Session Content References

Elderly and low performance status patients are under-represented on clinical trials.There thus exists a knowledge gap in how to best evaluate and treat these patients, while balancing the competing risks of cancer and non-cancer related mortality.

The incidence of cancer in patients age 65 or older is expected to increase 67% from 2010 to 2030.  Despite this these patients are under-represented on clinical trials. Cancer providers need to understand the limited data that exists regarding the treatment of elderly/frail head and neck cancer patients and how to best apply it to current practice.

We will go through three cases highlighting challenging situations which arise in the management of patients that are elderly/frail: the role of surgery in these patients, deciding on which radiosensitizer to use (if any) in elderly/frail patients undergoing definitive RT, and lastly frail patients with locally advanced squamous cell carcinoma of the skin who may benefit from a neoadjuvant immunotherapy approach.

We will start with an introduction of the speakers and will then start with the first case. At the end of the case an audience participation question will ask participants how they would approach the case. The moderator will then present a few slides of relevant background data then move to the panelists on how they would interpret the data in the context of the case and the treatment approach they would recommend. This would be repeated for the three cases, and then at the end the floor will open for QA both live using the microphones and electronically submitted questions.

References:

1. VanderWalde N. Treatment of Older Patients With Head and Neck Cancer: A Review. The Oncologist2013;18:568–578
2. Pignon JP, le Maitre A, Maillard E et al. Meta- analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009;92:4–14.

Upon completion of this live activity, attendees should be able to do the following:

1. Understand how to evaluate elderly/frail patients with head and neck cancer for potential surgery.
2. Understand the nuances of the decision about when to add radiosensitizers versus accelerated radiation alone, versus standard fractionated radiation in the curative intent management of head and neck cancer in the elderly/frail population.
3. The role of neoadjuvant immunotherapy for locally advanced squamous cell carcinoma of the skin.

Potential Challenges/Barriers to Change:

1. There is a lack of prospective clinical trials aimed at elderly/frail patients.
2. There is a lack of knowledge on the best way to evaluate frailty.
3. Certain treatments i.e. surgery in frail patients may require additional expertise/resources in terms of preoperative rehabilitation and postoperative care that not all centers may have access to.

HPV associated oropharyngeal cancer is highly curable, but at a high cost in quality of life and functional loss. De-escalation of surgical, radiotherapy or systemic treatments is currently under investigation to decrease toxicity while maintaining high levels of disease control. Failure to understand the current evidence base for de-escalation may compromise quality or safety of clinical care.

This session will examine the current state of evidence surrounding de-escalation of treatment in patients HPV-associated oropharyngeal cancer. Interdisciplinary experts will discuss key strategies for toxicity mitigation using minimally invasive surgery, radiation dose or volume reduction and/or systemic therapies. Radiation oncologists, medical oncologists, surgeons and related allied health care professions must understand the current evidence for de-escalation of therapy in HPV-associated OPC. This session will provide attendees data and practice implications from the perspective of multidisciplinary providers.

• Radiation oncologists, medical oncologists, surgeons and related allied health care professions determine when and how the latest evidence for de-escalation of therapy in HPV-associated OPC affect their current day-to-day practice.

References:

