From Steroids to Second-Line Therapy—What Drives the Move? 

Moderator: Welcome to today’s episode of our podcast series. I’m Jenny Lamberts with Oncology Learning Network, and I’m delighted to have you with us. This program is designed specifically for oncologists and transplant specialists, focusing on the evolving landscape of chronic graft-versus-host disease, or GVHD, management. 

Our discussion today centers on an important and timely question: What drives the move from steroids to a second-line or even third-line therapy in chronic GVHD? Is it the formal definitions that guide clinical trials, or does real-world practice tell a different story? At the heart of this lies the importance of accurate symptom classification—not just as a research endpoint, but as a driver of everyday treatment decisions and patient outcomes.  

To explore these critical issues, we’re joined by Dr Betty Hamilton, who brings deep expertise in the management of chronic GVHD. She will help us unpack how symptoms are classified, why those definitions matter, and how they influence the transition from frontline steroid therapy to second- and third-line options. 

Let’s get started with Dr Hamilton as we navigate the interplay between trial definitions, real-world practice, and the ultimate goal of improving outcomes for patients with chronic GVHD. 

Dr Hamilton: Hi, my name is Betty Hamilton. I am an associate professor at the Cleveland Clinic in Cleveland, Ohio. It's great to be here. And that’s a great question and gets to the crux of a lot of our basically alternative agents that we have now and that fortunately we do have now. 

I think when we talk about second-line therapies, a very important factor is just all the toxicities that we see with steroids and that we're aware of with steroids. But in clinical practice, when you have a patient with hyperglycemia, swelling, poor sleep, poor mood, fairly early on in their course, especially older patients—we're transplanting more older patients—I tend to reach for those second-line therapies sooner rather than later. 

And there are some ongoing trials that are actually trying to move up some of these therapies and randomizing patients to non-steroid therapies as well. And then, when you think about third-line therapies, it's really sort of that balance of not only efficacy, but really the toxicity too. You know, if a patient is not tolerating a therapy well, I think that's a big component that's not necessarily in a definition, but that is really relevant to clinical practice. 

Moderator: Thank you, Dr Hamilton, for helping us examine how symptom classification informs decision-making in chronic GVHD. Your insights highlight the nuances between clinical trial definitions and what we see in practice.  

As we’ve discussed today, the move from steroids to second- or even third-line therapies isn’t made in a vacuum. It hinges on how accurately we define and interpret symptoms. That classification guides trial design and plays a decisive role in determining when and how we escalate therapy in real-world settings.  

On behalf of our team, thank you for joining us for this episode. We hope this discussion supports your practice and your patients. Visit the Oncology Learning Network website for additional resources.