Taking a Multidisciplinary Approach to Thyroid Cancer Treatment

“We are now able to increase the lifespan in some of these most deadly forms of thyroid cancer solely due to gene profiling and targeted medicine,” said Geoffrey David Young, MD, PhD, FACS.

Amidst an evolving treatment landscape for patients with thyroid cancer, CancerNetwork® spoke with Geoffrey David Young, MD, PhD, FACS, chief of head and neck cancer surgery at Baptist Health, Miami Cancer Institute, on therapeutic practices and opportunities for improving patient outcomes now and in the future. Young provided comprehensive insights on disease management strategies for patients with thyroid cancer, focusing on ways to mitigate risk and the role of multidisciplinary care.

Young also discussed advances in imaging technology and the evolving role of molecular biomarkers in the treatment space, highlighting how BRAF mutations can help inform diagnostic and therapeutic practices. Looking ahead, he discussed the current research landscape and offered advice to community oncologists treating patients with thyroid cancer.

Q: Can you describe ways to mitigate the risk of thyroid cancer?

Young: Interestingly, there have been a lot of studies about cancer in general regarding maintaining a healthy weight, and thyroid cancer was borne out in the studies that if you are able to maintain a healthy weight and avoid obesity, it decreases your risk for thyroid cancer. We have seen that patients who have obesity or morbid obesity have an increased risk for thyroid cancer. That is one of the ways that you can help mitigate risk.

The other [way] is that we know that there is a radiation association with thyroid cancer, so people who are working around or exposed to radiation should mitigate their exposure. [If you are] working in labs, make sure that you have a thyroid shield on when you give x-rays, [and so on]. It is common in practice to help mitigate radiation exposure risks, which can be one of the causes of thyroid cancer.

Q: How can multidisciplinary efforts be utilized during diagnosis, treatment, and survivorship of thyroid cancer?

Young: One of the most interesting things about any cancer is the teamwork involved in treating a patient, and thyroid cancer is no exception to that rule. The thyroid cancer team usually consists of an endocrinology component, a surgical component—an ear nose, and throat [doctor], head and neck surgery, endocrine surgery—a lot of different subspecialties that are all capable of managing thyroid surgery and thyroid cancer. We often will need the expertise of our radiologists to help with imaging studies, our interventional radiologists for biopsies, and even our radiation oncologists and some endocrinologists, who will often prescribe doses of radioactive iodine. There is an important diagnostic component.

One of the things that has been introduced in the more [immediate] future, and certainly something we are lucky to have available to us, is nurse navigation. Nurse navigators help the patients go through all these various avenues and maintain their treatment path, sometimes even into survivorship. Obviously, these diseases tend to have a good prognosis, which is fantastic in the world of cancer, so we do have a lot of long-term survivors of thyroid cancer, and it is important to consider that we want their survivorship to be reasonable and not overwhelming once they have survived the disease.

Q: Are you able to touch upon a few of the latest advancements in imaging technologies for thyroid cancer? How often are these recommended for patients?

Young: [Most of the] imaging for thyroid cancer relies on ultrasound which, like any technology, gets better and better as time has progressed. Now, not only are ultrasounds clearer and easier to use, but they are also more readily available. A lot of doctors, endocrinologists, and surgeons have these in their offices and are able to utilize them. That has been a very nice component of it.

Nuclear imaging for thyroid cancer has also progressed. We have better technologies with SPECT [single-photon emission computed tomography] imaging that [combines] the nuclear medicines with the CT scan, so you get a better anatomic representation of where the disease is. [There are] certain types of PET scans. PET scans usually rely on radioactive sugar as the contrast. You can use different isotopes of different compounds in a PET scanning capability to look at disease. This becomes very important in the metastatic disease setting as well. We have had the basic tools for imaging for thyroid cancer that have been technologically advanced and combined to provide more specific, better-quality imaging that helps not only the diagnosis but also surgical planning, etc, for these cancers.

Q: Are there any new biomarkers that are being used to identify patients who are high-risk or to help monitor disease progression? How accessible are these to patients and clinicians alike?

Young: From a biomarker standpoint, we did a lot of research looking at BRAF mutations in thyroid cancer. These mutations are helpful to know once the patient is diagnosed, and they are also helpful in the diagnosis of thyroid cancer. Initially, to diagnose thyroid cancer, all we had was cytology. You looked at what the cells looked like under a microscope. When you are looking at a small smattering of cells that you get from a fine needle aspiration, which is what is ordered for a thyroid nodule that has concerning features, it is often difficult to tell whether there truly is cancer there. Those [samples] in between benign and cancer would cause a struggle for a lot of the cytopathologists who are reviewing these.

In the past decade or more, we have had the advent of molecular genetic profiling of these tumors to give a malignancy risk. There have been a lot of biomarkers and specific genes that have been identified as part of those paradigms in what they are looking at, as far as the genetic composition of these nodules, to identify whether they are malignant or not. Because of that, a decent amount of cytology is now referred out for molecular testing to help in diagnosis.