1. Mehanna H, Robinson M, Hartley A, Kong A, Foran B, Fulton-Lieuw T, Dalby M, Mistry P, Sen M, O'Toole L, Al Booz H, Dyker K, Moleron R, Whitaker S, Brennan S, Cook A, Griffin M, Aynsley E, Rolles M, De Winton E, Chan A, Srinivasan D, Nixon I, Grumett J, Leemans CR, Buter J, Henderson J, Harrington K, McConkey C, Gray A, Dunn J; De-ESCALaTE HPV Trial Group. Radiotherapy plus cisplatin or cetuximab in low-risk human papillomavirus-positive oropharyngeal cancer (De-ESCALaTE HPV): an open-label randomised controlled phase 3 trial. Lancet. 2019 Jan 5;393(10166):51-60. doi: 10.1016/S0140-6736(18)32752-1. Epub 2018 Nov 15. PMID: 30449623; PMCID: PMC6319250.
2. Rosenberg AJ, Vokes EE. Optimizing Treatment De-Escalation in Head and Neck Cancer: Current and Future Perspectives. Oncologist. 2021 Jan;26(1):40-48. doi: 10.1634/theoncologist.2020-0303. Epub 2020 Sep 21. PMID: 32864799; PMCID: PMC7794179.
3. Craig SG, Anderson LA, Schache AG, Moran M, Graham L, Currie K, Rooney K, Robinson M, Upile NS, Brooker R, Mesri M, Bingham V, McQuaid S, Jones T, McCance DJ, Salto-Tellez M, McDade SS, James JA. Recommendations for determining HPV status in patients with oropharyngeal cancers under TNM8 guidelines: a two-tier approach. Br J Cancer. 2019 Apr;120(8):827-833. doi: 10.1038/s41416-019-0414-9. Epub 2019 Mar 20. PMID: 30890775; PMCID: PMC6474272.

Upon completion of this live activity, attendees should be able to do the following:

1. Describe state of science and practice implications for de-escalation of HPV-OPC treatment via surgery
2. Describe state of science and practice implications for de-escalation of HPV-OPC treatment via radiation therapy
3. Describe state of science and practice implications for de-escalation of HPV-OPC treatment via systemic therapy

Potential Challenges/Barriers to Change

1. Volume and pace of growing body of evidence
2. Insurance coverage for new technologies
3. Lack of sufficient evidence matching patient desire for de-escalation.

The modern era of head and neck cancer treatment has ushered in an increasing employment of combined modality treatment approaches. Surgery, radiation therapy, systemic therapy including immunotherapy and targeted therapy modalities, are increasingly being used in combination to increase survival. As patients live longer, however, increased attention is being paid to quality of life and the long-term effects of treatment. Failure to develop multidisciplinary survivorship programs including recognizing patient populations at risk, developing in-treatment interventions to improve post-treatment outcomes and developing post-treatment strategies to attain the best possible functional outcomes for patients is an absolute necessity in a contemporary multidisciplinary head and neck cancer program.

This session, titled the “Development of Survivorship Programs”, will present a practical approach to developing a Survivorship Program and embed survivorship strategies in the entire continuum of care for the head and neck cancer patient. The session will be divided into three main areas:

1. To understand the importance of and develop pathways for survivorship in the head and neck cancer patient including developing pre-treatment strategies to identify patients at high risk for functional outcome failure.
2. To develop intervention strategies along the treatment pathways (pre-treatment, during treatment and after treatment) to maximize the best functional outcomes for patients.
3. To develop post-treatment strategies including understanding the importance of financial toxicity on the patient and the potential for virtual care in the survivorship management of the patient.

Statement of Need:

• The contemporary head and neck oncologist must appreciate that in order to achieve the best overall outcomes for our patients the development of robust multidisciplinary survivorship programs is critical. This session will provide attendees the opportunity to develop survivorship programs for their programs or further enhance those that are already established.
• The attendee will be able to acquire an approach to the development of a survivorship program that will focus on identification of patient populations at risk, development of in-treatment interventions to improve post-treatment outcomes and develop post-treatment strategies to maximize functional outcomes for patients.

References:

1. Guidelines and Advice documents on development of survivorship programs in a health system: https://www.cancercareontario.ca/en/guidelines-advice/cancer-continuum/survivorship
2. Recommendations for the Delivery of Psychosocial Oncology Services in Ontario https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/53191
3. Survivorship 101-Navigating Head and Neck Cancer-L Blumenfeld: https://swallowingdisorderfoundation.com/head-and-neck-cancer-survivorship/
4. Cancer Survivorship: Right Sizing Care-ML Nilsen https://www.oncnursingnews.com/view/cancer-survivorship-right-sizing-care
5. Financial toxicity in thyroid cancer: An analysis from the North American Thyroid Cancer Survivorship study Journal of Clinical Oncology 2016 34:3 suppl, 17-17-J de Souza

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills in the development of a survivorship program.
• Apply new strategies and make practice modifications to embed survivorship in the continuum of care for the head and neck cancer patient.

