Impact of Chronic Graft Versus Host Disease (cGVHD) on the Health Status of Hematopoietic Cell Transplantation (HCT) Survivors: A Report from the Bone Marrow Transplant Survivor Study.
Authors: Fraser Christopher , Bhatia Smita , Ness Kirsten , Carter Andrea , Francisco Liton , Arora Mukta , Parker Pablo , Forman Stephen , Weisdorf Daniel , Gurney James , Baker K. Scott 
Published: April 2020

Abstract
Chronic GVHD is a common complication following allogeneic HCT. The aim of this study was to better understand the impact of cGVHD on the overall health status of HCT survivors.
Methods: We assessed 6 health status domains: general health, mental health, functional status, activity limitation, pain and disease related anxiety in HCT survivors with and without cGVHD. Eligible subjects underwent allogeneic HCT at either City of Hope or the University of Minnesota between 1974 and 2000, were 18 years or older at the time of the interview and had survived 2 or more years after HCT. Data was analyzed from 584 HCT survivors who were enrolled in this retrospective cohort study. All patients had completed a 289 item questionnaire. Information regarding diagnosis of cGVHD was abstracted from medical records and presence of active GVHD in the preceding year was self-reported. Outcome measures were chosen to facilitate a global assessment of health status. Questions assessing general health, functional impairment (needing help with personal cares, household tasks, inability to attend school or work) and activity limitation (inability to climb up stairs or walk one block) were adapted from the National Health Interview Survey, the Brief Symptom Inventory (BSI) was used to assess the mental health domain and patients were asked if they had pain or anxiety as a result of their primary disease or its treatment with HCT.
Results: Median age at time of HCT was 30.8 years (range: 0.4–62) and the median length of time since transplant was 8.1 years (range: 2–27.7). The prevalence of cGVHD in participants was 54%. Of those with cGVHD 46% reported GVHD within the previous year. In a model adjusted for gender, age, time since transplant, donor type and conditioning regimen, subjects with cGVHD were more likely to report adverse general health, functional impairments, activity limitation, pain and to score in the lowest 10% of population norms on the BSI compared to those with no history of cGVHD. These adverse health outcomes were most marked for those with active cGVHD. In fact, health status did not differ between those with resolved cGVHD and those who never had cGVHD (Table 1). At least one adverse health outcome was reported in 59% of subjects with cGVHD.
Conclusions: Active cGVHD has a significant impact on many aspects of the overall health status of HCT survivors. The impact was most marked in the domains of functional impairment, activity limitation and pain. Those successfully treated for cGVHD do not appear to have long-term impairments. Clinicians should be aware of the global impact of cGHVD and the need to provide ongoing care with appropriate interventions such as physical and occupational therapy and mental health support.
Table 1 cGVHD General Health Mental Health Functional Impairment Activity Limitation Pain Anxiety Odds Ratios (95% confidence intervals) compared to those never diagnosed with cGVHD Ever had 1.8 (0.7–4.5) 2.4 (1.1–5.7) 5.5 (2.7–14.5) 4.5 (1.9–11.1) 4.2 (1.6–11.3) 0.7 (0.3–2.2) Active 2.5 (1.5–4.1) 2.5 (1.5–4.2) 5.3 (3.1–9.0) 4.7 (2.8–7.7) 3.9 (2.3–6.7) 1.3 (0.7–2.5) Resolved 0.7 (0.4–1.3) 0.9 (0.6–1.6) 1.1 (0.6–1.9) 1.0 (0.6–1.6) 1.1 (0.6–1.9) 0.5 (0.3–1.1)