NLM Director's Comments Transcript
Inconsistent Thyroid Cancer Treatment?: 09/19/2011

URL of this page: http://www.nlm.nih.gov/medlineplus/podcast/transcript091911.html

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I'm Rob Logan, Ph.D. senior staff National Library of Medicine for Donald Lindberg, M.D, the Director of the U.S. National Library of Medicine.
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A common treatment for thyroid cancer may be provided too frequently to persons who may not need it and too infrequently to patients in need, suggests a comprehensive study recently published in the Journal of the American Medical Association (JAMA).
However, the variance within the findings about the treatment of patients with radioactive iodine (which reduces the recurrence of thyroid cancer) prompted a constructive but critical editorial. The JAMA suggests the study's importance may be learning from some of its methodological flaws rather than its primary findings. editorial

The study's results are based on about 189,000 patients treated for thyroid cancer between 1990 through 2008 at 981 hospitals. The study's data are derived from the National Cancer Database, a project from the American College of Surgeons and the American Cancer Society, which includes data on all types of cancer.

The study found about one fourth to one third of patients with large tumors, or advanced-stage thyroid cancer, were not treated with radioactive iodine. Conversely, between one fourth to one third of patients with smaller tumors (and a less advanced stage of thyroid cancer) received radioactive iodine therapy. Among the participating hospitals, the use of radioactive iodine increased significantly during the study's 18 year period regardless of the stage of a patient's thyroid cancer.

The study's authors explain the findings suggest about a fourth to a third of advanced thyroid cancer patients (who should receive radioactive iodine according to clinical guidelines) did not obtain this therapy. At the same time, about the same percentage of patients with smaller tumors (who are not at an advanced stage of thyroid cancer) received radioactive iodine, which is not consistent with a recommended clinical guideline.

The study's authors explain radioactive iodine is a recommended treatment for patients with advanced thyroid cancer. The treatment for thyroid cancer often includes surgically removing a patient's thyroid gland and then, preventing cancer reoccurrence with radioactive iodine treatments.

Moreover, the study found there was a significant variation in radioactive iodine use among participating hospitals regardless of the stage when thyroid cancer patients were treated. For example, while 37 percent of persons with stage 1 (or low risk) thyroid cancer received radioactive iodine, the percent of treated patients ranged from 0 to more than 90 percent at other participating hospitals.

The study's six authors controlled for various differences to assess if the stage of cancer, gender, age, hospital type, or other characteristics explained the variation among hospitals to provide radioactive iodine to diverse thyroid cancer patients. Since these characteristics did not explain the wide variation in radioactive iodine use, the study's six authors attributed most of the variance to unspecified hospital characteristics.

The study's authors add about 44,000 Americans are diagnosed with thyroid cancer annually.

MedlinePlus.gov's thyroid cancer health topic page explains that similar to many cancers, thyroid cancer is most treatable when it is diagnosed in its early stages. MedlinePlus.gov's thyroid cancer health topic page adds the thyroid is a butterfly-shaped gland that is in your neck above your collarbone.

Meanwhile, the JAMA editorial's authors note the significant variation among hospitals may reveal more about incomplete research methods than differences in how medical institutions respond to thyroid cancer treatment guidelines.

Regarding the study's methods, the editorial's two authors write (and we quote), 'there is incomplete knowledge about how and why care was delivered in hospitals showing variation' (end of quote).

The editorial's authors add (and we quote) 'the study highlights the limits of using administrative data, which lack granular information about why decisions are made, to draw conclusions about the appropriateness of care' (end of quote). Among other challenges, the editorial's authors explain the research addresses two intermediate outcomes (variation among hospitals and adherence to treatment guidelines) without linking an intervention (radioactive iodine use) to meaningful clinical results. For example, the editorial's authors note the study's methods do not assess if thyroid cancer patients derived benefit or harm from a radioactive iodine procedure.

The editorial's authors add variation among hospitals should have been anticipated because (and we quote): 'no guideline or clinical trial refutes individual variation for a variety of clinical scenarios in treating thyroid cancer' (end of quote).

As a result, the editorial's authors suggest the radioactive iodine study may reveal more about inadvertent methodological flaws than insights regarding how hospitals comply with thyroid cancer treatment guidelines.

We should add it is insightful to see a major medical journal publish a national study with important findings – that is accompanied by a constructive criticism of its underlying presumptions and methods. Taken together, the two JAMA articles suggest it is yet-to-be determined if most thyroid cancer patients receive radioactive iodine at the most therapeutic time.

MedlinePlus.gov's thyroid cancer health topic page provides information about radioactive iodine therapy (from the American Cancer Society) within the 'treatment' section.

MedlinePlus.gov's thyroid cancer health topic page also provides information about diagnosis, treatment, prevention, screening, and management of thyroid cancer.

MedlinePlus.gov's thyroid cancer health topic page additionally contains research summaries, which are available in the 'research' section. Links to the latest pertinent journal research articles are available in the 'journal articles' section. Information about related clinical trials in your area is available in the 'clinical trials' section.

To find MedlinePlus.gov's thyroid cancer health topic page, type 'thyroid cancer' that's 'T..H..Y..R..O..I..D (cancer)' in the search box on MedlinePlus.gov's home page, then, click on 'thyroid cancer (National Library of Medicine).'

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NLM Director's Comments Transcript - Inconsistent Thyroid Cancer Treatment?: MedlinePlus