How has thyroid cancer care evolved in recent years? Dr. Kristen Otto from Moffitt Cancer Center discusses thyroid cancer treatment approaches, review the factors that impact care choices, including key testing, and shares advice for advocating for yourself.
Dr. Kristen Otto is a Head and Neck Endocrine Surgeon and an Associate Member in the Department of Head & Neck – Endocrine Oncology at Moffitt Cancer Center. Learn more about Dr. Otto.
Related Resources
Transcript
Katherine Banwell:
Hello and welcome. I’m your host, Katherine Banwell. Today’s webinar is part of the Patient Empowerment Network’s Evolve series to help thyroid cancer patients understand the latest research and how it may impact them. And in today’s program, we’re going to hear from an expert to learn more about thyroid cancer research and hear tips for having productive conversations with your healthcare team.
Before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you.
Well, let’s meet our guest today. Joining me is Dr. Kristen Otto. Dr. Otto, welcome. It’s so good to have you with us.
Dr. Kristen Otto:
Thank you.
Katherine Banwell:
Would you introduce yourself?
Dr. Kristen Otto:
Yeah. I’m Dr. Kristen Otto. I am a head and neck endocrine surgeon specializing in thyroid and parathyroid surgery at the Moffitt Cancer Center in Tampa, Florida.
Katherine Banwell:
Excellent.
Thank you so much for taking time to join us today.
Dr. Kristen Otto:
Thank you.
Katherine Banwell:
I’d like to start by discussing your role as a researcher. You’re on the front lines for advancement in the field of thyroid cancer. What led you here, and why is it so important to you?
Dr. Kristen Otto:
I did my training in ear, nose, and throat, is my background, and I immediately, going through that training, fell in love with the care of the cancer patient and the care of the oncology patient. I especially love thyroid and parathyroid surgery, and so it was an obvious marriage of my love for oncology and my love for thyroid and parathyroid surgery that led me to have a subspecialty in thyroid surgery.
As far as research, I’m very lucky to work in a collaborative, multidisciplinary oncology center like Moffitt Cancer Center. We are fortunate to have disease-based programs where we work closely with all the members of the team: endocrinology, radiology, radiation oncology, medical oncology, surgery. We all work very closely together to care for our patients, and also, to study our patients and their outcomes so we can better understand how to take care of patients in the future.
Katherine Banwell:
Oh, thank you so much for that, Dr. Otto. Let’s start with the basics. First, what are the types of thyroid cancer?
Dr. Kristen Otto:
Very good question. So, by far, the most common type of thyroid cancer is papillary thyroid cancer. That occurs in probably 80 to 85 percent of cases of thyroid cancer.
It’s a very predictable tumor, and one we understand has a very good outcome. We lump together thyroid cancers that we call differentiated thyroid cancers, and those are traditionally tumors that are made up of normal thyroid cells, and those are the papillary cancers, the follicular thyroid cancers, and then a smaller subtype of follicular cancers called oncocytic thyroid cancers. Those are generally considered to be still very responsive to treatment, very predictable in their behavior, and with very good outcomes.
As we move along – and also very differentiated tumors that are ones that look more like normal thyroid tissue. And then as we move along the spectrum, we start to see more aggressive thyroid cancers. And so, each of those tumors – papillary, follicular, oncocytic – can have a version that we call high-grade.
And if we start to see something that looks more high-grade, we know it’s going to have a more aggressive clinical course. There’s a type of thyroid cancer called poorly differentiated thyroid cancer, which is even less predictable in its behavior and more aggressive in its clinical course.
And then among the end of the spectrum is the most aggressive form of thyroid cancer, probably considered the most aggressive solid human tumor, and that’s anaplastic thyroid cancer. Fortunately, anaplastic thyroid cancer, or so-called “undifferentiated thyroid cancer,” same thing, is extremely rare because it has a very aggressive and rapidly fatal clinical course in many instances with some small exceptions.
There’s also a rare tumor called medullary thyroid cancer. Medullary cancer is oftentimes considered to be in the hereditary spectrum of thyroid cancers, and it’s made up of a different cell. It’s not the typical thyroid hormone-producing cell, but it’s a supporting cell in the thyroid. And it goes along with some other – often can go along with some other tumors in the head and neck, and in the abdomen, as well.
Katherine Banwell:
What sort of testing should be done following a thyroid cancer diagnosis?
Dr. Kristen Otto:
So, we generally start by classifying any given thyroid tumor or thyroid nodule with ultrasound. Ultrasound is the gold standard that we use for classifying thyroid tumors, and it actually tells us which thyroid nodules need to be biopsied and need to be further worked up and then may have a risk of being malignant.
Once we have a thyroid cancer diagnosis, it’s important to understand, of course, which type of thyroid cancer we’re dealing with. Because the most common type of thyroid cancer, as I mentioned, papillary cancer, has a very strong predilection to spread to lymph nodes in the neck. And we really need to understand if it has spread so that we can plan the best ultimate surgical procedure for the patient if that’s where we’re headed. And most of the time, that is where we’re headed.
So, ultrasound of the lymph nodes is a really important assessment tool. The other things we generally do, we like to get an understanding of the thyroid function. That comes through blood work, so we check labs, like the TSH and the free T4. Generally, having a thyroid cancer actually has no impact on thyroid function, so we expect the labs to all look normal. That can also help us to assess someone’s safety for going through surgery.
Katherine Banwell:
What about biomarker testing? Does that have a role in thyroid cancer care?
Dr. Kristen Otto:
It absolutely does, and, in fact, there’s a very standard protocol for using biomarkers. It’s a little bit of a generic term, but in thyroid nodule work-up and thyroid cancer work-up, we generally consider molecular testing or DNA, RNA testing to be part of the protocol. It helps us determine whether a thyroid nodule has a chance of being malignant or not, and then it also helps us to determine whether any particular thyroid cancer is going to be responsive to traditional therapies, such as surgery, radioactive iodine, or whether we need to maybe employ some alternative strategies. And then what is the long-term risk of recurrence in the future?
Katherine Banwell:
I mentioned that staging is part of the diagnosis. How is thyroid cancer staged?
Dr. Kristen Otto:
So, interestingly, thyroid cancer is the only adult solid tumor that is actually staged based on age. So, a patient under age 55 who has differentiated thyroid cancer – so, that’s the three common types, papillary, follicular, oncocytic.
If you’re under age 55, you can only ever have stage I or II disease. And that just should kind of further drive home the point that generally, patients do quite well with these tumors. Over age 55, we have stages I to IV, and it’s really based on, has the tumor spread beyond the thyroid to either lymph nodes in the neck or to distant sites in the body?
Katherine Banwell:
How does a patient’s stage affect care options?
Dr. Kristen Otto:
It may affect care options, and it actually may not. In the highest stages, if a patient has really got tumor spread, extensively invasive tumor spread outside the thyroid gland, it actually may become something that is not surgically amenable. But in general, for almost all types of thyroid cancer, surgery is the preferred method of treatment, even if the tumor has spread beyond the thyroid, let’s say, to lymph nodes in the neck.
Or even if it has – in many cases, if it has spread to distant sites such as the lungs or bones, we still approach the main tumor with surgery so that we can then ready the patient for additional options that may help to treat the metastatic disease, such as radioactive iodine.
Katherine Banwell:
Dr. Otto, I’d like to go back briefly to biomarker testing. Is this a standard test for anyone diagnosed with thyroid cancer?
Dr. Kristen Otto:
That’s a good question, and I think it’s something that is slightly debated at this point in time. Should we be doing it for every tumor? Probably not. We’re probably not at the point where all small standard intrathyroidal papillary thyroid cancers, for instance, need biomarker testing, but anything that is behaving outside the realm of what we expect normal, we would certainly do it. The other scenario where we routinely do biomarker testing is when we do a biopsy of a nodule in the thyroid gland and we don’t get a definitive result. So, these are the so-called “indeterminate thyroid nodules.” We’re not really sure if they’re benign or malignant.
They’re atypical or they’re suspicious. In those instances, we actually routinely do biomarker testing to try to help further drill down the true risk that this thing could be cancer.
Katherine Banwell:
What questions should patients be asking about these test results that will help them in their care?
Dr. Kristen Otto:
I think it’s important if we’re going to – so, there are lots of different ways we can do biomarker or molecular testing in the thyroid gland. There are probably three widely accepted testing platforms in the country, although many institutions have their own version of these tests. These three companies that do biomarker testing for thyroid nodules have slightly different methods of testing, and so the results are not always comparable and don’t always mean the same thing institution to institution.
And the test results come out differently, so one platform might tell you exactly what mutation you have, and another platform might tell you what is your risk of malignancy? And so, it’s not always comparing apples to apples. So, I think understanding the true molecular alteration present and how that informs treatment decisions, likelihood to spread to other sites of the body, likelihood to be responsive to treatment, is an important consideration.
Katherine Banwell:
Is there a hereditary component to thyroid cancer care?
Dr. Kristen Otto:
The vast majority of thyroid tumors we do not consider to be hereditary. There are some rare genetic syndromes that may predispose someone to a slightly increased risk of thyroid cancer. The one exception in the world of thyroid cancer that we know can be hereditary is the medullary thyroid cancer that we were discussing upfront.
Even most medullary thyroid cancers are not hereditary. There’s a small subset that go along with a syndrome called multiple endocrine neoplasia type 2 syndrome. So, a very, very small subset of thyroid cancers are proven to be hereditary.
Katherine Banwell:
Why is it important to seek care, even if it’s just for a second opinion, with a thyroid cancer specialist?
Dr. Kristen Otto:
Particularly on the surgical side, it has been proven that patients have better outcomes if they see a surgeon who is considered a high-volume thyroid surgeon. And that may be defined differently depending on what you read, but you generally want to see somebody who does at least 20 to 50 thyroid operations each year, rather than someone who does two or three each year. The cumulative expertise is obviously better if you see somebody who does it all the time.
And then access to some of the more state-of-the-art therapies such as biomarker or molecular testing, some of the fancy systemic therapy options, is also better for groups that are more subspecialty-focused, research-focused, and maybe tertiary care centers.
Katherine Banwell:
You’ve just brought up the issues, the idea of therapies, and the next step for many patients, of course, is to decide on a therapy approach with their healthcare team. What are the types of therapies available for people with thyroid cancer?
Dr. Kristen Otto:
As I mentioned, surgery is generally the mainstay of treatment for most types of thyroid cancer, most stages of thyroid cancer. So, we generally try to see if there’s any way to get the patient safely through an operation to remove the thyroid and maybe remove any involved lymph nodes in the neck. So, surgery is mainstay. For patients who can’t have surgery, or for tumors who are sort of beyond the point of surgery, we do have alternative options.
So, targeted therapies are kind of the hot topic in thyroid cancer treatment these days. So, these are a class of drugs that we call tyrosine kinase inhibitors that have really evolved over the years.
They are like chemotherapy in a sense, but unlike chemotherapy, they’re administered orally rather than IV. And the more targeted the therapy, presumably the fewer sort of toxic effects the treatment has. So, the targeted therapies are sort of another option. Another thing we occasionally use for thyroid cancer, especially as an adjunct to surgery, is something called radioactive iodine. And that’s a pill form of radiation that can help to oblate remaining thyroid cells that could be left behind after surgery.
And then, we very rarely use other treatment strategies such as external beam radiation therapy, standard chemotherapy, quite, quite rare for thyroid cancer.
Katherine Banwell:
Dr. Otto, you’re at the forefront of research. What are the new and emerging therapies for people with thyroid cancer?
Dr. Kristen Otto:
Really, those targeted therapy options, and I say that as a very broad category of treatments. So, the way this works is we have identified – the research world has identified various gene mutations that are responsible for the formation of thyroid cancers. They’re what we call the driver mutations. And the most common one that we all talk about that causes papillary thyroid cancer is something called the BRAF V600E mutation. There are now drug therapies that are specifically designed to target the BRAF mutation, so-called “anti-BRAF” drugs.
But we know that there’s actually additional mutations that various tumors have. So, other things that we see with papillary cancer, RET gene fusions, R-E-T gene fusions, we see. And there are anti-RET drugs. We see ALK gene fusions, and there are anti-ALK drugs. So, that’s really where this is going is, let’s understand all of the different molecular drivers for thyroid cancer, and then develop targeted therapies that can combat those particular mutations.
Katherine Banwell:
In recent years, cancer care has become much more personalized. How is treatment becoming tailored to the individual?
Dr. Kristen Otto:
It’s really that. It’s understanding the molecular drivers of the tumors, why they develop this tumor. Because not only does it tell us what they might respond to from a therapy perspective, but knowing those molecular drivers actually, in thyroid cancer, really helps us to understand, how is this tumor going to behave biologically over time?
What is, for instance, how likely is it gonna be to spread to lymph nodes? How likely is it going to be to develop distant sites of spread? So, those are very important things to understand how these tumors will behave.
Katherine Banwell:
Progress in new therapies, of course, wouldn’t be possible without clinical trials. When should someone consider a clinical trial participation?
Dr. Kristen Otto:
Unlike a lot of tumors, maybe more common tumors, we don’t have a lot of exposure to clinical trials for thyroid cancer patients. But I would say some of the obvious role for consideration for clinical trial would be patients who present with more advanced tumors. Specifically, tumors that have spread beyond the thyroid where we think that an upfront surgical approach is going to be either impossible or very difficult for the patient. We are now looking at strategies of trialing some of those targeted therapies before surgery to see if we can shrink tumors down and make tumors more amenable to surgery in the future.
So, that’s a real obvious one, where we would say, “If you have a tumor that’s a little bit more advanced than just something confined to the thyroid, think about referral for clinical trial.” Another one would be anybody who presents with widespread distant metastatic disease. Again, quite uncommon in thyroid cancer. But if that happens, we should always consider whether a trial is available.
Katherine Banwell:
In general, why do clinical trials matter? And how do they help improve care?
Dr. Kristen Otto:
It is how we decide what should become future standard of care. So, most things that are either FDA-approved or are considered current standard of care ultimately had their heyday in their clinical trial in the past. And so, we have to continue to push the science forward so that we can ever-improve outcomes for our patients.
Katherine Banwell:
How does participation differ from standard of care? What can patients expect day-to-day?
Dr. Kristen Otto:
As I mentioned before, thyroid cancer trials are a little less common than some other tumors. But in terms of expectations, typically, the medications, like I said, we oftentimes don’t have to go through insurance approvals for those drugs because they’re covered on the trial. You don’t have to go through insurance authorization for your follow-up scanning because that’s covered on the trial. So, usually, your whole surveillance plan is set out for you. It’s a pathway that’s set out for you by the guidelines of the trial.
Katherine Banwell:
Well, how has research changed what’s possible for thyroid cancer patients?
Dr. Kristen Otto:
I would say the best example is exactly what we were talking about with the targeted therapies, is particularly the targeted BRAF therapies. Because, as I mentioned in the intro, talking about the different types of thyroid cancer, and I mentioned that anaplastic thyroid cancer, the most feared, most aggressive, worst outcome thyroid cancer.
If you had this conversation with me 20 years ago, I would have said this is a universally fatal disease. Since we now understand that many anaplastic thyroid cancers are driven by the BRAF mutation, and now we have anti-BRAF therapy, we actually have a much better outcome than previously understood for those patients that do happen to have the BRAF mutation.
Katherine Banwell:
As we’ve been discussing, it’s really important to work with your healthcare team to identify what treatment would be best for you. So, Dr. Otto, I’m wondering how you define shared decision-making, and why is this critical to properly managing life with thyroid cancer?
Dr. Kristen Otto:
In most instances, surgery is the mainstay of treatment, and if we’re talking about surgery, of course, there’s always going to be a risk-benefit discussion to whether putting somebody under general anesthesia and taking out the thyroid gland is actually in their best interest and makes sense for them.
So, to me, understanding what is it like to live without your thyroid? Are you going to be good at taking your thyroid hormone supplementation after surgery? We also know that the thyroid gland sits near, in the neck, near structures that help control very functions like voice and swallowing. And so, if I would anticipate that there could potentially be any impact on a patient’s voice or the patient’s future ability to swallow, that also absolutely has to be part of the decision-making. Because even though we know that surgery is the best treatment for thyroid cancer, we know that thyroid cancer occurs in patients with lots of needs and other medical problems and other comorbidities. And so, we really do have to tailor that treatment to the patient, and make sure they understand what they’re signing up for.
Katherine Banwell:
All right. What key questions should patients be asking their healthcare team when considering treatment?
Dr. Kristen Otto:
I think it’s important to ask about stage. One of the things that we see frequently for patients who come to us for a second opinion is that there wasn’t a formal or thorough evaluation of staging of the tumor prior to recommendations for initial therapy. The classic example of this is somebody discovers a mass in the thyroid or a nodule in the thyroid, they get a biopsy, it’s cancer, and they get told, “Let’s go to surgery and take out your thyroid.” And they don’t remember to look comprehensively at the lymph nodes.
And so, if that happens, presumably, if there’s spread to lymph nodes and you just take out the thyroid, you’ve left disease behind. And so, patients can obviously be in a situation where they’re then having to play catch-up and have second operations and third operations to remove those lymph nodes, when in fact, those lymph nodes were there all along and could have been discovered if proper staging was done. So, I think staging is really important. We also talked about the fact that better outcomes are seen for patients and with surgeons who are considered high volume surgeons.
So, I think it’s always a fair question to ask your surgeon, “Well, how many of these do you do a year?” And if it’s three or five, that might be a red flag. Another thing I think is important for patients to ask is how their care will be integrated between the surgeon and the endocrinologist or the oncologist in the future. Because I think that it always is best for patients when they are able to work with true multidisciplinary teams, teams that speak to one another and have shared decision-making and adhere to sort of institutional guidelines and pathways for the treatment of the cancer.
Katherine Banwell:
Some patients are hesitant to speak up when it comes to their care choices. Why is it important for patients to share their preferences and treatment goals with their care team?
Dr. Kristen Otto:
So that they are concordant with what the surgeon or physician is recommending, for sure.
I mean, we can make recommendations all day long, but we’re not going to have satisfied, happy, healthy patients if we don’t ask what their needs and wants are. So, I would just encourage patients to never feel anxious or nervous to ask the questions that you’re thinking, because we really do want to know. As physicians, we want to know where your head is at and what is important to you, so that we can help serve that.
Katherine Banwell:
What symptoms or side effects should patients be aware of, and why is it important to communicate anything they’re experiencing with their care team?
Dr. Kristen Otto:
So, that’s a big question with a lot of discussion around it. So, in terms of symptoms that patients might experience when they’re first getting diagnosed with thyroid cancer, really honestly, many thyroid cancers are found by accident. We do imaging for some other reason. We do a CAT scan of the lungs because someone gets pneumonia, or we do a CAT scan of the spine ‘cause someone has a whiplash injury in a car accident.
And, lo and behold, we find a thyroid nodule, and that leads to the work-up. And so, I guess what I’m trying to get at is that many thyroid cancers are actually completely asymptomatic, silent. It’s only when thyroid cancer gets large that it starts to cause symptoms. Perhaps a mass you can feel in the neck, or a mass that might put pressure in the neck that somebody might experience if they try to swallow with their head turned, for instance. A lot of times, doctors and clinicians ask about things like voice changes in thyroid cancer, and I would argue that voice changes are actually quite rare as a result of thyroid cancer, and if they are seen, they should be taken very seriously. It would be an indicator of a very advanced, invasive thyroid cancer. So, voice changes aren’t as common. And then, in terms of what patients might expect in terms of symptoms or side effects as a result of treatment, the common things that we worry about.
So, the thyroid gland does sit up against the voice box in the neck, and behind the thyroid gland runs to important nerves, one on each side, that actually control the movement of the vocal cords. So, we always counsel patients that these nerves are at risk when we think about thyroid surgery. A change in voice after surgery, while never intentional or anticipated, is something that we would ask about. So, post-operative voice changes are important to look for. And then, the other thing we have to worry about in terms of a consequence of the surgery for thyroid cancer, is low calcium levels. And that is because the thyroid gland sits next to the little glands that control calcium levels, and those are called the parathyroid glands. They oftentimes can get a little bit swollen or bruised at the time of surgery such that they shut down and stop working, so patients can have low calcium temporarily, but that’s typically quite a temporary problem.
And there are some symptoms that go along with low calcium that we counsel patients to look for after surgery.
Katherine Banwell:
Dr. Otto, as we close out the program, what would you like to leave the audience with? Why are you hopeful?
Dr. Kristen Otto:
I think for thyroid cancer, the best thing to remember is these are highly predictable, highly responsive tumors, generally with quite good outcomes.
And we are just scratching the surface in terms of our understanding of the DNA and RNA alterations that lead to thyroid cancer, and we are now exploiting those things for treatments. So, even for the worst of the worst thyroid cancer, anaplastic thyroid cancer, we now are quite successful in treating these in many instances. So, there’s just a whole world of possibility for future management of these tumors.
Katherine Banwell:
That’s a very promising outlook to leave our audience with. Dr. Otto, thank you so much for joining us today.
Dr. Kristen Otto:
Thank you! Thank you for having me. I’m very appreciative.
And thank you to all of our collaborators. To learn more about thyroid cancer, and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell. Thanks for joining us.