Upon completion of this live activity, attendees should be able to do the following:

1. Develop knowledge and an approach to embed survivorship strategies in the entire continuum of care for the head and neck cancer patient
2. Understand the importance of pathway development for survivorship in the care of the head and neck cancer patient
3. Develop strategies to recognize patient populations at risk for targeted intervention prior to, during and after treatment
4. Acquire knowledge for developing in-treatment interventions to improve post-treatment outcomes
5. Develop post-treatment strategies to attain the best possible functional outcomes

Potential Challenges/Barriers to Change:

1. Lack of financial resources to support robust survivorship programs.
2. Lack of human resources and multidisciplinary care approaches to deliver a survivorship program.
3. Lack of knowledge regarding the importance that survivorship programs can play in the overall outcomes in patient care.

It is recognized that appropriate initial management of early stage oral cancer is necessary to optimize disease control and post-treatment function. Here we outline evidence-based approach to intraoperative management of surgical margins as well as how best to treat the at risk cervical lymphatics. We also will provide examples of appropriate options for reconstruction following ablation.

This case-based panel discussion will provide a multidisciplinary approach to the management of early oral cavity cancer. We will outline the current evidence related to intraoperative management of the margins for the primary tumor resection and also emerging techniques that may impact show this is done in the future. We also will discuss different approaches for management of the clinically N0 neck. Lastly, options for reconstruction following resection of early oral cavity tumors will be described.

• Depth of invasion greatly impacts prognosis in oral cavity cancer and recently this was recognized in the new 8^th Edition staging system. It is important for treating providers to understand how to assess depth of invasion and how to best assess the surgical margins and manage the clinically N0 neck in patients with oral cavity cancer. This 80 minute panel discussion will outline not only standard approaches to margin evaluation but also emerging technologies that may improve on our ability to clear disease. We also will illustrate the emerging evidence on the use of sentinel lymph node biopsies in the management of early oral cavity cancer.
• Clinicians need to use their knowledge of the significance of depth of invasion in oral cavity cancer in order to best manage the patient’s primary tumor and neck. Moreover, it is important to have a sound understanding of techniques used for reconstruction and removal of oral cancers and this will be provided in the context of our case-based discussion.
• Clinicians will understand techniques that may be used for intra-operative margin assessment in oral cancer in order to adopt these approaches in their practice. They also will recognize when sentinel lymph node mapping may be needed so they can offer it to their patients, when appropriate.

References:

1. Lydiatt WM, et al. Head and Neck cancers-major changes in the AJCC eighth edition cancer staging manual. CA Cancer J Clin 2017 Mar67(2):122-137.
2. Lai SY, Ferris RL. Evolving Evidence in Support of Sentinel Lymph Node Biopsy for Early-Stage Oral Cavity Cancer.  J Clin Oncol. 2020 Dec;38(34):3983-3986.
3. Garrel R, et al. Equivalence Randomized Trial to Compare Treatment on the Basis of Sentinel Node Biopsy Versus Neck Node Dissection in Operable T1-2N0 Oral and Oropharyngeal Cancer. J Clin Oncol. 2020 Dec;38(34):4010-4018.

Upon completion of this live activity, attendees should be able to do the following:

1. Outline an evidence-based approach to margin assessment for early oral cancer
2. Determine appropriate options for management of cervical lymphatics for different types of early oral cancers
3. Recognize the importance of reconstruction in management of early oral cancer in order to optimize postoperative function

Potential Challenges/Barriers to Change:

1. Emerging techniques for intraoperative margin assessment require specialized instruments and expertise and therefore may not be available at all sites.
2. The use of sentinel lymph node biopsy for early oral cancer requires training of both the surgeon as well as the pathology team to best identify and scrutinize the lymph nodes at most risk for metastatic disease.
3. Approaches to oral cavity reconstruction require training and experience in both regional and free flap repair in order to optimize functional results.

