Monumental treatment advancements over the past two decades have given patients with thyroid cancer the ability to live longer and better lives, according to an expert from Cleveland Clinic’s Taussig Cancer Institute. However, more work is needed to find curative treatments.
Over the past 20 years, there have been several advancements in the treatment of patients with thyroid cancer which have improved survival and quality of life, according to an expert.
However, the same expert said that more work is needed to find a curative approach for this patient population.
Dr. Jessica Geiger, a medical oncologist specializing in head/neck and thyroid cancers at Cleveland Clinic’s Taussig Cancer Institute in Ohio, said that the biggest advancement made over the years in treating thyroid cancer has been the development of targeted therapies.
In particular, tyrosine kinase inhibitors (TKIs), she said, have been shown to better improve survival and quality of life compared with the old standard of care.
“I would say over the last decade, rather than 20 years … there have been great monumental advancements in (the treatment of thyroid cancer),” she said in an interview with CURE®.
“The earlier TKIs … gave us options for patients whereas before we didn't have any,” Geiger continued “The newer drugs that have been developed and are now in use are a prime example of how personalized medicine can be groundbreaking and life-changing. Because now, instead of just getting an agent that has many different targets, and so many patients could just go on the same drug, it doesn't work very well. But if you have one particular specific type of mutation, or one specific gene fusion protein that'scausing this cancer to grow and spread and we have a targeted agent that targets that molecular aberration directly, you can have fantastic results that last for quite a long time.”
Improved Survival and Quality of Life
These advancements, according to Geiger, give patients with thyroid cancer options that they didn’t previously have. Prior to 2013, the only Food and Drug Administration (FDA)-approved systemic therapy for these patients was chemotherapy that was known to be ineffective and often led to many side effects, Geiger said.
Twenty years ago, a patient would first undergo surgery with radioactive iodine, depending on the subtype, and then the only other available treatment option was cytotoxic chemotherapy. There were no treatment options available at that time that could circulate through the bloodstream to attack cancerous cells in multiple locations with a patient’s body.
“You would just try to attend to the problem areas where the disease popped up, but you could never do anything that treated all of the lesions at the same time with one form of treatment,” Geiger said. “No doubt, patients were suffering. (And) patients were dying sooner than what they are now.”
Today, Geiger noted, patient survival has improved dramatically because the newer drugs can better target the disease and the genomic mutations.
Not only has survival improved over the past two decades, but so has quality of life. The initial TKIs that were previously used in these patients heavily affected their quality of life. Side effects such as fatigue, loss of appetite, changes in taste and the onset of nausea, can all lead to weight loss. The use of these TKIs was also associated with heart abnormalities, poor kidney function, high blood pressure, bleeding complications and wound healing complications.
But now, Geiger explained, the recently developed agents are much better tolerated than the previous ones.
“There’s an all-around benefit where patients are living longer with their cancer, and they’re living with a better quality of life (with) many fewer side effects than what they normally would,” she said.
Prior to the development of these agents, a patient may have had to undergo a total laryngectomy, which is the surgical removal of the larynx, which is better known as the voice box.
This procedure, Geiger said, can often become a “huge quality-of-life issue” for patients who now have to depend on and manage their tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe, or trachea, to help with breathing).
Patients who receive a tracheostomy often have to be trained in how to change the tubing, work with speech and language pathologists to make sure they are swallowing properly, or if they may be a candidate to be fitted for a voice prosthetic.
“We have been more thoughtful of these patients where normally the standard of care is if you’re able to have surgery, you have the surgery and avoid systemic therapy. But in a situation like that, some of these newer drugs have allowed us to question that treatment. And we’ve had patients who, for whatever reason, have said ‘Yeah, I’m not ready for such a big surgery,’” she said.
The recent developments of more effective TKIs luckily mean that a tracheostomy does not have to be a patient’s only option. In fact, as Geiger noted, some patients may only need to undergo a comprehensive surgery at first and then receive treatment with the more effective TKIs.
