The Rise in Pediatric Thyroid Cancer Cases

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic Podcast for medical professionals. Exploring the latest innovative research in clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase 1 and Sarcoma Programs. Today I'm happy to be joined by Dr. Rachel Georgopoulos, a pediatric otolaryngologist and director of the Thyroid HOPE Center and Dr. Stefanie Thomas, a pediatric hematologist and oncologist at Cleveland Clinic Children's. Stefanie was previously a guest on this podcast to discuss cancer in the AYA population. They're here today to talk to us about the rise in pediatric thyroid cancers and the Thyroid HOPE Center. So welcome.

Rachel Georgopoulos, MD: Thank you. Thank you for having us.

Stefanie Thomas, MD: Thank you so much.

Dale Shepard, MD, PhD: So maybe to start, you can give us a little bit of an idea of your roles here? So Rachel, maybe we'll start with you.

Rachel Georgopoulos, MD: Yeah. As you heard, I'm a pediatric otolaryngologist and director of our Thyroid HOPE Center, which is the head and neck oncology pediatric endocrine center here at the clinic.

Dale Shepard, MD, PhD: All right. Excellent. And Stefanie, remind us what you do here.

Stefanie Thomas, MD: I'm a pediatric oncologist and I see thyroid cancer patients with Rachel and mostly are involved in their care when they require systemic treatment outside of normal surgery and radioactive iodine treatment.

Dale Shepard, MD, PhD: Excellent. So we're talking about pediatric thyroid cancers and we'll talk about the HOPE Center and a little bit about that, but let's start off sort of more of a basic level. We're talking about pediatric thyroid cancer, which maybe something people don't immediately think of. But the rates are rising. And so tell us a little bit about that. So Rachel, maybe give us a little background on pediatric thyroid cancers.

Rachel Georgopoulos, MD: Yeah, absolutely. So I think to start off, it's probably important to mention that pediatric thyroid cancer and adult thyroid cancer, really can be thought of as different entities. And there has been a rise both in adult and pediatric thyroid cancers. A lot of the adult thyroid cancer rise is attributable to increased detection of cancers. In the pediatric population, there have been a few studies that have suggested that it's not only early detection, that we have been seeing this rise, because we're seeing an increase in tumors in varying sizes, varying stages, but there's probably more to it than that. And so I just wanted to right off the bat point out that they are very different clinical entities, but yeah, no, definitely an increase in the rise in both the adult and pediatric population.

Dale Shepard, MD, PhD: And so Stefanie, do we have any ideas as to why there might be this increase in pediatric patients? Certainly we do more imaging, as was mentioned in adults, but something we don't typically do as much in children. So why more?

Stefanie Thomas, MD: Yeah. Like what Rachel said, possibly part of it is screening. There are more kids now detected potentially with oncologic syndromes that would give them a greater increase possibility of having thyroid cancers that they are inherited and screening earlier, so that we're able to screen those patients. So that's possibly part of it. Additionally, there are some thoughts that there are environmental reasons that we could be seeing this rise in pediatric patients. So I don't think it is super well understood at this point. I think the adult literature is a little bit more conclusive in terms of it being really more of earlier detection. I think this is a combination of potentially some earlier detection, some environmental causes, and then also heritable diseases that we're then screening for. I mean you're picking things up a little bit earlier.

Rachel Georgopoulos, MD: If I can add something to that. I think that this also probably a little bit speaks to the fact that we are seeing patients who are surviving things like other cancers that they're diagnosed with and having been treated with radiation or kids who have pretty significant cardiac anomalies and maybe requiring lots of imaging, which speaks to one of what Dr. Thomas was saying with that environmental exposure, that we're seeing kids that may have had increased radiation exposure at a younger age then going on to develop these thyroid malignancies, is probably one of the contributing factors.

Dale Shepard, MD, PhD: Gotcha. So as we've detected more cases of pediatric cancer, has there been any shift at all in terms of the treatments available or are we still treating them pretty much the same way we always have?

Rachel Georgopoulos, MD: Yeah, so actually the ATA or American Thyroid Association, has come up with a specific set of guidelines. In terms of treatment, the treatment as you know Dr. Thomas had alluded to earlier on in the talk, traditionally as surgical management followed by potentially radioactive iodine if necessary. But what I'd like to draw attention to, is that pediatric thyroid cancer tends to more commonly be multifocal than in comparison to the adult's counterparts, meaning that even if you have a thyroid nodule or tumor in one of the thyroid lobes, it's not uncommon that you'll see micro metastases within the thyroid on the other side, more common, or it's recommended that then those children require total thyroidectomy as opposed to things like lobectomy, which you'll think about in adults. But also children tend to have a higher propensity for having metastasis to the central compartment or even to the lateral necks. And so, in speaking of that, because of that review of the literature, the development of that ATA guidelines, the treatment is still surgical management. But I would say that we're probably better at being more aggressive upfront in how we manage those patients.

