A study of long-term thyroid cancer outcomes
shows, among other findings, that moderate suppression of
thyroid-stimulating hormone (TSH), which drives the disease, may be as
beneficial as more extreme hormone suppression. Extreme TSH suppression
is associated with increased side effects including osteoporosis and
heart rhythm irregularities. Results are published online ahead of print
in the journal Thyroid.
"In these patients, if TSH levels are elevated, recurrence rates are
higher. Moderate TSH suppression tends to bring the level just below
the normal range and what we show is that heavily suppressing TSH even
further may have diminishing returns," says Bryan Haugen, MD,
investigator at the University of Colorado Cancer Center, professor and
head of the Division of Endocrine, Metabolism & Diabetes and Kern
Chair of Endocrine Neoplasms Research at the University of Colorado
School of Medicine. Haugen is also chair of a task force currently
updating guidelines that define the standard of care for the treatment
of thyroid cancer.
The international, multi-center study, which began in 1987, collected data from 4,941 thyroid cancer patients.
"This is a unique data resource," Haugen says. "Previous studies
have been limited to the small number of patients that could be enrolled
at a single center or to studies that mine data from more general
cancer registries. Because we combined the patient data from about 14
participating centers and collected the data ourselves, we have a large
set of high-quality, prospectively collected data."
For example, Haugen points out, the group could be sure that terms
like "progression-free survival" and "recurrence" were measured the same
way for every patient.
"Basically, because we built the database ourselves, we could be sure we were comparing apples to apples," Haugen says.
Additional findings include confirmation of previous, smaller
studies showing that patients with stage III and IV disease had improved
survival when treated with radioactive iodine after surgery. Also,
while the study showed that extreme hormone suppression offered no
additional survival benefit in high-risk patients, it showed that mild
suppression was useful even with low-risk patients.
"In my mind, this study might give doctors pause when prescribing
long-term, extreme TSH suppression in thyroid cancer patients. Contrary
to our results, there is evidence from previous studies that extreme
suppression may help in high-risk patients, but maybe then after a few
years, when there is no evidence of disease recurrence, this study
suggests that doctors could back off when we wouldn't have before,"
In Haugen's opinion, this study shows the necessity of a
prospective, randomized control trial testing extreme versus moderate
TSH suppression in high-risk thyroid cancer patients.