In treatment, it is a bit of a different story. Mainly molecular profiling and looking for specific gene mutations for your garden variety follicular or papillary well-differentiated thyroid cancers has not gained ground in utility as far as changing what we do. For poorly differentiated anaplastic tumors, there has been a big change in what we do. Patients with BRAF mutations in those tumors can get the appropriate targeted therapy, and we are now able to increase lifespan in some of these most deadly forms of thyroid cancer solely due to gene profiling and targeted medicine for them. It is very important in that role.

There have also been several new compounds that have come out in medullary thyroid cancer, which can also be hereditary and part of MEN [multiple endocrine neoplasia] syndromes that are targeted to specific mutations in medullary [disease]. That is how that fits in. We do not quite have circulating tumor markers, other than thyroid globulin, which is not a specific, targetable compound, but something we can also use to follow for the recurrence of thyroid cancer in the blood.

Q: Are there any promising targeted therapies, immunotherapies, or combination therapies on the horizon for thyroid cancer?

Young: Yes, mainly in the more advanced states. In metastatic disease or for poorly differentiated anaplastic cancers, we now have more forms of therapy based on identified targets. Patients, even with metastatic papillary cancers with BRAF mutations, might be eligible for some targeted therapy in addition to some of the other tyrosine kinase inhibitors that are available to treat patients with metastatic disease. That is an ongoing endeavor in the treatment of all cancers, including thyroid cancers.

Q: What are some of the current clinical trials that patients with thyroid cancer might be eligible for?

Young: There is not a tremendous [number] of clinical trials for well-differentiated thyroid cancers. That is probably a good thing because it means that patients do so well that there is not a lot of need for change. However, for the patients who do not do well—patients who develop metastatic disease, patients with poorly differentiated anaplastic cancers, and some of the medullary cases—we have seen an increase in the need for clinical trials in those arenas. There are some [trials] for anaplastic, poorly differentiated, medullary, and well-differentiated thyroid cancers, but not as many as there are in other cancers.

There is also an interesting take on things, where some institutions are doing clinical trials looking at observing known thyroid cancers and watching small thyroid cancer. These are based on studies that have been done—mainly in Asia—in which long-term monitoring of thyroid cancers, including active surveillance, shows that the disease rarely propagates to the point where an intervention is required. In enough patients, some of these studies have shown that long-term surveillance of certain thyroid cancers may be acceptable. This is something we are looking into at various institutions in this country as to the role of active surveillance of thyroid cancers and which patients might benefit from that. The mainstay of the treatment of thyroid cancer is still surgery, so that is because those things are being undertaken in more of a clinical trial kind of scenario.

Q: What should community oncologists know about the advancements of thyroid cancer treatment and what piece of advice do you have to give to them?

Young: As is with anything in medicine, this is a constantly evolving field. The nice thing is we have great guidelines from various societies. The ATA [American Thyroid Association] has wonderful recommendations for thyroid cancers, [including] how much surgery we should do and when to give radioactive iodine. We have all these wonderful guidelines that can help community oncologists. If you look at the trends in those guidelines, it is been [moving to] doing less rather than more, so maybe performing thyroid hemithyroidectomy, where we used to perform totals in certain patients meeting certain criteria, or maybe not doing radioactive iodine in patients for whom we used to do radioactive iodine. That evolvement of a bit of a less-is-more attitude has come through in thyroid cancer.

Now, a patient is a patient, not a guideline, so you have to always look at the particular patient’s situation and see not only how they fit in with the guidelines but also their comfort in the level of care being recommended and how aggressive they want to be.

Q: What do you hope your colleagues take away from this discussion?

Young: There are several main things that I like to always reiterate about thyroid cancer. The majority of the diseases are treatable. Therefore, long-term follow-up and survivorship are something that is ingrained within the disease, and we have to mitigate that for all of our patients. [Second], we do have hope now for some of the more hopeless thyroid cancers that used to exist, including anaplastic or poorly differentiated [cancers]. We are seeing longer, and longer survival based on patients’ molecular profiling in response to targeted therapies that we have not seen in decades past.

Nobody should ever take on cancer alone as a clinician. Having that multidisciplinary umbrella for cancer is helpful. I always encourage everyone to reach out to their colleagues in order to manage any patient with cancer.

Q: Is there anything else you wanted to highlight today?

Young: What I hope that people take away is that every patient is not a guideline and that every patient scenario is different. Because this disease tends to do very well a lot of times, we are going to make long-term relationships with these patients. It is very important that we keep abreast of the current trends and guidelines in order to make sure patients know all of their options and we are able to abide by their wishes and get them through their cancer journey in a way that they are comfortable and is acceptable and that they will also do well.