Clinical Update on Differentiated Thyroid Cancer - Episode 4

Expert Management of Differentiated Thyroid Cancer


Eric J. Sherman, MD: As there are now more treatments available for metastatic thyroid cancer, we’ve sort of changed from the old days where thyroid cancer was really managed by endocrinologists, and, early on, surgeons. Now it’s actually more of a multidisciplinary disease where medical oncologists and radiation oncologists are also involved, and it’s important to have everyone on the same team or the same side when trying to figure out the best next step for a patient. There is often more than 1 option to choose from—between surgery, radiation, a systemic therapy, and radioactive iodine [RAI]. At an academic center, this is a bit easier to do because we already have disease management teams set up. We meet at least once a week. We talk about the different cases, or more complicated cases, and everyone sort of comes to a consensus of what we think is the best way to move forward with a patient, and what options exist for each individual case.

This also involves pathologists. It involves nuclear medicine physicians. It involves radiologists. At times, it involves a dentist. A very large group of people try to make a decision. This is something that you’ve seen more in academic centers than you have actually seen in private practice. In the past, when an endocrinologist was trying to determine how to give radioactive iodine, it was easier to manage a patient in a private practice setting. Now you almost need to do this in more of an academic or a collaborative group, to try to really figure out how to move forward as each stage of the disease happens for each individual patient.

Johannes (Jan) Smit, MD, PhD: Multidisciplinary management of thyroid cancer patients is very important. It’s a disease of low prevalence. Cases of advanced thyroid cancer are very complicated and are especially difficult to manage, so I could not do my work without multidisciplinary meetings. These meetings consist of endocrinologists, oncologists, surgeons, radiologists, nuclear medicine specialists, and external irradiation specialists. The pathologist also takes part in those meetings, as do nurses and psychologists. We meet weekly, and I think this is the backbone of thyroid cancer management.

The presence of an oncologist in the multidisciplinary setting is essential, even in patients who are not being treated with oncologic drugs. The expertise of oncologists is really helpful in discussing the risk and management of patients—discussing whether treatment should be curative or palliative—and for determining growth rates of cancer. This is all part of the field of oncology, and I think the presence of oncologists, in that respect, is very important and worthwhile.

As in all multidisciplinary settings, it’s rather complicated to get so many experts together. They’re all occupied with their own specialties and their work, so it really has to be done in a formal setting. Without a formal setting, it’s not possible to do this management properly. So in our hospital, these are formal meetings. There are secretaries. The meetings take place at regular times, and all colleagues are expected to be present. Otherwise, we cannot do our work. This is essential for the continuity of the multidisciplinary treatment.

Marcia S. Brose, MD, PhD: The first thing to know is that every institution is different. They have different skills. Different people are focused on the care of these patients. To some extent, there are actually differences in who treats the patient. Maybe an endocrinologist will be giving systemic therapy. Or, this may be done by an oncologist. Let’s assume that an endocrinologist does the early treatment and the oncologist does the systemic therapy. They need to work together.

For years, our institution has worked fairly well together by communicating by phone. Most of the time, we pick up the phone and we talk to each other directly about each case. I would say that a multidisciplinary clinic or meeting does not necessarily replace that. There’s no replacement for direct communication among the physicians. One of the things that we’ve experienced at our center since we started having a multidisciplinary meeting once a month is that it really does help us to discuss the patients who fall into the gray zones. We can discuss whether a certain kind of therapy is appropriate. We may have a situation, for instance, where a patient has had a couple of rounds of radioactive iodine and we’re not really confident that the next round will help. Should we do it again, or should we do a different modality? Then it’s really great to have the nuclear medicine doctors in the room, as well as the endocrinologist and the oncologist.

There have been interesting cases where we’ve had patients with very complicated presentations and the surgeons didn’t feel confident that a surgical procedure was going to go well. It was going to be very morbid for the patient. In a scenario like this, we might discuss sort of rearranging the order of some of the therapies based on a specific instance. So I think that we benefit by meeting together in a group. It may save us from sending the patient to 5 different appointments. Maybe the patient sees 1 doctor. We can present the radiology and tumor case, get input, and then maybe go directly to the physician who will take on the next step in managing the patient.

Eric J. Sherman, MD: At this point, the disease is changing quite a bit. There are a lot of options. While there hasn’t been as much studied about patient volume in thyroid cancer, it has been studied enough in other cancers that for a rare or uncommon cancer like RAI-refractory thyroid cancer, it’s important that people who see a lot of this disease at least share their opinion on when someone should actually start treatment. What are the different treatment options? And even more importantly, what clinical trials exist? So even though we have more treatments available today than we did 2 decades ago, we’re nowhere near close to where we really need to be, in terms of the treatment of thyroid cancer. A lot of studies are going on to try to further advance the field. It’s important that patients get access to these options.

Transcript Edited for Clarity