Background- The lack of standardized response criteria has been identified as one of the major obstacles in the development of new therapeutic agents for chronic graft-versus host disease (cGvHD). In 2004, the National Institutes of Health initiated a multidisciplinary consensus project, one aim of which was to develop criteria for measuring response in therapeutic trials for cGvHD (http://palladianpartners.com/GvHD/docs/). This report presents the results of the first pilot study evaluating the feasibility and reproducibility of these new response criteria.

Methods- Eight raters (Oncology Fellows and Oncology Nurse Practitioners with limited experience with cGvHD) participated in a 2 ½ hour training session designed to provide an overview of comprehensive response evaluation in cGvHD and an opportunity to practice conducting functional and organ-specific evaluations. Each participant received a syllabus and a photo atlas illustrating common oral, ocular, and dermatologic manifestations of cGvHD. Feasibility and inter-rater agreement between experts in cGvHD (transplantation, dermatology, oral medicine, and rehabilitation medicine) and the panel of 8 novice raters were evaluated using four adult patients with varying manifestations of cGvHD. Percent Agreement was calculated using the following formula: %Agreement = #Agreements/(#Agreements + #Disagreements) x 100

Results

Response CriterionExtent of Agreement Between Experts(Es)-Novices (Ns) Agreement
Erythematous and/or Papular Skin Rash 62% agreement between Es and Ns 
Superficial Sclerosis 62% agreement between Es and Ns 
Deep Sclerosis 83% agreement between Es and Ns 
Skin Ulcers 97% agreement between Es and Ns 
Oral Cavity Pearson correlations ranged from 0.43–0.92 
Gastrointestinal System Upper GI: 100% agreement; Esophageal: 83% agreement; Lower GI: 86% agreement 
Functional Performance Measures 2 Minute Walk: 66% of Ns within 95% CI of Es;Grip Strength: 75% of Ns within 95% CI of Es 
Karnofsky PS All Ns within ± 20% of Es 
cGvHD Mild, Moderate, Severe? All Ns rated consistently one severity category lower than Es 
Severity of cGvHD Symptoms (0–10 scale) All Ns scored symptom severity within ± 2 points of Es 
cGvHD Improving, Stable, Worse? (7-point scale) 50% of Ns in absolute accord with Es; 50% of Ns direction of change consistent with Es 
Response CriterionExtent of Agreement Between Experts(Es)-Novices (Ns) Agreement
Erythematous and/or Papular Skin Rash 62% agreement between Es and Ns 
Superficial Sclerosis 62% agreement between Es and Ns 
Deep Sclerosis 83% agreement between Es and Ns 
Skin Ulcers 97% agreement between Es and Ns 
Oral Cavity Pearson correlations ranged from 0.43–0.92 
Gastrointestinal System Upper GI: 100% agreement; Esophageal: 83% agreement; Lower GI: 86% agreement 
Functional Performance Measures 2 Minute Walk: 66% of Ns within 95% CI of Es;Grip Strength: 75% of Ns within 95% CI of Es 
Karnofsky PS All Ns within ± 20% of Es 
cGvHD Mild, Moderate, Severe? All Ns rated consistently one severity category lower than Es 
Severity of cGvHD Symptoms (0–10 scale) All Ns scored symptom severity within ± 2 points of Es 
cGvHD Improving, Stable, Worse? (7-point scale) 50% of Ns in absolute accord with Es; 50% of Ns direction of change consistent with Es 
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Clinical evaluation of a patient with cGVHD by the novice raters lasted a median of 36 minutes (range 19–60). Completion of the five patient self report measures (SF-36, Lee cGVHD Symptom Scale, Human Activity Profile, FACT-BMT, and cGvHD Activity Assessment Patient Self-Report) required a median total of 14 minutes (range 18–22).

Conclusions- We are currently improving the clarity of the skin and oral definitions, and refining the photo atlas and training syllabus. Pediatric modifications of these criteria will undergo testing in Fall of 2005. Although limited by small sample size, this pilot study offers preliminary evidence of the reliability and feasibility of these cGvHD response criteria, and supports their use for prospective validation in larger patient cohorts and clinical trials.

Topics:
graft-versus-host disease, chronic, sclerosis, exanthema, graft-versus-host disease, papule, skin manifestations, skin ulcer, tissue transplants, transplantation, upper gastrointestinal tract series

Author notes

Corresponding author

2005, The American Society of Hematology
2005
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