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Expert sheds light on advances in thyroid cancer diagnosis, therapy
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PHOENIX — Molecular markers are just one of the new advances in the diagnosis and treatment of patients with thyroid cancer, according to a presentation here at the AACE Annual Scientific and Clinical Congress.
Bryan R. Haugen, MD, professor of medicine and pathology; head of the division of endocrinology at the University of Colorado School of Medicine, spoke of potential diagnosis and treatment methods depending upon patient age, stage of cancer and type of thyroid cancer. He described the three advances in the field as molecular markers, radioiodine ablation use and dosing, and advanced cancer therapy.
Bryan R. Haugen
“When we see patients with indeterminate nodule biopsies, we need to ask one of two questions: Which patients should I send to surgery? Or, in which patients can I avoid surgery and comfortably monitor?” he said during his presentation. “If we ask the question: can I monitor patients safely without sending them to surgery , we need a test with a high sensitivity and negative predictive value. Currently, the best test for this question is the Afirma gene expression classifier.”However, when it comes to molecular markers, Haugen added that current testing is conducted primarily for diagnostic purposes.
“Not too many years from now, we’re going to be using molecular markers for prognosis; not so much what it is, but what it’s going to do to the patient. That’s going to be the next important step in our field,” Haugen said.
Regarding radioiodine ablation, Haugen reported that it is needed less often in patients with lower-risk disease.
“Not all patients with one microscopic lymph node metastasis require radioactive iodine. You have to think about that and have that conversation with your patients,” Haugen said. “Lower administered doses are also becoming more and more acceptable.”
Haugen added that longer-term follow-up studies are needed, but that short-term studies appear promising. – by Samantha Costa
For more information:
Haugen B. General Sessions: Advances in Thyroid Cancer Diagnosis and Management. Presented at: the AACE Annual Scientific and Clinical Congress; May 1-5, 2013; Phoenix.
Disclosure: Haugen has received research funding from Veracyte.
Perspective
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Loren Greene, MD, MA
I thought the presentation was a very good summary but it lacked certain practical features to the clinician. Number one is the question about the cytology.
Who performs the cytology? This is a real practical problem. If you have confidence in a cytologist over a number of years, you might be reluctant to trust your cytology to another place, where you don't have the same confidence and direct communication. Even more importantly, you lose the opportunity to direct your slides in the proper direction. With indeterminate cytology, of Bethesda III, you still might want to know this first in the clinical context, so that you might direct the slides either to rule out benign disease with the Afirma assay, or to test for malignancy with the Quest or other assay. Am I trying to avoid surgery or push toward surgery for the individual?
If you are acquainted with and use a cytologist to look over your slides and you have trusted that cytologist over a number of years, it's hard to give up your slides for cytology right away for one of these molecular assays. In other words, it's almost as if you have to know you have adequate cells and send two sticks for cytology and for whatever molecular study you might want to do a priori and that also makes it impossible to decide whether you want to go for positive predictive value or negative predictive value because you don't know that you're going to have an indeterminate assay.
The point is that you want to go in the proper direction for the proper specimen. In other words, if I think it's probably malignant, I might want to go in that direction and I wouldn't want to go for Afirma test, whereas if I'm trying to avoid surgery and I think it's benign, I would certainly want to go for the Afirma assay. They've left us in a practical lurch by claiming the specimen, which is also an ethical issue.
However, when they established the Afirma assay, they only did it where they controlled the cytology and did it with known cytologists. I don't have the option anymore of redirecting it toward malignancy or benign — and that's a problem that will impact the clinician. They're doing both at the same time. That is of course inconvenience and cost to the patient as well as a second visit that has to be generated.
I think these assays are excellent and amazing and are really going to prevent patients from getting unnecessary surgery.
Regarding the second topic, more attention should be paid to concerns about secondary malignancy, especially in children treated with RAI. Dr. Charles Sklar at Memorial Sloan Kettering has done extensive work on this.
The other concern is whether we should refer patients who need treatment with chemotherapy to oncologists, try to work with oncologists to do clinical studies, or learn more about chemotherapy (from AACE, ATA or other organizations) so that we become more proficient. The answer depends upon where the endocrinologist is how much responsibility we want to undertake as endocrinologists.
However, not everybody out there has an excellent oncologist at their institution who they're working with only to say we're giving this over to oncology to do the chemotherapy, which might be the right answer; or to empower us to know more of how to treat patients with oncologic issues. I'm not quite sure which way we're going and I think that we have to determine a path — either we give up the highly malignant patients to the oncologists or we need more information ourselves to treat these patients and I'm not sure what the right answer is.
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