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Multidisciplinary Care of Low/Intermediate Risk DTC

Panelists:Marcia S. Brose, MD, PhD, University of Pennsylvania; Naifa Busaidy, MD, FACP, FACE, University of Texas MD Anderson Cancer Center; Eric J. Sherman, MD, Memorial Sloan Kettering Cancer Center; R. Michael tuttle, MD, Memorial Sloan Kettering Cancer Center; Francis Paul Worden, MD, University of Michigan Comprehensive Cancer Center
Published: Tuesday, Apr 26, 2016


Transcript:

R. Michael Tuttle, MD:
We’ve got this initial information, we’ve got a diagnosis, and we’ve got some initial feeling about prognosis. Let’s talk, at least briefly, about how we treat thyroid cancer. Naifa, let’s do this in two parts. Let me ask you about treating the low- and intermediate-risk patients and then I’ll come to Frank to tell me about treating these really high-risk patients, how might they differ or be the same. So, the typical low-ish-risk patient that we see that’s going to do well.

Naifa Busaidy, MD, FACP, FACE: Yes. First, we have to know how to define the low-ish, intermediate-risk patient. So, things that we talked about is the imaging preoperatively as well as intraoperatively, but it comes down to the postoperative pathology TNM staging. In thyroid cancer, we have the typical TNM, tumor nodal metastasis, staging that we have in other cancers, except we have age that comes in as a factor for differentiated thyroid cancer. So when we look at that, we locate the age and then the size of the tumor and the nodal status, whether it’s central or lateral neck disease, as well as whether or not they have distant metastases. The lower intermediate risk would be somebody who has no lymph nodes, but just has a T on the TNM and is an N0 patient. Those are fairly easy to deal with because, you know, okay, this is a patient who has low to intermediate risk with maybe the exception of the T3, T4 patients that are older. And the patients who have M1, or distant metastasis, are the high-risk patients.

So, in that sense, it’s easy to define the low- versus high-risk, but then everything else is intermediate, and the question is, what do you do with that? I always tell my patients that it’s a three-pronged treatment in thyroid cancer. Surgery is the first and best chance at [a] cure, and it depends on different philosophies—whether you do a lobectomy or total thyroidectomy at the outset—and is the subject of many debates around the country. But let’s say one has decided to do a total thyroidectomy, whether or not lymph nodes are removed prophylactically: if no lymph nodes are identified on preoperative imaging, then there is no specific standard that says you must remove lymph nodes for differentiated thyroid cancer. It depends on what surgeon you talk to and what you believe. But if lymph nodes are identified on preoperative imaging, then those lymph nodes should be removed in a proper manner in a proper lymph node dissection, and not just plucking or removing the lymph nodes that are abnormal.

And the reason I make a big deal about that is we see lots of patients that come to us and say, “My thyroid cancer keeps coming back year after year after year. When it is going to stop?” The question we ask ourselves is, did this disease ever disappear? You’ve probably always just had multiple surgeries of what’s called “plucking.” So, the surgery is the best chance at cure. Getting it done right up front with a thyroid cancer surgeon I think is the best chance at cure and will do well for the majority of our patients.

The second step is radioactive iodine after surgery, and with the new guidelines and more and more research that has been coming out, there’s been a more critical look at whether or not radioactive iodine is really necessary and is really helping patients. So, looking at those patients that we would consider from their staging and their risk factors, if they’re considered low-risk, surgery is probably all they needed and they probably did not need that adjuvant therapy with radioactive iodine. Whereas the patient who’s high-risk, who you know is probably going to recur, radioactive iodine may be necessary in those patients. The intermediate patients are a little bit harder, and the guidelines are how many pages?

