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Endocrine Center Unites Specialistsby Manny Gonzales
Thyroid cancer is one of the fastest growing cancer diagnoses in the United States, particularly among women. The good news, however, is that many cancers of the endocrine system, such as thyroid cancer, are usually slow-growing, and most patients with these diseases traditionally survive long-term. But any interference with the endocrine system’s delicately balanced regulation of hormones and the vital roles these hormones play in the body may result in chronic illness requiring long-term treatment and follow-up care. Before undergoing surgery or another form of treatment, patients who have endocrine tumors may require carefully coordinated endocrine evaluation and medical management to address hormone problems—and the collaboration of a range of specialists. At The University of Texas M. D. Anderson Cancer Center, collaboration across multiple fields to treat endocrine tumors and cancer-related endocrine dysfunction is not new. Three such doctors, along with their colleagues, have been working together to treat these diseases for years—Steven I. Sherman, M.D., professor in the Department of Endocrine Neoplasia and Hormonal Disorders; Gary L. Clayman, M.D., professor in the Department of Head and Neck Surgery; and Nancy D. Perrier, M.D., associate professor in the Section of Endocrine Tumor Surgery in the Department of Surgical Oncology. Because these doctors had been working together in “virtual” space only, there was a growing need for a common physical space where endocrinologists, surgeons, medical oncologists, radiation oncologists, and nuclear medicine specialists could address the individual problems of their patients and collaborate on research and clinical trial activity. Thus, the Endocrine Center opened its doors in September 2006, with Dr. Sherman as its medical director and Drs. Clayman and Perrier as its associate medical directors, making clear the important role that each of their departments plays in the laboratory and clinical programs active in the new center. “The Endocrine Center in fact is a manifestation of what M. D. Anderson doctors have been doing for more than a decade,” said Dr. Sherman. “But one of the reasons behind the creation of the center was the increasing demand for services, which is being largely driven by a growth in clinical population, along with new research opportunities for innovative approaches to diagnosis and treatment of these patients.” Possible reasons underlying increased incidence Although some studies have suggested that the rise in thyroid cancer incidence is due to radiation fallout from nuclear testing, others have attributed the increase to advances in diagnostic imaging that have enabled better detection.
Whatever the cause, 35,000 Americans will be diagnosed with the disease this year, up from 31,000 last year. Historically, most patients with the disease live long enough to die of something else. For those who appear cured, there remains a long-term risk of recurrence. “We have patients here who have thyroid cancer grow back 30 or 40 years after they were treated,” said Dr. Sherman. “Thus, the nature of our program is one in which we have an increasing number of patients coming in, and many of them survive long-term. The clinical program has grown by virtue of that fact alone.” Managing endocrine dysfunctions due to cancer and other causes The primary focus of the new center is on treating thyroid cancer and other endocrine tumors, but it also focuses on other types of endocrine dysfunction, which can be caused by or aggravated by cancers elsewhere in the body or treatment-related side effects. Anticipating such side effects and managing them as early as possible are essential in optimizing patient outcomes. “Half of what we do is consultation for M. D. Anderson patients being treated for other cancers,” said Dr. Sherman. As an example, he points to the fact that 25%–35% of M. D. Anderson’s inpatients have diabetes; therefore, the department has three endocrinologists who focus on treating diabetes in collaboration with specialists from elsewhere in the institution. Collaborating against disease in the lab and clinic The opening of the Endocrine Center was also driven by the need to accommodate the increasing amount of research and clinical trial activity generated by the collaborating departments. The Endocrine Center is currently home to one of the largest clinical trial programs in the country for patients with endocrine tumors, particularly thyroid cancer. This disease is of special concern because there has been no decline in its mortality rate since the introduction of radioactive iodine treatment in the 1940s. “For other forms of cancer, mortality rates are generally going down,” said Dr. Sherman. “But that’s not the case with thyroid cancer. In fact, in men, the mortality rate has actually increased.” The active clinical trial program at M. D. Anderson opens up a completely different and heretofore unavailable set of options to patients with thyroid as well as other endocrine cancers. “We have seen the rapid expansion of clinical trial activity for thyroid cancer at M. D. Anderson, and that reflects a national trend, which to a large degree, we’ve been leading,” said Dr. Sherman. In the past few years, much of the research activity in the field has shifted toward developing targeted therapies because many endocrine diseases, including some endocrine tumors, are caused by inherited genetic mutations. The concept of targeting therapies to a molecular abnormality is under study in many cancers, but in fact, according to Dr. Sherman, some of the targeted therapies developed recently may have even greater potential for effectiveness against some forms of thyroid cancer. What is already known about the genetics of thyroid cancer should help accelerate the process of connecting the genetic abnormalities of the tumors to the therapy, said Dr. Sherman.
The largest ever multicenter clinical trial in thyroid cancer, a phase II trial to determine the efficacy of motesanib diphosphate, a promising oral multikinase inhibitor, is currently underway. Another phase II trial is currently underway with decitabine, a DNA methylation inhibitor recently pioneered for use in leukemia at M. D. Anderson. The goal of the decitabine study is to determine whether the drug can induce radio-iodine responsiveness in thyroid cancers that were previously unresponsive to radioactive iodine treatment. Genetic counseling extends reach The creation of the Endocrine Center also affords the unique opportunity to integrate genetic counseling and screening into the treatment of patients with endocrine disorders. To that end, the Endocrine Center genetics counselor, Thereasa A. Rich, M.S., meets with patients in the clinic along with the clinicians. She discusses the risk factors regarding family history and the available options for genetic testing and screening. For instance, the fact that a patient with thyroid cancer has a family history of kidney stones could suggest the cancer is part of an inherited condition, multiple endocrine neoplasia type 2. The genetics counselor works to uncover such previously undiagnosed syndromes that might not ordinarily be found—information that could prove valuable for other family members. Additional clinic space and an expansion of the screening program for patients at high risk for inherited endocrine syndromes are being planned. “What we’re proposing for the future is to develop clinical and research programs that will tie together patient care, patient history, tumors, pathology, and clinical data,” said Dr. Sherman, “because endocrine tumors really represent a great opportunity to develop individualized, personalized medicine.”For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789. Other articles in OncoLog, April/May 2007 issue:
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