During the State-of-the-Science Lecture at the 43rd Annual Congress in Washington, DC, Jane Fall-Dickson, PhD, RN, AOCN®, of Georgetown University School of Nursing and Health Studies, discussed chronic graft-versus-host disease (cGVHD), specifically its oral cavity complications. She presented challenges, clinical data, and goals for improving its treatment and management options.
cGVHD is a major complication of allogeneic hematopoietic cell transplantation (HCT), a procedure in which a person receives blood-forming stem cells from a genetically similar, but not identical, donor. More patients are undergoing this procedure thanks to expanded indication, improved supportive care, and the ability to use unrelated donors. This has increased long-term patient survival as well as the risk and occurrence of cGVHD: Approximately 50% of patients will develop cGVHD after allogeneic HCT. The pathophysiology of this condition is not completely elucidated, she said, but noted that animal and human models point to immunologic mechanisms.
cGVHD resembles autoimmune disorders, and signs of the condition include oral ulcers, ocular sicca, nail dystrophy, fasciitis, bronchiolitis obliterans, loss of bile ducts, ulcerous scleroderma, and deep sclerosis. Fall-Dickson focused much of her talk on oral complications, which affect an estimated 80% of patients after HCT. The oral cavity is the most frequent site of cGVHD after a bone marrow transplant and the second most affected organ following HCT. Even mild levels of cGVHD can lead to significant impact on oral function, Fall-Dickson said.
She said that very few healthcare providers conduct an oral biopsy when a patient presents with oral complications, and proper identification, treatment, and management can be a challenge. Clinical diagnosis relies on patient history, context, and clinical exam; however, Fall-Dickson noted that only an oral biopsy can discriminate between cGVHD, dysplasia, and another malignancy.
Immunosuppression therapy is a mainstay for cGVHD; however, those agents can be highly toxic and lead to complications or infectious death. Ibrutinib recently received approval from the U.S. Food and Drug Administration for treatment of adults with cGVHD who have failed one or more prior therapies. The standard care also includes corticosteroids with or without calcineurin inhibitor, but no second-line therapies have received widespread acceptance, she said. Other options she mentioned were topical high- and ultra-high potency corticosteroid gel for localized disease, as well as corticosteroid elixirs and solution rinses. However, systemic immunosuppression and topical corticosteroids may offer only limited relief, and the majority of management strategies are not evidence-based, “which is a problem for us and has resulted in modest treatment advances,” Fall-Dickson said.
About 45% of patients with cGVHD live with late treatment effects for a prolonged period, potentially for the remainder of life. cGVHD-related oral pain, oral dryness, and taste alterations are of more concern to patients than the disease itself, she said, and may impact health-related quality of life. “This is a very serious condition, and the limited knowledge of supportive care needs leads to poorer quality care,” she said. Because of the lacking clinical research, effective novel agents are limited as well.
Fall-Dickson mentioned new treatment options under consideration: A National Institutes of Health-backed study is currently recruiting patients to assess dexamethasone to prevent oral cGVHD. Researchers at Massachusetts General Hospital are assessing topical dexamethasone and tacrolimus for oral cGVHD, and two hospitals in Brazil are examining combination clobetasol and dexamethasone for oral lesions.
“We need to get beyond steroids and move toward something unique,” Fall-Dickson said, highlighting the need for nurse involvement in these studies and discoveries because of their knowledge and close proximity to patients and their needs.