R. Michael Tuttle, MD: Too many.

Naifa Busaidy, MD, FACP, FACE: Yes. So, the guidelines are very, very, very long, and it’s easy to tell if the low-risk patients should skip radioactive iodine. But those intermediate patients—maybe the younger patient who has T3 disease or with a little bit of extrathyroidal extension, or the patient who had central lymph nodes—maybe those are patients with whom you could skip radioactive iodine, and you have a pro-and-con discussion with the patient whether or not you want to give it. Those are elderly with lateral disease. You’re going to at least take a look and decide if you want radioactive iodine. But, again, with good surgery and smaller lymph nodes, even those patients we may be able to skip radioactive iodine.

I think those intermediate patients are a lot harder in terms of what we’re going to do, and I think with more research and looking long-term at these patients how they do, we may actually have a better defined group of who we skip radioactive iodine in. So, after you’ve done surgery, asked yes or no to radioactive iodine, the third treatment is to give them thyroid hormone back because they no longer have a thyroid. And giving them a little more thyroid hormone than their body needs, or TSH suppression, is the anti-cancer therapy. So, with that explanation, a lot of the patients are happy and know that 85% to 90% of the time, you’re going to do fine just from this beginning treatment, if we do this right and not over treating you because our goal should be first do no harm.

R. Michael Tuttle, MD: We’ve clearly moved away from a one-size-fits-all approach. Frankly, it was easy to treat thyroid cancer. Everybody got surgery, everybody got radioactive iodine, and everybody got a TSH zero, I have nothing to do. All this selective use is really difficult. Where do you really keep the TSH? When I trained back in the last century, we kept everybody’s TSH at zero forever. What do you really do in Texas now, TSH or what?

Naifa Busaidy, MD, FACP, FACE: For the low-risk patient, the younger female with small-volume disease, the stage I patient, we’re actually keeping their TSH between 0.5 and 2. The higher-risk patient who we’re more worried about, we’ll keep their TSH between 0.1 and 0.5. And the highest-risk patient, we’ll keep their TSH not undetectable because there’s been some research to suggest that we can actually harm them, and increase atrial fibrillation and fractures, and harm their bone health. But maybe less than 0.1, but not all the way down to .01.

R. Michael Tuttle, MD: So, it’s very few that we keep their TSH zero anymore, right?

Naifa Busaidy, MD, FACP, FACE: Yes.

R. Michael Tuttle, MD: We’ve really moderated on that.

Transcript Edited for Clarity
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Transcript:

R. Michael Tuttle, MD:
We’ve got this initial information, we’ve got a diagnosis, and we’ve got some initial feeling about prognosis. Let’s talk, at least briefly, about how we treat thyroid cancer. Naifa, let’s do this in two parts. Let me ask you about treating the low- and intermediate-risk patients and then I’ll come to Frank to tell me about treating these really high-risk patients, how might they differ or be the same. So, the typical low-ish-risk patient that we see that’s going to do well.

Naifa Busaidy, MD, FACP, FACE: Yes. First, we have to know how to define the low-ish, intermediate-risk patient. So, things that we talked about is the imaging preoperatively as well as intraoperatively, but it comes down to the postoperative pathology TNM staging. In thyroid cancer, we have the typical TNM, tumor nodal metastasis, staging that we have in other cancers, except we have age that comes in as a factor for differentiated thyroid cancer. So when we look at that, we locate the age and then the size of the tumor and the nodal status, whether it’s central or lateral neck disease, as well as whether or not they have distant metastases. The lower intermediate risk would be somebody who has no lymph nodes, but just has a T on the TNM and is an N0 patient. Those are fairly easy to deal with because, you know, okay, this is a patient who has low to intermediate risk with maybe the exception of the T3, T4 patients that are older. And the patients who have M1, or distant metastasis, are the high-risk patients.

