NCCN Guidelines: Pretransplant Recipient Evaluation and Management of Graft-Versus-Host Disease

Guidelines in Oncology (NCCN Guidelines) for Hematopoietic Cell Transplantation (HCT), with a focus on pretransplant evaluation and management of graft-versus-host disease (GVHD).Substantial progress has been made in acute and chronic GVHD clinical classification and trial design, and the discovery of new therapeutic targets has propelled the field rapidly forward.1-3 However, the basic principles of GVHD clinical management have not changed, though they have become more complicated with the development and even FDA approval of new drugs for this indication.Similarly, use of HCT has shifted with the development of novel therapeutics in leukemia and lymphoma and the emergence of a new field of immunotherapy.With the near universal availability of donors for each patient who requires transplantation, often difficult decisions need to be made regarding the appropriateness of HCTover these novel therapies.Clinicians must now consider the fact that patients live longer, and live better, after transplantation for a variety of reasons.With this in mind, the number of transplant recipients alive and at risk for longterm complications of cancer therapy and HCT is increasing rapidly.Although excellent guidelines on the recommended long-term management of HCT survivors exist, 4 there has been a long-recognized need for guidelines for GVHD management.Other societies have thus far shied away from publishing authoritative guidelines in the absence of rigorous evidence, although one comprehensive review and recommendation on the topic has been published.5 These first NCCN Guidelines are a well-intended attempt to start addressing the need for guidance in HCT for general oncology practitioners, but add little for the subspecialist transplant physician.They provide a framework for the development of comprehensive guidelines in the future and endorse all essential contemporary diagnostic standards.However, this first version is incomplete in several areas, leaving substantial room for improvement in future editions.For example, the refined Mount Sinai Acute GVHD International Consortium (MAGIC) classification of acute GVHD should be endorsed as a current standard, widely accepted by lead organizations in HCT for its improved practicality.6,7 This system has at least equaled if not supplanted the modified Glucksberg criteria in common use.8 The guidelines also do not mention the burgeoning field of biomarkers in GVHD and whether these should be used in any of the algorithms or in acute GVHD clinical trials.9 There is no reference to the crucial role of organ-directed therapy and supportive care in the treatment of chronic GVHD, a topic that already has an authoritative treatment guide.10 An overly uninformative approach is taken to corticosteroid tapering schedules, an aspect of paramount importance in successful GVHD management.No mention is made regarding the importance of referral to a tertiary transplant center.General statements that monitoring for posttransplant complications is required make no reference to the potential differences in complications facing patients undergoing autologous and allogeneic HCT.Omissions such as See page 599 for related article.