In the era of immunotherapy, heralded by the approval of anti-PD1 checkpoint inhibitors for recurrent/metastatic head and neck cancer, the field is moving rapidly to determine how to integrate immunotherapy in the curative intent setting. To date, clinical trials have been disappointing. This suggests the need to better understand the anti-tumor effects and the immune microenvironment modulation by all treatment modalities, including surgery, radiation therapy, cytotoxic chemotherapy and immunotherapy, in order to best combine and sequence these treatments in previously untreated, locally advanced head and neck cancer.

The session is titled “Escalation Strategies and Novel Approaches in Locally Advanced Head and Neck Cancer.” During this session, four leaders in the field from radiation, surgical and medical oncology will present clinical and translational data addressing novel strategies for the treatment of locally advanced head and neck cancer in the modern era. Particular focus has been given to education regarding translational immunology, which will facilitate the design of rational multidisciplinary clinical trials to advance the field. In addition, the session will synthesize the complex literature on nasopharyngeal carcinoma to facilitate multidisciplinary competency in managing a curable cancer that is rising in incidence in the U.S.

• In order to enhance oncologic outcomes in locally advanced head and neck cancer, the multidisciplinary team must design clinical trials that are rational and based upon state of the art basic and translational science. In the modern era, the key knowledge gap is in immunology, in particular the interaction of standard treatment modalities with the immune microenvironment.
• The incidence of EBV-driven NPC is increasing in the U.S., particularly in the coasts. There is a large body of literature guiding the management of NPC, including both neadjuvant and adjuvant strategies, that U.S. oncologists receive little exposure to and can be difficult to absorb and adapt to practice for a relatively rare patient.

References:

1. https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
2. Bauman JE*, Cohen EC*, Ferris RL*, Adelstein D, Brizel D, Ridge D, O'Sullivan B, Burtness B, Butterfield L, Carson III W, Disis N, Fox B, Gajewski T, Gillison M, Hodge J; Le Q, Strome S, Raben D, Lynn J, Malik S. Immunotherapy of head and neck cancer: Emerging clinical trials from a National Cancer Institute Head and Neck Cancer Steering Committee Planning Meeting. Cancer 2017 Apr 1;123(7):1259-1271.

Upon completion of this live activity, attendees should be able to do the following:

1. Understand key immune players that mediate response and resistance in the context of radiation and immunotherapy combinations
2. Describe recent advances and future directions in integration of neoadjuvant immunotherapy prior to surgery in HNC
3. Describe clinical trials of radiosensitizers as well as developing data regarding drivers of radioresistance in head and neck cancer
4. Learners will develop an understanding of the data which support induction versus adjuvant systemic treatment for patients with locoregionally advanced NPC.

Potential Challenges/Barriers to Change:

1. Lack of a multidisciplinary head and neck cancer team in current practice setting.
2. Lack of clinical research resources in current practice setting.

Disparities in treatment and outcomes by race, socioeconomic status and other factors exist in head and neck cancer. It is critical to recognize these disparities in order to improve care for all patients.

Reference:

1. Zandberg DP, Liu S, Goloubeva O, Ord R, Strome SE, Suntharalingam M, Taylor R, Morales RE, Wolf JS, Zimrin A, Lubek JE, Schumaker LM, Cullen KJ.Oropharyngeal cancer as a driver of racial outcome disparities in squamous cell carcinoma of the head and neck: 10-year experience at the University of Maryland Greenebaum Cancer Center.Head Neck. 2016 Apr;38(4):564-72. doi: 10.1002/hed.23933. Epub 2015 Jun 30.PMID: 25488341.

