BACKGROUND
Thyroid cancer has been the fastest rising cancer in women. Fortunately, there are excellent treatment options that result in an excellent prognosis for most patients. Surgery is the first treatment in most patients followed by levothyroxine therapy. In high risk patients, radioactive iodine therapy is an option as well. While levothyroxine can be seen as a replacement for the removed thyroid gland, it is actually an important part of the long-term treatment for thyroid cancer. In the past, the usual treatment was to achieve TSH suppression with a low TSH. However, current American Thyroid Association guidelines for the management of thyroid cancer recommend a TSH target in the low normal range for most low risk thyroid cancers. This is because the risks of TSH suppression generally outweigh the potential benefits of a further reduced rate of recurrence. However, real-world approaches toward TSH suppression are not well understood. The present survey study sought to understand TSH suppression practices in a diverse group of clinicians caring for patients with thyroid cancer.

THE FULL ARTICLE TITLE
Papaleontiou M et al. 2021 Thyrotropin suppression for papillary thyroid cancer: A physician survey study. Thyroid. Epub 2021 Apr 23. PMID: 33779292.ummary of the study

WHO WAS STUDIED AND HOW DID THEY DO THE STUDY?

Physicians participating in the care of patients with thyroid cancer were surveyed for the study. Physicians practicing into different locations in the United States were included in the survey. The survey included 41.7% endocrinologists and 58.3% surgeons (roughly half were endocrine or general surgeons and the other half otolaryngologists). Roughly half of clinicians had been in practice ≥20 years (versus <20 years), and 51.9% had cared for 0 to 20 thyroid cancer patients in the past year, 21% cared for 21 to 40 patients, and 27.1% cared for >40 patients.

A total of 80.4% of physicians were likely or extremely likely to recommend TSH suppression for intermediaterisk papillary thyroid cancer, 48.8% recommended it for low-risk papillary thyroid cancer and 29.7% recommended it for very-low-risk papillary thyroid cancer. Of those likely to recommend TSH suppression therapy, a little less than half would continue TSH suppression for >5 years. In general, surgeons were significantly less likely to recommend TSH suppression than endocrinologists. High-volume clinicians (those with >40 thyroid cancer patients in the past year) also were less likely than low-volume clinicians (≤20 cases) to recommend suppression for patients with low-risk papillary thyroid cancer and physicians who estimated a higher risk of recurrence (especially in excess of actual risk) were much more likely to recommend TSH suppression.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
The study revealed that the target TSH level for patients who had low risk of recurrence of thyroid cancer was often lower than what was recommended by the current clinical guidelines from the American Thyroid Association. This means a higher dose of levothyroxine to keep the TSH levels lower than the normal range as is typically done for patients with thyroid cancers with a moderate to higher risk for recurrence. However, those physicians who had a higher volume of patients diagnosed with thyroid cancer were more likely to follow the current guidelines for maintaining TSH level in the low normal range which would typically require a lower dose of levothyroxine.

The results of the study indicate a need for further education for physicians and providers who take care of patients who have thyroid cancer. More familiarity with the current clinical guidelines for the management of this condition would likely lead to more standardization of therapy and less side effects from higher doses of thyroid hormone.

— Vibhavasu Sharma, MD, FACE

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