miércoles, 7 de septiembre de 2011

Use of Radioactive Iodine to Treat Thyroid Cancer on the Rise ► NCI Cancer Bulletin for September 6, 2011 - National Cancer Institute

NCI Cancer Bulletin for September 6, 2011 - National Cancer Institute: Use of Radioactive Iodine to Treat Thyroid Cancer on the Rise

The proportion of patients in the United States with well-differentiated thyroid cancer (papillary, follicular, or Hurthle cell tumors) who received radioactive iodine after surgery rose from 40 percent to 56 percent between 1990 and 2008, and this increase was seen across all tumor sizes. Dr. Megan R. Haymart of the University of Michigan and her colleagues reported their findings August 17 in JAMA.

This increase came despite the low risk of recurrence for these patients after total thyroidectomy alone and conflicting evidence about whether radioactive iodine treatment benefits patients with low-risk disease. This increase in treatment may be exposing patients to unnecessary harms, as well as incurring greater costs.

The researchers used data from 189,219 thyroid cancer patients in the National Cancer Database, which is maintained by the American College of Surgeons Commission on Cancer and the American Cancer Society and captures about 85 percent of patients with thyroid cancer in the United States.

Patients who were younger and healthier were more likely to receive radioactive iodine, but African American patients and those without health insurance were less likely to receive radioactive iodine. In an analysis of radioactive iodine use by stage of disease in patients treated in 2004 to 2008, patients with the earliest-stage tumors (stage I) were less likely than those with stage IV disease to receive radioactive iodine. However, there was no difference in use between patients with stage II or stage IV disease or between patients with stage III or stage IV disease.

Hospitals varied widely in their use of radioactive iodine for patients with all stages of the disease, as well. Using data from 2004 to 2008, the authors also found that patients treated at a hospital with a higher case volume of thyroid cancer patients were more likely to be treated with radioactive iodine. “For every 1 additional case a hospital treats, the odds of radioactive iodine use increase by 0.6 percent,” explained the authors.

Characteristics of the patients and their tumors accounted for just 21 percent of the variation among hospitals, and unknown hospital factors accounted for 29 percent of the variation, suggesting that “disease severity is not the sole determinant of radioactive iodine use,” they noted.

The data set used provides “incomplete knowledge about how and why care was delivered in hospitals showing variation,” wrote Dr. Edward H. Livingston of the University of Texas Southwestern Medical Center and Dr. Robert A. McNutt of the Rush University School of Medicine in an accompanying editorial. “Without an assessment of hard, irrefutable measures of clinical decision making that include individual preferences for treatment, decisions about the appropriateness of clinical treatments and variations of care cannot be made.”

According to data from NCI’s Surveillance, Epidemiology, and End Results program, the incidence of well-differentiated thyroid cancer has more than doubled in the last 30 years. “This study highlights the need to develop better prognostic models for these patients, since it’s unlikely that a randomized trial [of radioactive iodine] will ever be done,” due to the very large number of patients and long follow-up that would be required, commented Dr. Ann W. Gramza, a physician with NCI’s Thyroid Clinical Research Program at the NIH Clinical Center.

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