Upon completion of this live activity, attendees should be able to do the following:

1. Understand disparities in treatment and outcomes by race in head and neck cancer
2. Understand disparities in treatment and outcomes by socioeconomic status in head and neck cancer
3. Understand potential ways to improve disparities in head and neck cancer.

Potential Barriers to Change:

• Lack of knowledge/expertise of the subject matter
• Lack of knowledge/expertise to implement solutions.

There are many treatment approaches for HPV+ oropharyngeal cancer and confusion often arises which approach is the best and most ideal approach. There are also numerous on-going trials for this disease which often causes confusion as what is the acceptable standard of care of trial. Failure to be informed of what is the current standard of care can be problematic and can lead to unwarranted failures.

The goal of this session is understand what is the current standard approach to treat HPV+ oropharyngeal cancer. In this talk, the speaker will discuss the various broad approaches to de-intensify treatment for this disease and give evidence why some of the approaches have not been successful. The speaker will end by informing the audience the need to implement personalized approach in treating HPV+ oropharyngeal cancer in keeping with the importance of precision medicine in 2022.

• The session will inform the radiation oncology professional to stay current with the current standard of care and the various de-escalation approaches for HPV+ oropharyngeal cancer.
• The session will provide the necessary data to give the best care for HPV+ oropharyngeal carcinoma
• To deviate from the current acceptable standard of care, patients should be placed on clinical trial.

References:

1. 1.Tsai c. McBrdie S, riaz N, et al. Evaluation of Substantial Reduction in Elective Radiotherapy Dose and Field in Patients With Human Papillomavirus–Associated Oropharyngeal Carcinoma Treated With Definitive Chemoradiotherapy. JAMA Oncology 2022
2. Riaz n, Sherman E, Pei X., et al. Precision Radiotoherapy: Reduction in Radiation for Oropharyngeal Carcinoma in the 30 ROC Trial. JNCI 2021.

Upon completion of this live activity, attendees should be able to do the following:

1. Know what is the accepted standard of care for HPV+ oropharyngeal cancer
2. Know the general de-escalation trials
3. Know the novel personalized approach for HPV+ oropharyngeal cancer.

Potential Challenges/Barriers to Change:

1. Lack of novel PET tracer to implement personalized approach for HPV+ oropharyngeal carcinoma
2. Lack of knowledge of novel therapeutic trials
3. Lack of understanding what is accepted standard of care.

Cutaneous squamous cell carcinoma is a growing clinical problem with staging, treatment and survival approaches.

Reference:

1. Schmalbach, C OTO clinics.

Upon completion of this live activity, attendees should be able to do the following:

1. Review the indications for adjuvant radiation in high risk cSCC
2. Highlight evidence base for benefit of adjuvant RT
3. Demonstrate techniques of IMRT and planning considerations
4. Outline considerations for identifying appropriate cSCC candidates for surgical versus non-surgical management
5. Highlight staging options for advanced cSCC to include the role of sentinel node biopsy
6. Discuss primary surgical resection options to include MOHS Micrographic Surgery and wide excision
7. Review current approved systemic therapy in cSCC
8. Discuss emerging strategies under clinical investigation in the curative setting
9. Consider systemic treatment paradigms in solid organ transplant patients with cSCC
10. Identify groups of immunosuppressed patients who are at higher risk for non-melanoma skin cancers
11. Describe topical and systemic agents used to reduce the frequency of non-melanoma skin cancer in higher risk patients

Potential Challenges/Barriers to Change:

1. Practice patterns
2. Financial implications
3. Inertia

In the era of HPV associated HN Ca, survival is significantly better resulting in many more patients presenting with long term sequelae of therapy. Although dysphagia has been a subject of research, we have not made strides in patients with silent aspiration. We will see a generation of patients who were treated in their 50s present with delayed dental problems, nutritional needs, depression from long term side effects and functional and cosmetic needs. Awareness of long-term dental problems is lacking. Identifying depression and methods to overcome many of these side effects and more importantly prevent them are lacking.

