Expert Explores Advancements in Aggressive Thyroid Cancers

Raymond L. Chai, MD

Raymond L. Chai, MD

Although most cases of thyroid cancer are highly treatable, patients with aggressive subtypes of the disease and those who are radioactive iodine (RAI)-refractory must overcome different obstacles in the treatment landscape. The introduction of molecular and targeted therapies, however, can improve the quality of life of these patients, as well as their survival.

Prior to recent research, patients with more aggressive subtypes, such as anaplastic thyroid cancer (ATC), have had limited treatment options. The 1-year survival rate for patients with ATC is less than 5%, according to Raymond L. Chai, MD. Although most patients can be treated with surgery or RAI, patients can become RAI-refractory and may require a different treatment option.

Research is looking at different ways to treat these patients with advanced subtypes of thyroid cancer, including combinations with BRAF inhibitors. In May 2018, the FDA approved the combination of BRAF inhibitor dabrafenib (Tafinlar) plus MEK inhibitor trametinib (Mekinist) for the treatment of patients with unresectable or metastatic BRAFV600E—positive ATC.

The role of combination therapy with BRAF inhibitors continues to be investigated in this space. Treating patients who become RAI-refractory or who have an aggressive subtype such as ATC is the biggest challenge in this space now.

“This is something that provides a real option for patients with ATC, whereas previously in the past, the options for these patients were quite limited,” said Chai, assistant professor of otolaryngology at Mount Sinai.

In an interview withTargeted Oncology, Chai discussed the latest treatment advancements for thyroid cancer that he has seen over the past few years and how he sees quality of life improving for patients with advanced subtypes of thyroid cancer. He also shared a personal message for oncologists in honor of Thyroid Cancer Awareness Month.

TARGETED ONCOLOGY: How have you seen the treatment landscape of thyroid cancer evolve over the last decade?

Chai:What we have now are some molecular targeted therapies that weren’t an option before for advanced thyroid cancer that is refractory to RAI. There are also new advances coming down the pipeline with which you can [change] RAI-refractory patients to potentially make them RAI-added. There are a lot of tremendous advances with molecular and targeted therapies that have been recently FDA approved and are coming down the pipeline.

TARGETED ONCOLOGY: How have you seen the quality of life evolve as the landscape has advanced?

Chai:It’s been tremendous. One of the medications, lenvatinib (Lenvima), has led to a dramatic increase in progression-free survival, and that’s something that has been a tremendous benefit for our patients. I think what is even more exciting is for ATC, which, for decades, has not had any real viable options. There has been new research published that is showing benefit for new molecularly targeted inhibitors that improve both the survival and quality of life [for these patients].

TARGETED ONCOLOGY: What are the current standard of care for patients with thyroid cancer?

Chai:Standard treatment is thyroidectomy, either taking it out of 1 side, which is a thyroid lobectomy, or both sides which is total thyroidectomy. Depending on specific risk factors noted on pathology, we decide whether or not we should give RAI, which has been the standard treatment for over 50 years. This is 1 of the true targeted therapies that we have in oncology. It’s a precision thing, which shows an uptake in the thyroid cells, and it’s been around for a long time. That’s the standard treatment, but now the problem is, what do we do with people who don’t respond well to RAI? Now, we have some solutions for that.

TARGETED ONCOLOGY: How frequently do you see patients relapse or progress? What are the options for these cases?

Chai:It certainly happens. Thyroid cancer is 1 of those diseases in which there is a tremendous spectrum in how they can present. Most people will do very, very well, in which the risk is not really dying of disease but for things potentially coming back even years or decades down the road, so they require fairly close surveillance. However, there are people who come in who have very advanced cancers who don’t do so well. There’s this very large spectrum of people who can just have a thyroid lobectomy and go home the same day versus more advanced treatments and surgeries, such as a ventricular resection or even taking out their entire voice box, a total laryngectomy.

TARGETED ONCOLOGY: What areas are under investigation now to further develop the treatment landscape?

Chai:The treatment for ATC is tremendously exciting. There’s been recent data that have been published using combinations with BRAF inhibitors, and [these combinations] have a dramatic response for patients. This is something that provides a real option for patients with ATC, whereas previously in the past, the options for these patients were quite limited.

TARGETED ONCOLOGY: What would you say are the biggest challenges that need to be overcome in the thyroid cancer space?

Chai:It’s to come up with the appropriate treatment regimen that is going to minimize the chance for recurrence and maximize the chance for survival, versus something that is too aggressive. Again, the vast majority of patients with thyroid cancer do extremely well, so a lot of the conversation is about if we should take out just 1 side with a thyroid lobectomy or should we take both sides out with a total thyroidectomy. That’s something that we debate quite often, in terms of things that are less aggressive. I think the challenge right now is what are future targeted therapies that can be done for these more aggressive cancers. Even though this new regimen for ATC is very exciting, new research certainly still has to be done.

TARGETED ONCOLOGY: What does the community need to know about the treatment landscape for thyroid cancer now?

Chai:There are new options for RAI-refractory disease with targeted therapies. Again, ATC is something in which the disease has been known to be 1 of the most aggressive malignancies in humans with a 1-year survival rate of less than 5%. Now there are options that have shown, for the first time, people can have a durable response and potentially even cure for this disease.

TARGETED ONCOLOGY: September is Thyroid Cancer Awareness Month; is there a particular message you would like to share with fellow oncologists?

Chai: