Many of the therapies for cGVHD are ancillary and/or supportive, and these treatments are often important in maintaining the patient’s comfort and quality of life. The 2014 Diagnosis and Staging Working Group report from the National Institutes of Health is an excellent resource on this topic. It provides an organ-based approach, which is a useful framework for evaluating the need for ancillary treatment.

The extent to which the use of such supportive care can reduce or replace the need for systemic therapies in patients with cGVHD is not well characterized. Consider dry eye, for example. In patients with mild ocular cGVHD, first-line therapy includes both lubrication and ophthalmic prednisolone with cyclosporine (0.05%-0.5%). High-dose steroids should be used for short periods only; however, dry eye can be a persistent, severe morbidity for which the use of scleral lenses may ultimately be needed to improve the patient’s chronic symptoms. We know that scleral lenses can help a patient to feel more comfortable. We do not know, however, whether using those lenses might spare the individual from having to take steroids or other treatments. There is very little research on this question. Outside of ocular cGVHD, there are many other elements of ancillary and supportive care to note, including patient education regarding osteoporosis, emollients and topical agents for skin involvement, steroid mouthwashes for oral involvement and areas of ulceration, and therapies to treat and prevent infections.

We are fortunate to have a variety of systemic treatments that have been recently approved by the US Food and Drug Administration for use in patients with steroid-refractory cGVHD. Belumosudil and ruxolitinib are the most recent additions, whereas ibrutinib was approved for cGVHD in 2017. Each of these agents is indicated for use after the failure of prior lines of therapy in adult patients and in pediatric patients aged 12 years and older with cGVHD. Unfortunately, our experience thus far with these therapies has been limited mostly to individuals who are steroid refractory and very advanced. A patient who has just been diagnosed with cGVHD and has failed steroids may be very different from someone who has had cGVHD for 10 years, in terms of their ability to respond to a new therapy. We are seeing activity with these newer agents in patients who have already had 3 or 4 lines of therapy, so this is very encouraging. My hope is that the changes we expect to see over the next several years will have a very positive impact on patient morbidity.