SPEAKER 1: Long-term corticosteroids have a lot of toxicities that blend into the syndrome of chronic graft versus host disease, sometimes becoming more problematic than graft versus host disease itself. So in people that don't respond to corticosteroids, or that have a partial response to corticosteroids, then we have to initiate second line. And I would say that this is the majority of people with moderately severe to severe chronic graft versus host disease as defined by the NIH consensus criteria.

Second lines are also multiple in chronic versus host disease. Probably the second line of therapy that has been more extensively studied in chronic graft versus host disease has been extracorporeal photopheresis ECP. And there's quite a bit of data here. There is one randomized study by Flowers and collaborators that although it did not reach its primary endpoint, it showed that chronic graft versus host disease of the skin was actually improved by the use of ECP as a second line therapy in people that did not respond favorably to corticosteroids.

This study has been published a few years ago. There are multiple other studies that are single, non-randomized, that is phase 2 type of data. We published at MD Anderson, when I was there, a large cohort of 71 patients that showed good response rate of chronic graft versus host disease in different organs, including eye, mouth, skin, and also liver, as I mentioned previously, and very importantly too, 50% response rate in chronic graft versus host disease of the lung, which although is not very frequent, it occurs in approximately 5% of patients, it can have a tremendous impact on outcomes.