BACKGROUND
Graves’ disease is the most common cause of hyperthyroidism in the United States. Treatment options include antithyroid drugs, radioactive iodine therapy and surgery. The goal of treatment is to normalize thyroid hormone levels. Frequently patients are treated with anti-thyroid drugs initially. Radioactive iodine therapy and surgery, so-called definitive treatments as they turn the overactive thyroid into an underactive thyroid, often is only offered when this treatment fails. However, previous studies have suggested that patient quality of life remains decreased even in patients whose hormone levels are normalized on antithyroid drugs. This study was done to evaluate whether thyroid surgery improved general quality of life indicators and thyroid specific symptoms in patients who were already being treated with antithyroid drugs.

THE FULL ARTICLE TITLE
Gunn AH et al 2021 Patient-reported outcomes following total thyroidectomy for Graves’ disease. Thyroid. Epub 2021 Dec 3. PMID: 34663089

SUMMARY OF THE STUDY
Adult patients who underwent total thyroidectomy for Graves’ disease between 2015 and 2020 were studied. Patient reported outcomes were evaluated using a thyroid specific survey (questions that specifically relate to symptoms of abnormal thyroid function) and a core quality of life symptom score to develop a Total Symptom Burden Score. Survey data was obtained before surgery (up to 4 mo prior), short term after surgery (less than 1 month) and long term after surgery (greater than 1 month – range 94-548 days).

The study included 85 patients with an average age of 42 years of which 84% were women. Of these, 47% identified as non-Hispanic white, 35% as non-Hispanic black, 7% as Hispanic and 5% as other. Nearly all patients were on antithyroid medication prior to surgery and of these, 2/3rd had a normal serum free thyroxine (FT4) prior to surgery.

The major changes noted were between symptoms prior to surgery compared to short term after surgery. Specific thyroid symptoms that improved significantly after surgery included “feeling hot,” “racing heartbeat,” “diarrhea,” and “difficulty swallowing.” The quality-oflife symptoms that significantly improved at short-term assessment included “general activity,” “mood,” “relationships with other people,” “walking,” “enjoyment of life,” and “work.” The Total Symptom Burden Score improved significantly within 30 days after surgery. Older patients, men and patients who identified as non-Hispanic other or multiple races seemed to show a greater improvement in symptoms scores.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study concluded that in patients with Graves’ disease who reported quality-of-life symptoms on anti-thyroid drugs reported significantly improved symptoms after surgery. It is possible that patients chosen for surgery were ones with worse symptoms initially and were the ones with continued quality-of-life symptoms and that with even longer treatment with anti-thyroid medications, these symptoms would improve even without surgery. However, it does show that surgery can be expected to improve quality-of-life symptoms in patients with Graves’ disease and should be considered as an option for some patients.

— Marjorie Safran, MD

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