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Announcer:
You’re listening to Project Oncology on ReachMD. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
Welcome to Project Oncology on ReachMD. I'm Dr. Charles Turck, and joining me to share their perspectives on how we can optimize the care of patients with chronic graft versus host disease, or GVHD for short, are Drs. Doris Ponce and Annie Im. Dr. Ponce is the Director of the GVHD Program of Adult BMT at Memorial Sloan Kettering Cancer Center in New York City. Dr. Ponce, thanks for being here today.

Dr. Ponce: 
Thank you very much. Thank you for having me.

Dr. Turck: 
And Dr. Im is an Associate Professor of Medicine in the Division of Hematology and Oncology at the University of Pittsburgh School of Medicine. Dr. Im, it's great to have you with us.

Dr. Im: 
Thank you so much for having me.

Dr. Turck: 
Well starting with you, Dr. Im, would you share some best practices for recognizing and diagnosing patients with chronic graft versus host disease?

Dr. Im: 
Sure, and thank you for this important question. I do think that early detection and diagnosis of chronic GVHD really is key to being able to treat and manage symptoms and manifestations before it progresses too far. So what we do in our practice is we screen all patients for all symptoms of chronic GVHD. There are, of course, some features of chronic GVHD that we know are diagnostic and that are common manifestations, things that a patient would notice. And so of course, we're looking out for those types of things, but even beyond that, for symptoms and signs that may not be either as well recognized or maybe things that patients might recognize as something to talk about or to report; we like to go through all of the systems and all of the organs and screen patients for any kinds of signs or symptoms of chronic GVHD. So we do these in our patients who are survivors of transplant and anyone who's post transplant and look for these signs and symptoms. We know that chronic GVHD can happen most commonly within the first year, but even any time after that, so we continue to ask about signs and symptoms.

Dr. Turck: 
And as a follow-up to that, Dr. Im, how do you tailor your treatment approach based on a patient's unique goals and needs?

Dr. Im: 
Yeah, that's a great question. I always like to say to patients and their families that the treatment of chronic GVHD has really two approaches. And so on the one hand, we want to be thinking about treating and approaching the underlying immune problem, which is the underlying immune cells that are detecting things in the patient's body as foreign. Right? So we want to first talk about systemic treatments if that's indicated, and this really is for the either moderate or severe chronic GVHD. And so there's treatments that are targeted towards the immune system and suppressing that immune system.

On the other hand and equally as important to talk about when we're talking about management is treating organs or some of the symptoms that patients may have. And these might not be treatments that stop the underlying process of chronic GVHD but can really make a difference in helping patients to feel better and to help mitigate some of their symptoms. And so those are always two approaches that we're talking about simultaneously.

Dr. Turck:
Turning to you now, Dr. Ponce, who are the key members of the GVHD care team?

Dr. Ponce: 
Sure, that's also a very important question. So if we look at graft versus host disease, we'll see that typically multiple organs are affected, especially when they come to our practice, they tend to have a more advanced graft versus host disease. And the organs most commonly involved include the mouth, the eyes, and the skin. So based on that, we design a multidisciplinary care clinic with this model; we have other places around the country that have a similar one, where there are multiple care providers that help to take care of these patients.

So at my institution, we have a trained nurse who she's dedicated to graft versus host disease, and she does conduct a very dedicated review of system focused on graft versus host disease. And part of our care team members includes dermatologists, so again, the skin is a common organ involved with graft versus host disease. We do have a dentist, as well. We have a rehabilitation physician, who's very critical because patients tend to have difficulties with range of motion. So it's quite critical to teach the patient how to navigate and how to improve their mobility. We also have a nutritionist as a part of our team, which we had found very, very critical because again, our patients might have issues with their food and their nutrition, but also sometimes if they can Google and get information that might not be customized to their issue, like they have mouth sensitivity and what kind of food will be better. So for those kinds of things, nutritionists are very resourceful. And we recently added an ophthalmologist, which certainly is a great addition to our practice. And on top of that, we do have a pharmacist and a social worker as needed. And other services as needed include pulmonary, gynecology, and gastroenterologists.

