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Endocrine cancers

About

What is covered

This interactive flowchart covers NICE guidance on endocrine cancers.

Updates

Updates to this interactive flowchart

28 August 2018 Lutetium (177Lu) oxodotreotide for treating unresectable or metastatic neuroendocrine tumours (NICE technology appraisal guidance 539) added to neuroendocrine tumours.
7 August 2018 Lenvatinib and sofafenib for treating differentiated thyroid cancer after radioactive iodine (NICE technology appraisal guidance 535) added to thyroid cancer.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on endocrine cancers in an interactive flowchart

What is covered

This interactive flowchart covers NICE guidance on endocrine cancers.

Updates

Updates to this interactive flowchart

28 August 2018 Lutetium (177Lu) oxodotreotide for treating unresectable or metastatic neuroendocrine tumours (NICE technology appraisal guidance 539) added to neuroendocrine tumours.
7 August 2018 Lenvatinib and sofafenib for treating differentiated thyroid cancer after radioactive iodine (NICE technology appraisal guidance 535) added to thyroid cancer.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Cabozantinib for treating medullary thyroid cancer (2018) NICE technology appraisal guidance 516
Minimally invasive video-assisted thyroidectomy (2014) NICE interventional procedures guidance 499
Interstitial photodynamic therapy for malignant parotid tumours (2008) NICE interventional procedures guidance 259
Intraoperative nerve monitoring during thyroid surgery (2008) NICE interventional procedures guidance 255

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Cabozantinib

Cabozantinib and vandetanib are the only systemic treatment options for unresectable, locally advanced or metastatic medullary thyroid cancer. Both drugs are currently available through the Cancer Drugs Fund for progressive and symptomatic disease. Best supportive care is the only other available option for people who cannot have cabozantinib or vandetanib.
Clinical trial evidence suggests that cabozantinib is effective in delaying disease progression compared with best supportive care, but may not prolong survival. Without reliable comparative data, it was considered that cabozantinib and vandetanib are likely to be similarly effective.
The cost-effectiveness estimates for cabozantinib compared with best supportive care and vandetanib are less than £30,000 per quality-adjusted life year gained. Therefore, cabozantinib can be recommended as a cost-effective use of NHS resources.
For more information see the committee discussion in the NICE technology appraisal guidance on cabozantinib for treating medullary thyroid cancer.

Everolimus and sunitinib

NETs can affect the pancreas, gastrointestinal tissue and lungs and are difficult to diagnose and treat. They can significantly affect emotional health and often mean that people are unable to work. There is particularly high unmet need for people with NETs that affect the lungs.
Clinical trial evidence shows that everolimus and sunitinib are effective for treating pancreatic NETs compared with current treatment (best supportive care). Everolimus is effective for treating gastrointestinal and lung NETs compared with current treatment (best supportive care).
For treating pancreatic NETs, everolimus and sunitinib were recommended because they met NICE's end-of-life criteria. The cost effectiveness estimates varied, from below £20,000 up to £30,000 per quality-adjusted life year (QALY) gained.
For treating gastrointestinal NETs, everolimus did not meet the end-of-life criteria but was recommended because it is cost effective, at below £20,000 per QALY gained.
For treating lung NETs, everolimus did not meet the end-of-life criteria. The cost-effectiveness estimates for everolimus varied, from below £20,000 up to £30,000 per QALY gained. It was recommended because of the cost-effectiveness estimates and the limited treatment options available for people with lung NETs.
NICE's end-of-life criteria are that life expectancy for people with the condition should be less than 24 months and that treatment should extend life by more than 3 months.
For more information see the committee discussion in the NICE technology appraisal guidance on everolimus and sunitinib for treating unresectable or metastatic neuroendocrine tumours in people with progressive disease.

Lenvatinib and sorafenib

Lenvatinib and sorafenib (tyrosine kinase inhibitors) are the only treatment options for progressive, locally advanced or metastatic differentiated thyroid cancer after surgery and radioactive iodine. For people who cannot have lenvatinib or sorafenib, best supportive care is the only option.
Clinical trial evidence shows that lenvatinib and sorafenib are both effective in delaying disease progression, but there is a higher response rate (that is, more tumours shrink) with lenvatinib and it may delay progression for longer. Clinical expert advice is that this response is associated with an improvement in symptoms, which is valued by patients. Lenvatinib and sorafenib also increase the length of time people live, but it is uncertain by how long.
The cost-effectiveness estimates are higher than what NICE normally considers acceptable, and lenvatinib and sorafenib do not meet NICE's end-of-life criteria. But the treatments do increase length of life and there are no other treatments available for the condition. Also, the cost-effectiveness estimates do not capture the benefits of people having a response to treatment, that is, an improvement in symptoms.
Taking all this into account, lenvatinib and sorafenib are recommended as treatment options for differentiated thyroid cancer after radioactive iodine. However, they are recommended only for people who have not had tyrosine kinase inhibitors before, or who have to stop them early because of tolerability (specifically, toxicity that cannot be managed by dose delay or dose modification). This is because there is not enough clinical evidence and no cost-effectiveness evidence to determine whether the treatments are effective when used sequentially.
For more information see the committee discussion in the NICE technology appraisal guidance on lenvatinib and sorafenib for treating differentiated thyroid cancer after radioactive iodine.

Rationale: lutetium (177Lu) oxodotreotide

NETs can affect the pancreas and gastrointestinal tissue and are difficult to diagnose and treat. Current treatment options include everolimus, sunitinib and best supportive care.
Clinical trial evidence shows that lutetium (177Lu) oxodotreotide (referred to as lutetium) is effective for treating somatostatin receptor-positive gastrointestinal and pancreatic NETs. Indirect comparison with everolimus, sunitinib and best supportive care suggests lutetium is effective for treating gastrointestinal and pancreatic NETs in people with progressive disease.
For treating pancreatic NETs, lutetium meets NICE's end-of-life criteria. Compared with everolimus, sunitinib and best supportive care, the cost-effectiveness estimates are within the range NICE normally considers acceptable. So lutetium can be recommended for treating pancreatic NETs.
For treating gastrointestinal NETs, lutetium does not meet the end-of-life criteria because life expectancy for this form of the disease is between 5 and 6 years. But it can be recommended because the most plausible cost-effectiveness estimate is within what NICE normally considers acceptable and treatment options for gastrointestinal NETs are limited.
For more information see the committee discussion in the NICE technology appraisal guidance on lutetium (177Lu) oxodotreotide for treating unresectable or metastatic neuroendocrine tumours.

Glossary

neuroendocrine tumours

Paths in this pathway

Pathway created: March 2018 Last updated: August 2018

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