“Depending on the molecular profile, we’ve saved patients, or at least delayed patients, from having a total laryngectomy or being (tracheostomy)-dependent, which again I think is a significant improvement,” she said.
Watch and Wait
Even though there have been tremendous advancements that improve survival and quality of life, that doesn’t mean that every patient should receive immediate treatment, she explained.
For instance, if a patient’s lesion is small enough, Geiger said she tells patients that she’ll see them again in six months.
However, all of this is dependent on the presence of genomic mutations. And, as Geiger added, every patient should receive genetic testing to find out which treatment might be best for them.
“It’s a combination of looking to see what their molecular profile is to see what options we have available, but then looking back at the patient characteristics, clinically how they’re doing and feeling … and what is their overall tumor burden because not everybody warrants treatment at that time,” she said. “Even though we have better options and more options for treatment, that doesn’t mean, at least right now, that I’m more eager to use them sooner than I would otherwise.”
More Room for Improvement
Although these advancements have been significant for patients with thyroid cancer, they only touch the surface, as they pertain to four or five different genetic mutations out of the dozens that exist in thyroid cancer, Geiger said.
“There’s a lot of patients that are not getting these highly selective therapies because they don’t exist,” she explained.
The hope, Geiger said, is there will be more targeted therapies for all the different mutations over the next 20 years.
Another major concern she said is that “cancer is very smart.” A provider can give patients these therapies, but the cancer may find a way around it.
For instance, a patient’s cancer could develop a new mutation or “a new driver that allows the cancer to unlock another door to progression that was once blocked by that other drug,” Geiger explained.
“Identifying those escape mechanisms or escape mutations and then developing another drug to (attack that), I think that’s going to be important as the years go on,” she said.
Another hot topic right now in the thyroid cancer space is immunotherapy, which is a treatment that has been commonly utilized in other cancers such as lung cancer.
While there are a few studies evaluating the use of immunotherapy in thyroid cancer, they haven’t shown the treatment to be as effective as has been seen in other cancers, she described. Again, Geiger noted that some patients may not need to receive immunotherapy.
Patients with targetable genomic mutations, she said, may respond to those treatments for years — possibly eliminating the need for immunotherapy.
“I have some patients who have been on these medicines for over two years and still get the same responses, which is amazing. Two years in the grand scheme of things is a long, long time,” she added. “… We know that not everybody responds to immunotherapy. In thyroid cancer, the majority of patients actually will not benefit from immunotherapy; meaning that you could give it to them … but they’re not going to respond to it. It’s probably a very small subset of thyroid cancer patients where immunotherapy will work.”
Of note, there is no FDA-approved immunotherapy available to patients with thyroid cancer, according to Geiger.
Unnecessary Stress and Anxiety
Technological advances over the past 20 years have significantly improved the capabilities of imaging and ultrasound testing. As a result, providers have been able to detect more thyroid cancers. While a good development for some patients, Geiger noted that this may have caused a tremendous amount of stress and anxiety in patients that may not have had to worry.
“If you look to see the types of thyroid cancer we’re better at detecting, it’s the very small, very slow-growing ones that probably for a majority of those patients would never have come to clinical fruition,” she said. “The patients would have died with that small thyroid cancer rather than from it.”
A Focus on Multidisciplinary Care
Despite the added concern for some patients that may have been considered low-risk, the treatment advancements over the past 20 years have been significant for those with a diagnosis of thyroid cancer, according to Geiger.
In the next 20 years, she continued, a shift to a multidisciplinary approach may lead to more treatment advancements and even better outcomes. Instead of a focus on the medical oncologists, a patient’s care team should also comprise Interventional radiologists (professionals who can perform minimally invasive surgeries), radiation oncologists and endocrinologists, so that they may all consult on what is the best treatment approach.
“Having a multidisciplinary approach for some of these really advanced and aggressive thyroid cancers is key because there’s a lot of moving pieces involved. I think molecular testing for whenever the patient is considered recurrent, or highly aggressive late-stage type of cancer, I think that is key because you need that information well before any other treatment is started,” Geiger concluded.
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