Dr. Turck:
For those just tuning in, you're listening to Project Oncology on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Drs. Doris Ponce and Annie Im about the management of patients with chronic graft versus host disease, also known as GVHD.

So, Dr. Ponce, if we continue focusing on the multidisciplinary team, would you tell us about a case that demonstrates collaborative and patient-centered care in action?

Dr. Ponce: 
Of course. So I remember we had a patient who came with advanced chronic graft versus host disease as a new visit. And this particular patient has severe oral graft versus host disease; he could barely really swallow, and oral intake was quite limited. And on top of that, he had skin involvement with ulcers, which caused issues with also range of motion. So it's a perfect case because it illustrates how the collaborative effort is important.

So in this case, we have our dermatologists who help with wound care and how to approach the specific issues he had in the skin throughout. We took care of systemic treatment. For oral graft versus host disease, we have our dentists who provide guidance in oral care while also a thorough evaluation of their mouth with samples, and we also did a biopsy. We also requested GI assessments as the patient had difficulty swallowing. And there were concerns that the oral GVHD could have a possible component of infection. So that was very critical. And also we have our rehabilitation physician, who helped us to guide a customized physical therapy for our patient. This patient had range of motion difficulty, and in how to navigate activities of daily living and how to improve flexibility, our rehabilitation physician was quite resourceful. So the patient assessment was done in a one-day visit, excluding the GI that he eventually got a upper endoscopy. And this was scheduled for a different day, but everything else was done on the same day. And honestly, having the input from all the physicians really crafted a very customized treatment for our patient and enhanced the care of the patient.

Dr. Turck: 
Now before we close, I'd like to hear some key takeaways from each of you on how we can optimize our approach to chronic GVHD. Dr. Im, let's hear from you first.

Dr. Im: 
Sure, thank you. So, you know, a couple of thoughts. I think that education really is key. Education for our providers, who may be taking care of patients as well as education for patients and families. You know, as you heard Dr. Ponce mention and talk about, this really is a multidisciplinary approach. And it's always a team of providers that really are, I think, essential in taking care of patients with chronic GVHD. And so I think it's really important to find care that's going to provide the team-based approach. It really, again, is important to know that there are a team of people that are involved because everyone has their own area of expertise that I think is really essential in caring for these patients.

And the last thing that I'll say is the field has really exploded in the past several years in terms of newer therapies and FDA-approved drug options that we have for treatments that are effective and well tolerated. And so I think that it's really important to continue this research and to continue to be involved in this research. For patients and their families, I think it's a great opportunity to find research studies and clinical trials that provide access to newer drugs or that may be asking other really important questions in chronic GVHD. And so I really look forward to continuing to be a part of this field and seeing that this field move forward. So it’s a really great opportunity for patients and their families to be a part of this.

Dr. Turck:
Thanks, Dr. Im. And Dr. Ponce, you have the final word.

Dr. Ponce: 
Thank you very much. So I think following from what Dr. Im highlighted, it's a team effort in terms of care. And adding to that, patients can be their own advocate. We see this when patients return back to their community, there's still a need to continue to assess if there's any unusual symptoms. I think it's important to just have a conversation with your transplanter or your primary physician who is the person providing care, and point those because it could be something related to graft versus host disease or might not. And the earlier that we start treatment and we detect, the easier it is really to manage. We don't want to get a patient when they are very advanced with their symptoms because reversibility can be more difficult, whereas if they’re starting with symptoms of graft versus host disease and they’re mild, it will be easier to control and to treat. So patient advocacy is important.

Dr. Turck:
Well with those comments in mind, I want to thank my guests, Drs. Doris Ponce and Annie Im, for joining me to discuss how we can better manage patients with chronic GVHD. Dr. Ponce, Dr. Im, it was great having you both on the program.

Dr. Im: 
Thank you so much.

Dr. Ponce: 
Thank you for having us. Thank you.

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