Complications of head and cancer therapy are common in survivors and continue indefinitely and dental and oral , swallowing, depression and nutritional complications increase overtime following therapy. As complications can occur years following therapy, it is important that head and neck practitioners recognize these complications and need for prevention, follow-up and early management. Experts in the fields of dental, swallowing, psychologists and nutritionists will educate us on these needs.

• It is imperative that the multi-disciplinary team be aware of prevention of long term side effects of head and neck cancer patients.
• Attendees need to determine methods to prevent the side effects and recognize early signs of long term sequelae of treatment for head and neck cancer patients.
• At the end of the session attendees will be able to identify which patients need ancillary care for our head and neck cancer patients.

References:

1. Warnakulasuriya S, Greenspan JS (eds). Text Boof of Oral Cancer. Springer 2020 (sections 26.4036.5); ISBN: 978-3-030-32316-5. 5. https://doi.org/10.1007/978-3-030-32316-5.
2. Sroussi H et al. Common oral complications of head and neck cancer> Cancer Med Review 2017. doi: 10.1002/cam4.1221
3. Radiat Oncol J. 2020 Jun;38(2):84-92. doi: 10.3857/roj.2020.00213. Epub 2020 Jun 25.

Upon completion of this live activity, attendees should be able to do the following:

1. Identify depression as a predictor of head and neck cancer overall survival, mediated by tumor treatment response and activity/sleep disturbance, along with some emerging data showing similar outcome relationships with anxiety.
2. Determine ways to prevent long term oral complications of head and neck cancer treatment
3. Learn prophylactic ways to prevent or decrease long term dysphagia complications.

Potential Challenges/Barriers to Change:

1. Lack of resources
2. Lack of coverage
3. Lack of expertise to implement

Patients treated for head and neck cancers have a high rate of loco-regional recurrence and metastases. The current standards of care are largely based on institutional data or small multi-institutional retrospective collaborative series. There is a need to highlight some of the challenges in the management of these complex patients and present an expert consensus on the treatment and care of these patients. This session will serve to bring together experts in radiation oncology, head and neck surgery and medical oncology to educate the audience on various aspects of management of patients with recurrent and metastatic head and neck cancers with lectures and case-base discussion.

• This sessions aims to provide information on management of patients with recurrent and metastatic head and neck cancers.
• Faculty participating in this session will be discussing strategies for re-irradiation of head and neck cancers, appropriate surgical management and the role of immunotherapy for metastatic head and neck cancer patients.

References:

1. American College of Radiology ACR Appropriateness Criteria- Retreatment of recurrent Head and neck cancer after prior definitive radiation. McDonald et al. 2014
2. Refining Patient Selection for Reirradiation of Head and Neck Squamous Carcinoma in the IMRT Era: A Multi-institution Cohort Study by the MIRI Collaborative. Ward et al. IJROBP 2018 Mar 1; 100 (3): 586-594
3. A Multi-institutional Comparison of SBRT and IMRT for Definitive Reirradiation of Recurrent or Second Primary Head and Neck Cancer. Vargo et al. IJROBP 2018 Mar 1; 100 (3): 595-605.

Upon completion of this live activity, attendees should be able to do the following:

1. Have a better understanding of the challenges in the management of recurrent and metastatic head and neck cancer patients
2. Understand the role and strategies for re-irradiation and surgical salvage in local and regionally recurrent head and neck cancers
3. Understand the role of novel therapies and immunotherapy in the treatment of metastatic head and neck cancers

Potential Challenges/Barriers to Change:

1. Lack of expertise in managing patients with recurrent and metastatic head and neck cancers
2. Lack of comprehensive multidisciplinary team providing care for these patients

In the setting of curative therapy for salivary gland malignancies, clinical questions remain related to the extent of surgical resection and indications for adjuvant radiation. In recurrent/metastatic salivary gland malignancies, various histologies may be more responsive to certain therapies than others. Genomic profiling and testing for potential therapeutic targets are necessary to improve outcomes.