Dale Shepard, MD, PhD: So Stefanie, when you think about something that's fairly rare, but important to make sure we catch, what kind of guidance can you give in terms of providers that might be listening? What would be the things that they should be thinking that would trigger them to look for a thyroid cancer? It's becoming more prevalent, it sounds like they need to be looking and more mindful of it.

Stefanie Thomas, MD: We've seen patients recently that have definitely caught their thyroid cancers on exam. So doing good thyroid exams as part of your physical exam, which I don't think is something as a pediatrician that I really focused on doing, honestly. And I think maybe there is more importance of that now, as we're seeing this increase. I think identifying patients that are high risk. So those that have environmental exposures, including prior chemotherapy, prior radiation, and making sure that guidelines are followed to be able to see if those patients are developing thyroid nodules, would be very helpful. And additionally, if anyone does have any cancer predisposition syndromes, getting those patients into multidisciplinary clinics, where it is standard to do these screening tests, would be really important in the pediatric age range.

Dale Shepard, MD, PhD: All right. So we're talking about multidisciplinary care. So Rachel, tell us a little bit about what we have set up here at Cleveland Clinic with this Thyroid HOPE Center.

Rachel Georgopoulos, MD: The Thyroid HOPE Center in reference to our pediatric thyroid cancer patients, is an appointment where you'll see both myself as well as the pediatric endocrinologist. We will do a meeting with our radiologist who will review all imaging, including, and most commonly what's done is ultrasounds. Oftentimes we'll try to, if necessary, also get our wonderful pediatric oncology colleagues to see the patients as well, especially if they've had surgery or they have a genetic predisposition or a family history where, assessing the tumor for tumor biomarkers, would be important.

Dale Shepard, MD, PhD: And so during that appointment, the focus is sort of on developing a game plan, a treatment plan. And is that normally treatment that is delivered here at the clinic or is it sort of, sometimes patients may travel from a distance and then you're coordinating care with other facilities?

Rachel Georgopoulos, MD: So we've had a combination. I've definitely had patients come from a distance for care here. What we try to do is make it as easy as possible for patients, especially those that are traveling, but all patients. And so prior to their surgery. And then we see patients who have been diagnosed with thyroid cancer at intervals, usually every six months for particular period of time, depending on how aggressive their cancer or tumor is. And so we'll coordinate imaging day of as well as lab work, as well as their appointments.

Stefanie Thomas, MD: And to add a little bit to that, I think what is really great about the HOPE Center is that in the moment, and at that one visit, they get to see endocrinology and they get to see the ENT doctors, and we also are able to jump in if we need to. But that all of the surgery is done here with expert care at Cleveland Clinic, the radioactive iodine is done here at Cleveland Clinic. We have a few clinical trials open for novel drugs that if we do need to do systemic therapy that can be given here as well. So we're able to really provide the full range of treatment here at Cleveland Clinic at part of that HOPE Center. And if you can get the patients into basically any of us, we're able to navigate and get them into the whole system at large.

Dale Shepard, MD, PhD: Is there a particular characteristic of patient that would be best suited to be seen at the HOPE Center or pretty much any patient with a diagnosis of thyroid cancer would benefit?

Rachel Georgopoulos, MD: I would say any patient with thyroid cancer. And I get referrals a lot for patients with a concern, so we see patients even prior to diagnosis. So patients with a thyroid mass or nodule that we're working up as well.

Dale Shepard, MD, PhD: Now, Stefanie, you mentioned about trials and novel drugs, and we've also discussed here, so far, that things like radiation can actually lead to predisposition for thyroid cancer. So I'm guessing that patients, providers, everybody involved, is a little nervous about giving radiation as a treatment. Is the effort to try to eliminate the need for radioactive iodine, or are these more for patients who have failed radioactive iodine?

Stefanie Thomas, MD: Typically for patients the radioactive iodine has not been effective or the tumors themselves don't seem to be up taking iodine as they should. I know in pediatric cases, we are less likely to want to do re-radiation with iodine, compared to some of our adult colleagues, who do it a little bit more aggressively because of those concerns for long term effects. I hope there are some planned phase three kind of clinical trials that are coming up. They're potentially bringing some of these novel therapies based on the genetic factors in the thyroid cancers themselves up front. So potentially being able to spare some of these younger patients, radioactive iodine treatment, we're not quite there yet, but I think that's where people want to go. Because a lot of these drugs are actually very well tolerated and kids, and if we can move to a less toxic treatment regimen, I think everyone would be very happy.

Dale Shepard, MD, PhD: And I guess along with that, everybody asks, so I'll ask you, role of immunotherapy?

Stefanie Thomas, MD: There's not a ton right now. There's definitely targeted drugs, but not necessarily immunotherapy that at least I've seen. I don't know if Rachel, if you've seen other data.

