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  • New Diagnostic Urgency and New Pharmacotherapy for Thyroid Cancer


    Thyroid cancer is on the rise. Fortunately, treatment options are also expanding. Carcinoma of the thyroid gland is the most common malignancy of the endocrine system.1 Overall, the incidence for thyroid cancer has been increasing through the last decade. Four main types of thyroid cancer exist: papillary thyroid cancer, which is the most prevalent; follicular thyroid cancer (Hürthle cell carcinoma is a form of this and is treated the same); medullary thyroid cancer; and anaplastic thyroid cancer.2 The disease occurs more often in women than men, typically affecting individuals who are between the ages of 25 and 65. Thyroid cancer commonly presents as a cold nodule, with the incidence of cancer in a cold nodule being 12% to 15%. This incidence is higher in individuals younger than age 40 and in those with calcifications present on preoperative ultrasonography. The estimates from 2013 show that in the US alone, there were 60,220 new cases and 1850 deaths from thyroid cancer.1

    Patients who had radiation administered in infancy and childhood for benign conditions of the head and neck have an increased risk of cancer as well as other thyroid gland abnormalities. Thyroid gland malignancies in these patients may first appear as early as 5 years following radiation, and can appear even 20 or more years later. There has also been a high risk of thyroid cancer associated with radiation exposure resulting from nuclear fallout, especially in children. Patients who have genetic conditions such as familial medullary thyroid cancer, multiple endocrine neoplasia type 2A syndrome, or multiple endocrine neoplasia type 2B syndrome have heightened risk as well. Other risk factors for the development of thyroid cancer include history of goiter, a family history of thyroid disease or thyroid cancer, being female in gender, and being Asian.1,2

    The disease can be elusive since it may not cause early symptoms and patients may not report issues until they become aware of complications as the tumor increases. During routine exams, it is necessary to assess patients for developing tumors. Patients may report noticing a lump in the neck, trouble breathing, trouble swallowing, or hoarseness.2 Detection and diagnosis are possible through several different tests and procedures. These include examination of the thyroid, neck, and blood. Initial detection can occur during a routine exam while checking for general signs of health, including checking for signs of disease, such as lumps or swelling in the neck, voice box, and lymph nodes, and anything else that seems unusual. Typical procedures2 used to determine a diagnosis may include:

    • Laryngoscopy, performed to see if the vocal cords are moving normally.
    • Blood hormone tests to assess thyroid-stimulating hormone, calcitonin, and antithyroid antibody levels.
    • Blood chemistry tests to measure calcium levels.
    • Ultrasound procedures to determine the size of a thyroid tumor and whether it is solid or a fluid-filled cyst. Additionally, ultrasound may be used to guide a fine-needle aspiration biopsy.
    • CT scan, computed tomography, computerized tomography, or computerized axial tomography.
    • Fine-needle aspiration biopsy of the thyroid.
    • Surgical biopsy of the thyroid nodule or one lobe of the thyroid.

    There are five types of standard treatment for thyroid cancer. Surgery is the most common, and can include lobectomy, with possible additional biopsies of nearby lymph nodes; near-total thyroidectomy; total thyroidectomy; and lymphadenectomy. Radiation therapy (external or internal), including radioactive iodine therapy, is also used, particularly for follicular and papillary thyroid cancers. Chemotherapy, thyroid hormone therapy, and targeted therapy (such as tyrosine kinase inhibitor therapy) are also treatment options.2

    Current pharmacotherapy for thyroid cancer includes anthracyclines such as Adriamycin (doxorubicin hydrochloride), kinase inhibitors such as Caprelsa (vandetanib) and Cometriq (cabozantinib), and most recently, multikinase inhibitors such as Nexavar (sorafenib).3 The FDA recently expanded the approved uses of Nexavar to treat late-stage (metastatic) differentiated thyroid cancer. Nexavar works by inhibiting multiple intracellular (c-CRAF, BRAF, and mutant BRAF) and cell surface kinases (KIT, FLT-3, RET, RET/PTC, VEGFR-1, VEGFR-2, VEGFR-3, and PDGFR-β) thought to be involved in tumor cell signaling, angiogenesis, and apoptosis, thereby limiting cancer cell growth and division. The drug’s new use is intended for patients with locally recurrent or metastatic, progressive differentiated thyroid cancer that no longer responds to radioactive iodine treatment.4,5

    PDR Network can be a useful resource for information on available products such as those used to treat thyroid cancer, as well as other drug types, offering alerts and specific product labeling. Keep current with information on products by using PDR.net and by keeping your contact information up to date with us. If you use an electronic health record (EHR), please ask for it to include the PDR drug data feeds, including PDR BRIEF, which delivers updated drug information, full labeling, and safety warnings integrated into your electronic prescribing system automatically and at NO cost to you. Drug information in EHRs is often months out of date, which is why PDR BRIEF is available at no cost to providers and EHR vendors. PDR Network can also assist with certain requirements under Stage 2 of Meaningful Use. There are a total of 20 objectives that require reporting under Meaningful Use Stage 2 (MU2). One of the core MU2 objectives, "use certified EHR technology to identify patient-specific education resources," requires that physicians provide more than 10% of their unique patients with education resources specific to their needs.6 PDR+ for Patients drug education guides are just one resource that may currently be available in your EHR that you can provide to your patients to help you meet this objective. When PDR+ for Patients drug education guides are integrated into your EHR, you can use them to help you fulfill this requirement and help your patients start and stay on therapy. Click here to see a sample. Don’t have PDR+ in your EHR? Email us at EHR@pdr.net and tell us the name of your EHR. We’ll let them know you want PDR in your EHR.

    Salvatore Volpe, MD, FAAP, FACP, CHCQM
    Chief Medical Officer
    PDR Network



    1. National Cancer Institute. General Information About Thyroid Cancer (Health Professional version) [article online]. Available at www.cancer.gov/cancertopics/pdq/treatment/thyroid/HealthProfessional. Accessed December 4, 2013.
    2. National Cancer Institute. General Information About Thyroid Cancer (Patient version) [article online]. Available at www.cancer.gov/cancertopics/pdq/treatment/thyroid/Patient. Accessed December 4, 2013.
    3. National Cancer Institute. Drugs Approved for Thyroid Cancer. [article online]. Available at www.cancer.gov/cancertopics/druginfo/thyroidcancer. Accessed December 4, 2013.
    4. Nexavar [package insert].Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2013.
    5. U.S. Food and Drug Administration. FDA News Release: FDA approves Nexavar to treat type of thyroid cancer. [article online]. Available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm376443.htm. Accessed December 4, 2013.
    6. Centers for Medicare and Medicaid. EHR Incentive Programs [materials online]. Available at www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/6Patient-specificEducationResources.pdf. Accessed November 27, 2013.