Adaptive Tyrosine Kinase Inhibitor (TKI) Therapy In Patients With Thyroid Cancer
Condition: Thyroid Cancer; Thyroid Cancer, Medullary; Differentiated Thyroid Cancer; Papillary Thyroid Cancer; Follicular Thyroid Cancer; Poorly Differentiated Thyroid Gland Carcinoma
MeSH terms: Thyroid Neoplasms; Thyroid Cancer, Papillary; Adenocarcinoma, Follicular; Thyroid Diseases
Intervention: Lenvatinib; Sorafenib; Cabozantinib; Vandetanib
Intervention description: Standard of Care: Lenvatinib 24 mg daily. All participants will start receiving standard of care treatment.
Participants in the Adaptive Therapy regimen will receive TKI therapy in cycles: continuous treatment at the indicated dose until the patients' tumor marker (thyroglobulin in DTC or calcitonin in MTC patients) drops by ≥50% from the level at the time of enrollment ("baseline" level). A new cycle of TKI treatment will begin when/if the tumor marker increases to or above the "baseline" level.; Standard of Care: Sorafenib 400 mg twice daily. All participants will start receiving standard of care treatment.
Participants in the Adaptive Therapy regimen will receive TKI therapy in cycles: continuous treatment at the indicated dose until the patients' tumor marker (thyroglobulin in DTC or calcitonin in MTC patients) drops by ≥50% from the level at the time of enrollment ("baseline" level). A new cycle of TKI treatment will begin when/if the tumor marker increases to or above the "baseline" level.; Standard of Care: Cabozantinib 140 mg daily. All participants will start receiving standard of care treatment.
Participants in the Adaptive Therapy regimen will receive TKI therapy in cycles: continuous treatment at the indicated dose until the patients' tumor marker (thyroglobulin in DTC or calcitonin in MTC patients) drops by ≥50% from the level at the time of enrollment ("baseline" level). A new cycle of TKI treatment will begin when/if the tumor marker increases to or above the "baseline" level.; Standard of Care: Vandetanib 300 mg daily. All participants will start receiving standard of care treatment.
Participants in the Adaptive Therapy regimen will receive TKI therapy in cycles: continuous treatment at the indicated dose until the patients' tumor marker (thyroglobulin in DTC or calcitonin in MTC patients) drops by ≥50% from the level at the time of enrollment ("baseline" level). A new cycle of TKI treatment will begin when/if the tumor marker increases to or above the "baseline" level.
Intervention MeSH terms: Sorafenib; Lenvatinib
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Masking description: Researchers consenting the patients will become unblinded upon treatment assignment.
Enrollment: 6.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: Thyroid disease; Tyrosine kinase inhibitor; TKI; Medullary thyroid cancer; DTC; Advanced thyroid cancer; Progressive thyroid cancer; MTC

Summary:

      Participants will have been diagnosed with advanced progressive thyroid cancer and are about
      to start treatment with a tyrosine kinase inhibitor (TKI).

      The purpose of this study is to evaluate the efficacy and tolerability of tyrosine kinase
      inhibitor therapy (Lenvatinib or Sorafenib for differentiated thyroid cancer [which includes
      papillary thyroid cancer, follicular thyroid cancer, and poorly differentiated thyroid
      cancer]; and Cabozantinib or Vandetanib for medullary thyroid cancer) through adaptive
      (intermittent) versus conventional (continuous) regimen.
    

Eligibility criteria:

        Inclusion Criteria:

          -  All histologically or cytologically confirmed diagnosis of thyroid cancer, other than
             anaplastic or stromal-cell derived cancers.

          -  Participants with differentiated thyroid cancers (DTC) must have negative
             thyroglobulin antibodies.

          -  Measurable disease meeting the following criteria and confirmed by central
             radiographic review:

               -  At least 1 lesion of ≥ 1.0 centimeter (cm) in the longest diameter for a non-
                  lymph node or ≥ 1.5 cm in the short-axis diameter for a lymph node which is
                  serially measurable according to Response Evaluation Criteria in Solid Tumors
                  (RECIST) 1.1 using computerized tomography/magnetic resonance imaging (CT/MRI).
                  If there is only one target lesion and it is a non-lymph node, it should have a
                  longest diameter of ≥ 1.5 cm.

               -  Lesions that have had external beam radiotherapy (EBRT) or locoregional therapies
                  such as radiofrequency (RF) ablation must show evidence of progressive disease
                  (substantial size increase of ≥ 20%) within 12 months to be deemed a target
                  lesion.

          -  Participants must show evidence of disease progression comparing (a) scan in screening
             and (b) historical scan obtained within 12 months prior to signing informed consent,
             according to RECIST 1.1 assessed and confirmed by central radiographic review of CT
             and/or MRI scans.

