Radioiodine-Refractory DTC: NCCN Guidelines

Marcia Brose, MD: Currently the NCCN [National Comprehensive Cancer Center] Guidelines recommend either sorafenib or lenvatinib for the treatment patients who have RAI [radioactive iodine]–refractory differentiated thyroid cancer. There’s actually a preference for using lenvatinib to follow if all other comorbidities and everything else is equal. The basis for that, on the opinion of the experts who wrote the NCCN Guidelines, is that there is a higher response rate with lenvatinib over sorafenib. That, together with the fact that there’s an overall survival advantage, is why lenvatinib is currently preferred in the first-line setting.

Comorbidities will play into whether you will give sorafenib first versus lenvatinib. If patients have extremely high blood pressure, many times lenvatinib is not the preferred choice, and sorafenib, which can cause higher blood pressure but not to the same extent, would be preferred in that case.

There are also some patients who might have invasive disease in the neck that I might want to control a little more gradually instead of having these very rapid responses, and I have done that in the past. Interestingly, in both cases when I’ve had to use sorafenib first or lenvatinib because of the toxicity or a high-risk setting, many times I eventually have to give the other agent anyway. In the case of lenvatinib, I can start with a lower dose if I’m concerned about either blood pressure or invasive disease.

Age is another interesting marker because we know patients who are over 65 years old will have improved overall survival. I think this is why, in general, lenvatinib is chosen, and half the patients will be over age 65, so that’s a common reason for lenvatinib to be a preferred agent.

The data showing that overall survival was improved are important because this is practice changing, and it was the first time overall survival was shown to be improved in patients who are being treated with a kinase inhibitor in the setting.

Transcript edited for clarity.