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ATA: Ethical, surgical, medical guidelines coming for anaplastic thyroid cancer
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CHICAGO — The American Thyroid Association will publish new guidelines on ethical, surgical and medical considerations for patients with anaplastic thyroid cancer, according to speakers at the Annual Meeting of the American Thyroid Association.
“We have been working on these anaplastic thyroid cancer guidelines for the past 2.5 years,” Electron Kebebew, MD, FACS, professor of surgery and chief in the division of general surgery at Stanford Cancer Center, said during a presentation. “Unlike other patients with thyroid cancer, those with anaplastic thyroid cancer require a multidisciplinary team, including endocrinologists, oncologists, surgeons, bioethicists and pathologists. We should all be focused on the patient, but what is equally important is communication among the different subspecialists, which is extremely important to optimize best patient care.”
M. Sara Rosenthal, PhD, bioethicist and medical oncologist at the University of Kentucky, discussed new guidelines on ethical considerations.
“We first want to establish the goals of care — we have to talk to the patient and find out what they want,” she said. “The treatment route is based upon what the patient’s preferences are, assuming that they have decision-making capacity.”
Breaking bad news
Regarding when to “break bad news,” the guidelines recommend discussing results as soon as possible, preferably within 1 week of diagnosis. Physicians may use the SPIKES model — a protocol for disclosing unfavorable information — or something similar to relay a truthful prognostication discussion.
“Offer therapies that constitute beneficent care,” Rosenthal said. “Always maximize benefit while minimizing harm. One may also discuss all relevant clinical trials but ensure that all trials meet Belmont Report guidelines.”
When discussing the broad goals of care for patients with anaplastic thyroid cancer, Rosenthal said for aggressive therapies, physicians should reassess goals of care at critical junctures and know when to change the goals of care.
Additionally, Advance Directives must be discussed, along with code status, nutrition/hydration and Voluntary Stopping of Eating and Drinking (VSED).
Regarding ICU care, the guidelines specifically state: “We endorse the ‘7-Step’ process for resolution over ICU-related care developed by the American Thoracic Society with respect to potentially inappropriate treatments in ICU settings, as well as the Society of Critical Care Medicine Ethics Committee recommendations.”
Recommendations for other topics to discuss with patients include the latest in innovative therapies, palliative care and pastoral care as supportive therapies that are distinct from hospice care.
“Hospice must also be discussed as an option when natural death is foreseeable within 6 months without treatment,” Rosenthal said. “It is ethically obligatory to discuss Medical Assistance in Dying (MAID) options to meet legal requirements for informed consent — even if the physician practices in a non-MAID state.”
Role of surgery
Kebebew discussed updates on the guidelines on the role of surgery in patients with anaplastic thyroid cancer.
“The role of the surgeon in anaplastic thyroid cancer is not as intense as the role of some of the other physicians as many of these patients are not eligible for surgery,” Kebebew said. “However, surgery is one of the few things that has been associated with improvements in OS.”
In terms of tumor resectability, surgical intervention should not include debulking and only R0/R1 resection should define resectability without major visceral resection.
The surgical criteria to keep in mind, according to Kebebew, are the extent of the disease, what the resectable structures are and the morbidity/mortality of the procedure.
When evaluating the extent of disease for surgical intervention, patients with stage 4a/4b are the best surgical candidates. A subset of patients with stage 4c anaplastic thyroid cancer may be considered for surgical treatment for locoregional disease control, palliation or for the prevention of future complications.
Additionally, rapid and multimodal imaging for clinical staging is essential.
Regarding the optimal extent of surgery, complete resection may be associated with improved DFS and OS with or without combination chemotherapy and radiotherapy.
“However, even when complete resection is possible, OS is short and laryngectomy and pharyngectomy are not recommended as most patients will not benefit from this type of operation. These procedures compromise QOL” he said.
The panel additionally recommends total or near total thyroidectomy and only a therapeutic lymph node dissection based upon tissue biopsy or ultrasound and anatomic imaging.
“In terms of airway management, nearly 23% of these patients will experience airway symptoms during radiotherapy and 36% will die of airway obstruction,” Kebebew said. “The panel agrees that airway management should be an individualized approach in certain patients. We do not recommend tracheostomy in those without impending airway compromise, as this procedure is associated with more advanced disease, shorter survival and delays in radiotherapy.”
Medical therapies
Although there are no published randomized trials on treatment in anaplastic thyroid cancer, progress is being made in the treatment of the disease with systemic and radiotherapies, according to Keith C. Bible, MD, PhD, medical oncologist in the division of endocrine and general oncology care at Mayo Clinic in Rochester, Minnesota.
“We are handicapped with regard to advances of the highest quality evidence in support of the recommendations,” he said during a presentation. “However, accumulating multi-institutional data indicate improved OS in response to the early application of multimodal therapies in patients with stage 4a/4b disease.”
There are numerous recommendations on medical considerations in the guidelines, according to Bible.
Regarding multimodal therapy, early application of therapy in stage 4a/4b anaplastic thyroid cancer appears promising. Moreover, multimodal therapy appears to reduce the risk for asphyxiation.
Moreover, emerging evidence, encompassing more than 300 patients across 50 centers, suggest increasing evidentiary support for an individualized targeted therapeutic approach for certain patients.
“Following the FDA-approval of dabrafenib (Taflinar, Novartis) plus trametinin (Mekinist, Novartis) for BRAF V600E-mutant anaplastic thyroid cancer, we now recommend rapid BRAF assessment in parallel with comprehensive genetic testing in patients with anaplastic thyroid cancer,” Bible said.
Other ongoing research appears promising for neoadjuvant therapy in patients with unresectable or poorly resectable anaplastic thyroid cancer with the potential to convert them to resectable status, he said.
“The question remains as to who would be best candidates for this and is there a prolongation of survival from this approach? These are questions that require more illumination over time,” Bible said.
Decision-making algorithms
The panel developed algorithms to provide guidance on initial therapy approaches to anaplastic thyroid cancer. For patients with stage 4a disease, the panel recommends an aggressive, multimodal treatment approach. For those with stage 4b disease, an individualized decision to treatment is recommended, with surgery also recommended in select patients. In unresectable 4b disease, treatment considerations include a radiation-based treatment plan and surgery when warranted.
“However, there is an alternative consideration plan, which is attempting to apply a targeted approach when available in BRAF-altered tumors or potential other targetable alterations in hopes of down-staging the tumor to make it surgically resectable,” Bible said. “Patients with stage 4c disease have poor outcomes. This is a dreaded situation and encompasses about half of all patients with anaplastic thyroid cancer at our institution. We have much less evidence on treatment and OS, and so it is important to talk about hospice and supportive care with these patients.”
For patients with stage 4c disease who desire aggressive care, the panel recommends evaluation of targetable mutations and use of targeted therapy when possible.
“The time has passed where we should think about anaplastic thyroid cancer with nihilism and we need to look towards trying to move the needle forward. We are making some progress, but more progress is needed,” Bible said. – by Jennifer Southall
Reference:
Bible KC, et al. Arthur Bauman Clinical Symposium: Medical considerations in anaplastic thyroid cancer. Presented at: Annual Meeting of the American Thyroid Association; Oct. 30-Nov. 3, 2019; Chicago.
Kebebew E, et al. Arthur Bauman Clinical Symposium: Surgical considerations in anaplastic thyroid cancer. Presented at: Annual Meeting of the American Thyroid Association; Oct. 30-Nov. 3, 2019; Chicago.
Rosenthal MS, et al. Arthur Bauman Clinical Symposium: Ethical considerations in anaplastic thyroid cancer. Presented at: Annual Meeting of the American Thyroid Association; Oct. 30-Nov. 3, 2019; Chicago.
Disclosures: Bible, Kebebew and Rosenthal report no relevant financial disclosures.