In this session, clinical controversies related to surgical and radiation management of salivary gland cancer will be highlighted. Additionally, various histologies will be reviewed in the recurrent/metastatic setting, with a focus on therapeutic targets and novel systemic approaches.

• Review of guidelines through case-based scenarios related to the extent of surgical resection based on grade and stage.
• Review of various salivary histologies and relevant therapeutic targets and associated responses in the recurrent/metastatic setting.

Upon completion of this live activity, attendees should be able to do the following:

1. Identify relevant scenarios based on grade and stage that inform extent of surgical resection.
2. Ability to take a histology and target-dependent approach to the management of recurrent/metastatic disease.

Potential Challenges/Barriers to Change:

1. Lack of clinical trial opportunities for rare disease
2. Insurance reimbursement challenges for targeted therapies

There are many ongoing advances in the management of thyroid cancers in the context of basic science discovery about their mutational makeup, evolving research on best practices and multidisciplinary treatment options, and advanced diagnostic and surgical techniques. Failure to stay informed leads to lower quality of care by practicing clinicians and inability to advance the science of diagnosis and treatment.

• This session will provide multidisciplinary practitioners access to the latest information about diagnosis and therapies for various types of thyroid cancer.
• This session will enable multidisciplinary practitioners to apply their knowledge to complex situations for which the evidence is poorly understood or evolving.
• After this session, practitioners will be able to draw on novel state of the art information to manage their patients according to the latest scientific information and techniques.

References:

1. Poller DN, Baloch ZW, Fadda G, Johnson SJ, Bongiovanni M, Pontecorvi A, Cochand-Priollet B. Thyroid FNA: New classifications and new interpretations. Cancer Cytopathol. 2016 Jul;124(7):457-66. doi: 10.1002/cncy.21703. Epub 2016 Feb 23. PMID: 26914615
2. Pozdeyev N, Gay LM, Sokol ES, Hartmaier R, Deaver KE, Davis S, French JD, Borre PV, LaBarbera DV, Tan AC, Schweppe RE, Fishbein L, Ross JS, Haugen BR, Bowles DW. Genetic Analysis of 779 Advanced Differentiated and Anaplastic Thyroid Cancers. Clin Cancer Res. 2018 Jul 1;24(13):3059-3068. doi: 10.1158/1078-0432.CCR-18-0373. Epub 2018 Apr 3. PMID: 29615459; PMCID: PMC6030480.
3. Subbiah V, Kreitman RJ, Wainberg ZA, Cho JY, Schellens JHM, Soria JC, Wen PY, Zielinski C, Cabanillas ME, Urbanowitz G, Mookerjee B, Wang D, Rangwala F, Keam B. Dabrafenib and Trametinib Treatment in Patients With Locally Advanced or Metastatic BRAF V600-Mutant Anaplastic Thyroid Cancer. J Clin Oncol. 2018 Jan 1;36(1):7-13. doi: 10.1200/JCO.2017.73.6785. Epub 2017 Oct 26. PMID: 29072975.

Upon completion of this live activity, attendees should be able to do the following:

1. Describe the current state of fine needle technologies and apply currently available tools for diagnosis.
2. Name at least two major molecular alterations that have been shown to be highly prognostic in thyroid cancer.
3. Integrate multimodal therapies (surgery, radioactive iodine, external beam radiation, chemotherapy, targeted therapy) to make a treatment plan for a complex individual thyroid cancer patient.

Potential Challenges/Barriers to change:

1. Participants may have limited access to some of these technologies or therapies due to unfamiliarity or unavailability of multidisciplinary team members with experience. This can be overcome by understanding when consultation with outside experts may be beneficial.
2. Participants may not have knowledge or confidence to implement changes in care. This can be overcome by continued lifelong learning and mentorship from specialists who can assist and encourage practice change.
3. Insurance approvals may cause roadblocks for patients who might benefit from profiling or novel therapies. In these cases, being aware of current clinical trials may provide options for these patients.