Experts Updating Thyroid Cancer Guidelines

Allison Gandey

July 11, 2008

July 11, 2008 — Thyroid cancer experts are meeting in Boston, Massachusetts, to finalize new recommendations for differentiated and medullary disease. The working documents are scheduled to be presented and discussed at a meeting of the American Thyroid Association today and tomorrow. This is reportedly the first time the association has opted to present management guidelines in such a format for clinicians from multiple disciplines.

"Our goal is to help medical professionals and their patients by advancing the diagnosis and treatment of thyroid cancer," program chair, secretary, and chief operating officer of the association, Richard Kloos, MD, from Ohio State University Medical Center, in Columbus, said in a news release.

According to the US Department of Health and Human Services and the American Cancer Society, more than 37,000 people will be diagnosed with thyroid cancer in the United States in 2008. Papillary thyroid cancer is the most common type and accounts for about 70% to 80% of all thyroid cancers.

The last guidelines offered by the taskforce were published in 2006. "Thyroid cancer is becoming increasingly common and we need to diagnose it earlier," David Cooper, MD, from the Johns Hopkins Thyroid Clinic in Baltimore, Maryland, said during an interview. "We also need to figure out which cases are benign and which cases we should treat more aggressively."

Dr. Cooper was lead author of the 2006 guidelines on thyroid nodules and differentiated thyroid cancer. He said the updates will include more information on imaging.

Imaging and Recombinant Human TSH to be Addressed

"The use of ultrasound in the diagnosis of thyroid nodules has expanded in recent years and we will be addressing that," Dr. Cooper said. He added that the algorithm on positron emission tomography scanning is out of date and requires a bit of an overhaul. The group is also looking at the role of recombinant human thyroid-stimulating hormone (TSH) in differentiated disease — an area studies have validated in recent years, he said.

The field welcomed promising new work this summer. As reported by Medscape Oncology at the time of publication, several new agents have shown activity in refractory thyroid cancer. In a editorial published online June 9 in the Journal of Clinical Oncology (DOI: 10.1200/JCO.2008.17.3682), David Pfister, MD, and James Fagin, MD, from the Memorial Sloan-Kettering Cancer Center, in New York, predict that a paradigm shift in the treatment of this cancer is not far off.

And in the July 3 issue of the New England Journal of Medicine (2008;359:31-42), researchers published results of 1 of the largest clinical trials ever in this patient population. The results suggest that the experimental drug motesanib (under development by Amgen) has shown activity in progressive advanced thyroid cancer. Dr. Cooper said that these and other studies will help shape the new guidelines.

The taskforce is adding 3 new experts, bringing the group to 13. Looking to develop a more international perspective to the work, European thought leaders Furio Pacini, MD, from the University of Siena, in Italy, and Martin Schlumberger, MD, from the Institut Gustave Roussy, in Villejuif, France, will join the group. And adding to the surgical perspective of the team will be head and neck cancer surgeon David Steward, MD, from the University of Cincinnati, in Ohio.

Prioritizing a Difficult-to-Diagnose and Treat Subspecialty

A second group, led by Dr. Kloos, will update the medullary thyroid cancer guideline. "This is a difficult disease because it is so rare," Dr. Kloos said during an interview. As a result, he noted, few clinicians have extensive experience in this area and expert guidelines are desperately needed.

About 20 to 30 mutations signal medullary thyroid cancer. In the new guidelines,the taskforce will prioritize disease categories — with 1 being the most aggressive and 4 being the least aggressive — and will recommend appropriate care. Current guidelines include 3 main categories; the update will add a fourth.

"We get phone calls every week from physicians who are faced with cases and are struggling with how best to manage them," Dr. Kloos said. "With these new guidelines, we are seeking to answer these questions with encyclopedic thoroughness."

Dr. Kloos' team will be putting the final touches on the new guidelines at the meeting and hopes to have the document completed next month. It will be published after that and presented orally at the American Thyroid Association's annual meeting in Chicago in October.

The guidelines on differentiated disease are expected to take a little longer. After the current meeting, Dr. Cooper and his group will work to finalize the guidelines in the fall, for possible publication in early 2009.

The current meeting is designed to bring together endocrinologists, surgeons, nuclear medicine physicians, and fellows. Organizers are expecting more than 250 attendees. The workshop is taking place at the Boston Park Plaza Hotel. For more information, visit the national thyroid cancer workshop website.

An estimated 30,000 free copies of the 2006 guidelines have been downloaded so far. For a copy, visit the American Thyroid Association website.

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