          -  Participants with DTC must not be eligible for possible curative surgery and must be
             radioiodine (RAI)-refractory / resistant as defined by at least one of the following:

               -  One or more measurable lesions that do not demonstrate iodine uptake on any
                  radioiodine scan

               -  One or more measurable lesions that has progressed by RECIST 1.1 within 12 months
                  of RAI therapy, despite demonstration of radioiodine avidity at the time of that
                  treatment by pre- or post-treatment scanning.

               -  Disease progression in a patient that has received a cumulative activity of RAI
                  of ≥ 550 millicuries (mCi) (22 gigabecquerels), with the last RAI dose
                  administered at least 6 months prior to study entry.

               -  Otherwise deemed not a candidate for further RAI therapy by a multidisciplinary
                  tumor board within 60 days of enrollment.

          -  Participants with DTC must be receiving thyroxine suppression therapy and thyroid
             stimulating hormone (TSH) should not be elevated (TSH should be ≤ 0.1 mU/L).

          -  "Measurable" tumor marker (non-stimulated thyroglobulin >10 ng/mL or CEA>10 ng/ML in
             patients with DTC; or serum basal calcitonin >10 pg/mL in patients with MTC)

          -  Participants may have received prior multi-kinase targeted therapy except the TKI used
             in this trial. For example, patients getting Lenvatinib on this study may have been
             previously treated with Sorafenib, Vandetanib, Sunitinib, Pazopanib, etc. Each of the
             TKI targeted agents will be counted individually, regardless of the duration of its
             administration.

          -  Participants with known brain metastases who have completed whole brain radiotherapy,
             stereotactic radiosurgery or complete surgical resection, will be eligible if they
             have remained clinically stable, asymptomatic for 30 days.

          -  All chemotherapy or radiation related toxicities must have resolved to < Grade 2
             severity per Common Terminology Criteria for Adverse Events (CTCAE v 5.0), except
             alopecia infertility, anemia (see separate criteria) and any toxicities deemed
             irreversible by the treating physician.

          -  Participants must have an Eastern Cooperative Oncology Group (ECOG) Performance Status
             of 0 - 2.

          -  Adequately controlled blood pressure (BP) with or without antihypertensive
             medications, defined as BP ≤ 150/90 mm Hg at screening and no change in
             antihypertensive medications within 1 week prior to Cycle 1/Day 1

          -  Adequate renal function defined as calculated creatinine clearance ≥ 30 mL/min (using
             Cockcroft/Gault formula)

          -  Adequate bone marrow function

          -  Adequate liver function

          -  Males or females age ≥ 18 years at the time of informed consent

          -  Females must not be breastfeeding or pregnant at Screening or Baseline.

          -  Males and females must follow all contraception guidelines as outlined in the protocol
             guidelines.

          -  Voluntary agreement to provide written informed consent and the willingness and
             ability to comply with all aspects of the protocol

        Exclusion Criteria:

          -  Participants who have received any anticancer treatment (including Chinese herbal
             medicine specified for the treatment of tumor) within 21 days or any investigational
             agent within 30 days prior to the first dose of study drug. This does not apply to the
             use of TSH-suppressive thyroid hormone therapy.

          -  Major surgery within 21 days prior to the first dose of study drug.

          -  Palliative radiation therapy within 14 days prior to the first dose of study drug.

          -  Participants having > 30 mg/mL urine protein on urine dipstick testing (Participants
             with urine protein < 1 g/24 hour (h) will be eligible).

          -  Gastrointestinal malabsorption or any other condition that in the opinion of the
             investigator might affect the absorption of Lenvatinib, Sorafenib, Cabozantinib, or
             Vandetanib.

          -  Significant cardiovascular impairment: history of (a) congestive heart failure greater
             than New York Heart association (NYHA) Class II, (b) unstable angina, (c) myocardial
             infarction, (d) stroke, or (e) cardiac arrhythmia associated with impairment within 6
             months of the first dose of study drug.

          -  Bleeding or thrombotic disorders (Treatment with low molecular weight heparin is
             allowed).

          -  Radiographic evidence of major blood vessel invasion/infiltration.

          -  Active hemoptysis (bright red blood of at least 0.5 teaspoon) within 21 days prior to
             the first dose of study drug.

          -  Active infection (any infection requiring systemic treatment).

          -  Active malignancy (except for DTC/MTC or definitively treated basal or squamous cell
             carcinoma of the skin, or carcinoma in-situ of the cervix or bladder) within the past
             24 months.

          -  Known intolerance to any of the study drugs (or any of the excipients).

          -  Any medical or other condition which, in the opinion of the investigator, would
             preclude participation in a clinical trial.

          -  Females who are pregnant or breastfeeding.

          -  Participants who are taking prohibited medications outlined in protocol documentation.