Rachel Georgopoulos, MD: No, I have not.

Dale Shepard, MD, PhD: So Rachel from a surgical standpoint, is there anything that's particularly novel that's coming along in terms of minimizing risk for patients, increasing safety, decreasing length of stay? Are there surgical advances in thyroid cancer for children?

Rachel Georgopoulos, MD: I'll tell you that we do, do the surgeries with what's called the nerve monitor. I don't know that it's anything particularly new, but something more routine and definitely recommended and that is to hopefully help minimize any kind of risks to the recurrent laryngeal nerve, which is, I'd say one of the biggest things that people worry about with thyroidectomy procedures. Now, there are some people that are doing things like taking thyroids out in different ways like through sub mentally and through the mouth and those types of things. We're not really doing that with kids, but we have been more aggressive about managing things like lymph node metastases in the neck.

Dale Shepard, MD, PhD: Gotcha. What are the biggest gaps, do you see? What's limiting us moving forward in the field? Where would you like to see improvement?

Rachel Georgopoulos, MD: Yeah. I think there's a lot more that probably can be done in regards to research in pediatric specific thyroid cancer. Getting a better flavor and sense for looking into biomarkers, looking into other genetic predispositions for the development of thyroid cancer. And I think there's still a lot to be learned. And like Stefanie alluded to, if we can do treatment options that are least toxic and have the lowest long term effects, because we're treating kids of less than often teenage years, that would be best. And so I think there's a lot to still be learned.

Dale Shepard, MD, PhD: Stefanie, what do you think?

Stefanie Thomas, MD: I agree with everything Rachel said. I think the small population, even nationally, as in all rare diseases makes it difficult to study. I think there are some nice national collaborations that are going on now that will hopefully be able to answer some of these basic biology questions, to let us know how many patients would be potentially be treated with targeted therapy rather than more systemic treatments that could be more toxic. I think there's a movement in adult thyroid cancer to be able to minimize total thyroidectomies and be able to do lobectomies instead. And maybe having a better understanding of some of those risk factors and some risk modeling, to be able to help understand if there are patients in the pediatric age range that would be appropriate for too. I think right now it's hard because the numbers are so small, we just don't have as many patients to be able to understand what that risk modeling would look like in that population.

Dale Shepard, MD, PhD: Rachel, are there advocacy groups or support groups that are helpful for this disease?

Rachel Georgopoulos, MD: I know a lot of people will connect online. We haven't really set something like that up, but I do think that, that's very helpful.

Dale Shepard, MD, PhD: And Stefanie, do you think there are better opportunities from an educational standpoint, just to sort of raise awareness?

Stefanie Thomas, MD: I do. I think both awareness of medical professionals and just the community as a whole, it would be very beneficial. And I know frequently thyroid cancer could be dismissed by a lot of people. By medical professionals, by other cancer patients as almost like cancer light type of thing. And I know that thyroid cancer, you end up being on thyroid replacement for the rest of your life. It is a chronic disease. It has a lot of emotional and physical effects, especially on teenagers that are going through that autonomy and gaining really an understanding of themselves.

And so support groups I think are really important surrounding this, just like any other chronic disease. And transition of care from pediatric to adult, I think is also very important, specifically on the endocrinology side of things where, if our patients stop taking their medication, for whatever reason, their chances of their thyroid cancer coming back are much higher. So that thyroid replacement is actually their chemotherapeutic drug, which is what I try to explain and it's super important. And that's really hard in that teenage population.

Rachel Georgopoulos, MD: I just want to add on to that because I thought the way you said that was so dead on. It really needs to be looked at as a chronic disease. And that's one of the reasons we develop this thyroid hope is because we're following these patients longitudinally. They do have a high chance of having problems like lymph node metastases, down the line, which is why we'll do ultrasound screenings on them every three to six months. And luckily we have things like thyroglobulin, which we can track and trend, but it really is, in my mind viewed, as a chronic disease that we're looking at from then on.

Dale Shepard, MD, PhD: And I know Stefanie, you have your interest in AYA and from a cancer standpoint, is this something where the plan is that much like congenital heart disease and pediatric populations, people will continue following really, well into adulthood or do you anticipate there's a handoff at some point for your program?

Rachel Georgopoulos, MD: We haven't really handed off, but we do have some adult colleagues that are interested to help tag along. And if the patient is interested in moving on to some adult care, we do have wonderful colleagues that do collaborate with us.

Dale Shepard, MD, PhD: An opportunity for the HOPE Center 2.0.

Rachel Georgopoulos, MD: That's correct. Yeah.

Dale Shepard, MD, PhD: Well it's really great work you guys are doing and I appreciate you guys giving us some good insight today.

Rachel Georgopoulos, MD: Thank you. Thank you so much for having us.

Stefanie Thomas, MD: Thank you so much, Dale.

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