status. So the skin, the sweat glands, the fascia, the eyes, the mouth, the lungs, genital tract, weight loss. This is put together in the NIH [National Institutes of Health] clinical scoring and organ systems, which captures these organs on a scale of 0-3. So it’s a 4-point scale, at least you can see it goes from score 0 with no symptoms all the way to severe symptoms, and each of the organ sites that has 1 of these scores. This is put together in a global severity score. So mild chronic GVHD is 1-2 organs involved with no more than a score of 1, plus no lung involvement. Severe, on the other hand, is at least 1 organ with a score 3 or lung score of 2 or 3. And then, the moderate chronic is 3 or more organs with no more than a score of 1, or 1 organ, but not lung, with the score of 2, or lung with a score of 1. This gives us the opportunity to be uniform in our scoring of chronic GVHD. This is really critical, especially when we're starting to conduct large scale clinical trials, so that we can actually compare and use the same language across different centers.

Nelson Chao, MD: So what is the patient staging based on this criteria just discussed?

Corey Cutler, MD, MPH, FRCPC: We had a patient with dry eyes, then scleroderma changes, decrease in motion, and a drop in the FEV1, DLCO [diffusing capacity for carbon monoxide], and PFTs [pulmonary function tests]—that’s dyspnea. So this patient does get a lung score of at least 1 and obviously has a moderate graft-versus-host disease at this point. The lung score, as you can see from that scoring table, is the most prominent organ, which predicts very poor outcome at this point.

Transcript edited for clarity.