So, in that sense, it’s easy to define the low- versus high-risk, but then everything else is intermediate, and the question is, what do you do with that? I always tell my patients that it’s a three-pronged treatment in thyroid cancer. Surgery is the first and best chance at [a] cure, and it depends on different philosophies—whether you do a lobectomy or total thyroidectomy at the outset—and is the subject of many debates around the country. But let’s say one has decided to do a total thyroidectomy, whether or not lymph nodes are removed prophylactically: if no lymph nodes are identified on preoperative imaging, then there is no specific standard that says you must remove lymph nodes for differentiated thyroid cancer. It depends on what surgeon you talk to and what you believe. But if lymph nodes are identified on preoperative imaging, then those lymph nodes should be removed in a proper manner in a proper lymph node dissection, and not just plucking or removing the lymph nodes that are abnormal.

And the reason I make a big deal about that is we see lots of patients that come to us and say, “My thyroid cancer keeps coming back year after year after year. When it is going to stop?” The question we ask ourselves is, did this disease ever disappear? You’ve probably always just had multiple surgeries of what’s called “plucking.” So, the surgery is the best chance at cure. Getting it done right up front with a thyroid cancer surgeon I think is the best chance at cure and will do well for the majority of our patients.

The second step is radioactive iodine after surgery, and with the new guidelines and more and more research that has been coming out, there’s been a more critical look at whether or not radioactive iodine is really necessary and is really helping patients. So, looking at those patients that we would consider from their staging and their risk factors, if they’re considered low-risk, surgery is probably all they needed and they probably did not need that adjuvant therapy with radioactive iodine. Whereas the patient who’s high-risk, who you know is probably going to recur, radioactive iodine may be necessary in those patients. The intermediate patients are a little bit harder, and the guidelines are how many pages?

R. Michael Tuttle, MD: Too many.

Naifa Busaidy, MD, FACP, FACE: Yes. So, the guidelines are very, very, very long, and it’s easy to tell if the low-risk patients should skip radioactive iodine. But those intermediate patients—maybe the younger patient who has T3 disease or with a little bit of extrathyroidal extension, or the patient who had central lymph nodes—maybe those are patients with whom you could skip radioactive iodine, and you have a pro-and-con discussion with the patient whether or not you want to give it. Those are elderly with lateral disease. You’re going to at least take a look and decide if you want radioactive iodine. But, again, with good surgery and smaller lymph nodes, even those patients we may be able to skip radioactive iodine.

I think those intermediate patients are a lot harder in terms of what we’re going to do, and I think with more research and looking long-term at these patients how they do, we may actually have a better defined group of who we skip radioactive iodine in. So, after you’ve done surgery, asked yes or no to radioactive iodine, the third treatment is to give them thyroid hormone back because they no longer have a thyroid. And giving them a little more thyroid hormone than their body needs, or TSH suppression, is the anti-cancer therapy. So, with that explanation, a lot of the patients are happy and know that 85% to 90% of the time, you’re going to do fine just from this beginning treatment, if we do this right and not over treating you because our goal should be first do no harm.

R. Michael Tuttle, MD: We’ve clearly moved away from a one-size-fits-all approach. Frankly, it was easy to treat thyroid cancer. Everybody got surgery, everybody got radioactive iodine, and everybody got a TSH zero, I have nothing to do. All this selective use is really difficult. Where do you really keep the TSH? When I trained back in the last century, we kept everybody’s TSH at zero forever. What do you really do in Texas now, TSH or what?

Naifa Busaidy, MD, FACP, FACE: For the low-risk patient, the younger female with small-volume disease, the stage I patient, we’re actually keeping their TSH between 0.5 and 2. The higher-risk patient who we’re more worried about, we’ll keep their TSH between 0.1 and 0.5. And the highest-risk patient, we’ll keep their TSH not undetectable because there’s been some research to suggest that we can actually harm them, and increase atrial fibrillation and fractures, and harm their bone health. But maybe less than 0.1, but not all the way down to .01.

R. Michael Tuttle, MD: So, it’s very few that we keep their TSH zero anymore, right?

Naifa Busaidy, MD, FACP, FACE: Yes.

R. Michael Tuttle, MD: We’ve really moderated on that.

Transcript Edited for Clarity
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