Chronic graft-versus-host disease (cGVHD) is a complex condition that can affect multiple organ systems and requires a range of specialized interventions. Multidisciplinary care is important to ensure the proper recognition and treatment of cGVHD. In this roundtable discussion, our experts talk about the benefits of a team-based approach to care for optimal patient outcomes.

The approach to the care of patients with cGVHD, by definition, should be multidisciplinary because there are multiple organs involved. The big challenge lies in determining how to put that into practice. Those of us who practice at larger centers often have the luxury of having a cGVHD clinic that offers this multidisciplinary approach. At our center, for example, the cGVHD clinic has ophthalmologists, dermatologists, transplant physicians, and physiatrists who see most of our patients with cGVHD, and we can also pull in additional experts as needed. This approach allows patients to be seen holistically and not just by the transplant physician. That is a model that certainly can be set up at larger centers.

Another challenge is determining how smaller centers that may not have the same resources can replicate this model. I think it is important that these smaller centers partner with the right experts within the center, identifying an ophthalmologist and dermatologist, for example, who have an interest in cGVHD and, in some way, recreating a virtual clinic (if not a physical one) that can provide more global care to the patients. Dr Cutler was involved with a journal supplement that addresses some of those issues.

I think that something worth highlighting is the importance of bidirectional communication between the transplant team and the local oncologist who resumes care of the patient. The local oncologist may not necessarily know how to manage cGVHD, but they can at least recognize cGVHD and know when to call us. Patients also need to be proactive and call at the first signs of cGVHD onset.

We are trying to ensure that every patient has access to a knowledgeable subspecialist. But, as Dr Perales said, not every center, unfortunately, can have on-site expertise co-localized with the transplant team. Patients who live far away from a large center need to be able to access specialty ophthalmology, dermatology, and pulmonary medicine. So, it is part of our mission to educate community-based providers on what they should be looking for when they are faced with a patient with cGVHD. Further, the journal supplement that Dr Perales mentioned provides a nice review of some of the major manifestations of cGVHD and thoughts from within the subspecialties of cGVHD. We are hoping that both academic subspecialists and community-based providers will use it as a tool.

I also think that patients can benefit from knowing more about what to look for and from being active participants in their care. A major component of that is being early reporters and identifiers of the signs and symptoms of cGVHD.

Even at a place such as Massachusetts General Hospital, you have to grow and build what you want to be there. A dermatologist does not necessarily have cGVHD expertise from the inception of their practice, but they grow this expertise with referrals. Further, patients are very appreciative of our ability to get them in to see specialists more quickly than they could in the community.

We perform a cGVHD screening even for individuals with minimal symptoms; for those with more severe symptoms, we consider oral medicine and have pulmonary specialists whom we refer patients to. Another aspect to keep in mind is that patients with cGVHD are at a higher risk for developing other medical complications/issues (whether those are cardiovascular or renal), which we call “late effects after transplant.”

At my center, we have implemented a survivorship program for our patients, where, approximately 1 year after their transplant, they meet with designated members of our survivorship team, which includes clinical providers and a social worker. We not only assess what is going on with their cGVHD but also take into account the chemotherapy and treatments for their malignancy that they were taking going into the transplant. Additionally, we assess for any psychosocial distress that patients may be experiencing from their cGVHD to try to give a holistic plan that serves as a roadmap for these patients. We are able to share that with their local providers, whether they are primary care physicians, oncologists, or subspecialists, so that everybody can try to get on the same page to optimize the care of these patients over the long-term.