Thyroid cancer: lines of therapy
12 standard-of-care settings across 6 lines and 5 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.
| Line | All comers | BRAF | FRα | RET | Risk group |
|---|---|---|---|---|---|
| Screening, prevention and diagnosis | 1 | · | · | · | · |
| Early / localised | 1 | · | · | · | 2 |
| Second line | · | · | · | 1 | · |
| Third line and beyond | · | · | 2 | · | · |
| Special situations | 1 | · | · | · | · |
| Other settings | 2 | 2 | · | · | · |
Screening, prevention and diagnosis
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Nodule work-up | Ultrasound with TI-RADS; FNA only for nodules meeting size/appearance thresholds; Bethesda reporting; molecular classifier (Afirma, ThyroSeq) for indeterminate results. | NCCN · 2A | 40 |
Early / localised
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Medullary, localised | Total thyroidectomy with central neck dissection; prophylactic thyroidectomy in RET germline carriers by codon-based age; calcitonin surveillance. | NCCN · 2A | 57 | |
| Risk group | Low-risk differentiated (pT1-T2 N0) | Lobectomy or total thyroidectomy; no radioiodine ablation (ESTIMABL2, IoN); modest TSH suppression then normal-range TSH. | NCCN · 2A | 83 | |
| Risk group | Intermediate/high-risk differentiated | Total thyroidectomy with therapeutic node dissection; radioiodine (1.1-3.7 GBq adjuvant; higher for known metastases) after recombinant TSH; TSH suppression. | NCCN · 2A | 86 |
Second line
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| RET | Medullary, advanced progressive RET-mutant | Selpercatinib first line (LIBRETTO-531); cabozantinib or vandetanib if RET-selective therapy unavailable or failed. | NCCN · 1 (preferred)ESMO-MCBS · 3 | 86 |
Third line and beyond
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| FRα | Advanced/refractory | Lenvatinib; selpercatinib (RET); BRAF/MEK (anaplastic). | NCCN Guidelines: Thyroid Carcinoma | 86 | |
| FRα | Radioiodine-refractory, progressive | Genotype first: selpercatinib (RET fusion), larotrectinib/entrectinib (NTRK), dabrafenib-trametinib (BRAF V600E); otherwise lenvatinib (or sorafenib); consider MAPK-inhibitor redifferentiation to restore iodine uptake. | NCCN · 1 (lenvatinib)ESMO-MCBS · 3 | 86 |
Special situations
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Survivorship | Lifelong levothyroxine with risk-adapted TSH targets; calcium/PTH monitoring after surgery; salivary care after radioiodine; low-risk patients can be discharged to primary care. | — |
Other settings
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Differentiated | Thyroidectomy ± radioactive iodine; TSH suppression. | NCCN Guidelines: Thyroid Carcinoma | 94 | |
| All comers | Papillary microcarcinoma (≤1 cm, no spread) | Active surveillance or lobectomy; total thyroidectomy and radioiodine not indicated. | NCCN · 2A | 32 | |
| BRAF | Anaplastic, BRAF V600E | Rapid BRAF testing; dabrafenib-trametinib (ROAR), often with pembrolizumab, then surgery and radiation if rendered resectable. | NCCN · 2A | 84 | |
| BRAF | Anaplastic, BRAF wild-type | Multimodal chemoradiation (paclitaxel-based) if feasible; lenvatinib; immunotherapy for PD-L1-high or TMB-high; NTRK/RET/ALK agents if fusion-positive; early palliative care. | 98 |
Sequence and caution pairings
SequenceApproved
BRAF/MEK inhibition → surgery in anaplastic thyroid cancer
Shrink a BRAF-mutant anaplastic thyroid tumour with pills first, then remove what is left; some patients now survive years instead of months.
SequenceStandard of care
MAPK inhibitor redifferentiation → radioiodine
A short course of a MEK or BRAF pill can coax iodine-resistant thyroid cancer into taking up iodine again, letting radioactive iodine work once more.
Regimens in the library
Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.