Differentiated Thyroid Cancer with a Focus on Adverse Event Management - Episode 5

RAI-Refractory DTC: Patient Education of Systemic Therapy

Approaching patient education of RAI-refractory DTC therapy with lenvatinib, fostering open communication between patients and providers, and monitoring medication adherence.

Steven I. Sherman, MD, FACE: The strategy we use in our clinic for most of our patients who start on systemic therapy with lenvatinib or other tyrosine kinase inhibitors [TKIs] typically begins several clinic visits before they end up starting treatment. Usually, these patients have been followed for some time and have progressed from a rather indolent course to slowly developing more rapidly progressive disease.

It gives us an opportunity, often for 6 to 12 months in lead time, to discuss what it means to be on systemic therapy, what the adverse effects are, and what to expect as part of the clinical course. These patients are generally well informed and readily aware of what to anticipate when they finally get started.

That lead-in time allows us to reach a common conclusion between the patient and the caregiver team about exactly when is the right time for that individual patient to accept the balance between risk and benefit of starting treatment. It’s a continued discussion at each clinic visit about what their goals of care are and how they’re experiencing their treatment. Making sure that they’re given an opportunity to respond, spontaneously offering what their adverse effects are and their symptoms, then making sure they’ve addressed specific questions about the most common toxicities so we’re not leaving anything unaddressed.

When we begin patients on lenvatinib therapy, we structure follow-up for them as well to make sure we are not just monitoring them for response, but importantly monitoring them for their tolerance of treatment. They go home, and they may be reporting their blood pressure to us, but after 2 to 4 weeks of therapy, we will have gotten initial safety laboratory measurements to look at their kidney function, their liver function, their electrolytes.

We monitor their calcium status because patients who have had thyroid surgery may have some marginal parathyroid function that can be unveiled during lenvatinib treatment. We monitor their thyroid hormone levels and, most important, their TSH [thyroid-stimulating hormone] to make sure we don’t lose that important TSH suppression.

This gets built into their regular follow-up regimen from that first safety monitoring. Typically, after 2 to 3 months of therapy we also bring them back for imaging to look at their response to treatment and, hopefully, to see and be able to assess the degree of tumor shrinkage that they’ve had. But most importantly, making sure that their tumor has stopped growing.

This continues throughout the first year. The patient will be followed on an every 2- to 3-month basis in the clinic. After a year, the patients who are tolerating the therapy well, their follow-ups may get spaced out and be less frequent.

For patients who live a bit from our center, we may also coordinate their follow-up with local physicians, making sure we don’t miss those opportunities, those critical time points, where we need to monitor for safety and adverse effects.

We make sure we don’t miss opportunities to communicate with patients. Fortunately, most of our patients are quite comfortable with electronic communication through our electronic medical record. We’re able to regularly follow up with them even between their clinic visits to ensure that they’re taking their medication and that they are not experiencing these adverse effects. It is critically important, especially at the beginning of treatment, that they don’t feel that they’re just given a prescription and sent home to suffer silently. It’s very important that we make sure that they know that we’re there, and that they feel that the partnership extends to them when they’re home taking their medication.

But that always starts with questions about their adverse effects, how they’re feeling, and are they having any problems taking the medication. Just as we have taken care of these patients for months or years before they started their systemic therapy where we’ve been monitoring their thyroid hormone and other medications, that extends to how we take care of them when they started a TKI like lenvatinib.

Transcript edited for clarity.