Disclosures: The authors report no relevant financial disclosures.
April 22, 2021
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Most physicians suppress TSH in patients with intermediate-, low-risk thyroid cancer

Disclosures: The authors report no relevant financial disclosures.
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Most physicians treating patients with thyroid cancer said they would suppress thyroid-stimulating hormone in those with low- and intermediate-risk thyroid cancer, according to a study published in Thyroid.

Megan R. Haymart

“We found that many physicians suppress TSH in intermediate-, low- and very low-risk patients, with some continuing this practice for longer than 5 years,” Megan R. Haymart, MD, professor of medicine and the Nancy Wigginton Endocrinology Research Professor of Thyroid Cancer in the department of metabolism, endocrinology, and diabetes at the University of Michigan, told Healio. “Physicians with higher thyroid cancer patient volume were less likely to suppress TSH in low-risk and very low-risk papillary thyroid cancer patients, while physicians who estimated a higher likelihood of recurrence were more likely to recommend TSH suppression in a patient with very low-risk papillary thyroid cancer.”

Most endocrinologists and surgeons recommend TSH suppression with intermediate-risk papillary thyroid cancer, and nearly said they would recommend TSH suppression for low-risk cancer patients. Data were derived from Papaleontiou M, et al. Thyroid. 2021;doi:10.1089/thy.2021.0033.

Haymart and colleagues surveyed physicians and surgeons who were identified as providers by patients with differentiated thyroid cancer affiliated with the Surveillance, Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County. Surveys were mailed to 482 physicians identified by more than one patient and 172 randomly selected from a cohort of providers identified by only one patient. A total of 448 providers completed the survey for a 69% response rate.

Participants were asked how likely they were to recommend TSH suppression based on three scenarios involving patients with intermediate-risk, low-risk and very low-risk papillary thyroid cancer. Responses were based on a 4-point Likert scale, with responses including extremely unlikely, unlikely, likely and extremely likely. Providers who were likely to recommend TSH suppression were asked how long they would continue suppression in each scenario.

TSH suppression common

A total of 58.3% of respondents were surgeons, and the remaining 41.7% were endocrinologists. Of the study participants, 80.4% said they were likely or extremely likely to recommend TSH suppression for intermediate-risk papillary thyroid cancer, 48.8% would recommend TSH suppression for low-risk thyroid cancer and 29.7% would recommend TSH suppression for patients with very low-risk cancer. Of providers who were likely or extremely likely to recommend TSH suppression, 39.7% said they would continue suppression for more than 5 years in intermediate-risk thyroid cancer, 41.5% said they suppress TSH for 5 or more years in low-risk cancer and 45.8% would continue suppression for 5-plus years in very low-risk thyroid cancer.

Haymart said the proportion of providers who would continue TSH suppression in patients with intermediate- to low-risk cancer for many years was concerning for the researchers.

“Inappropriate TSH suppression can lead to patient harm,” Haymart said. “Risks include loss of bone mass and arrhythmia, with older patients at greatest risks. The fact that close to half of those who initiate TSH suppression in patients with low-risk and very low-risk papillary thyroid cancer continue this practice for longer than 5 years is worrisome. Longer TSH suppression duration increases risks of harm.”

High-volume physicians less likely to suppress TSH

In multivariable regression analysis, surgeons were less likely to recommend TSH suppression in intermediate-risk thyroid cancer compared with endocrinologists (OR = 0.36; 95% CI, 0.19-0.69). Physicians who saw more than 40 patients with thyroid cancer in the past year at the time of the survey were less likely to recommend TSH suppression for patients with low-risk thyroid cancer (OR = 0.53; 95% CI, 0.3-0.96) and very low-risk cancer (OR = 0.49; 95% CI, 0.24-0.99) compared with providers seeing 20 or fewer patients with thyroid cancer in the past year. Participants who said there were 10% or greater odds of cancer recurrence in the next 10 years in patients with very low-risk thyroid cancer were more likely to recommend TSH suppression compared with those who said recurrence odds were 5% or less (OR = 2.34; 95% CI, 1.91-4.59).

“It was reassuring to see that physicians with higher thyroid cancer patient volume were less likely to suppress TSH,” Haymart said. “This highlights the importance of physician experience and expertise in reducing low-value care. It suggests that future efforts may need to be targeted toward low-volume physicians.”

For more information:

Megan R. Haymart, MD, can be reached at meganhay@med.umich.edu.