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Researchers assess radioactive iodine use in medium-risk thyroid cancer
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The use of radioactive iodine in patients with thyroid cancer tends to vary. However, the pattern for which it is used depending on risk categories is not entirely clear. Recent data indicate that patients with medium-risk thyroid cancer may require more intensive management compared with those with high-risk disease.
Megan R. Haymart, MD, assistant professor of medicine in the division of metabolism, endocrinology and diabetes, and in the division of hematology/oncology at The University of Michigan Health System, and colleagues evaluated the use of radioactive iodine (RAI) in nine US regions in 85,948 patients with well-differentiated thyroid cancer. Patients were diagnosed between 2004 and 2008 at 986 hospitals associated with the US National Cancer Database.
“The proportion of patients across US regions receiving RAI was similar in medium- and high-risk patients,” Haymart and colleagues wrote. “Regional treatment variation was seen in all risk categories, with a greater number of nonclinical correlates of RAI use in low-risk patients compared with medium- and high-risk patients.”
The patients’ RAI use was measured, and they were categorized according to: low risk (tumor size ≤1 cm and American Joint Committee on Cancer stage I disease); medium risk (neither low nor high-risk); and high risk (American Joint Committee on Cancer stage III or IV).
According to data, the use of RAI varied from 49% to 66% across geographic locations. These regional differences continued after the researchers examined patient and hospital characteristics. Furthermore, they evaluated less vs. more intensive-use regions within the low-risk group (OR=0.36; 95% CI, 0.25-0.53); medium-risk group (OR=0.23; 95% CI, 0.16-0.34); and the high-risk group (OR=0.3; 95% CI, 0.19-0.49).
These findings suggest controversy relating to current indications for RAI, which is suggested for use over time, for all tumors. However, Haymart and colleagues suggest a need to re-evaluate the risks and benefits of RAI considering the increasing rate of thyroid cancer.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopIain J. Nixon, MBCHB
This study underlines the wide spectrum of RAI use across the United States. Previous work from the same group has examined the increasing use and the heterogeneity of use of RAI, but this work goes further; demonstrating that there are significant differences not only overall, but also on a regional basis and within risk groups among patients with thyroid cancer. The authors are right to point out the lack of randomized studies in this field. Recent work from Europe has suggested that low dose RAI may be as effective as high dose. Retrospective work has suggested that select patients can safely be managed without RAI, and a prospective trial is under way to address this question more definitively. It is slightly surprising that high-volume centers favor the use of RAI in comparison with low-volume centers, although such statistics are difficult to interpret.
Until prospective results are available, physicians' decisions in relation to the use of RAI must be based on imperfect retrospective work, which continues to drive the variation in practice seen in the US. This is likely to be replicated the world over.
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