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Despite an overall increase in the use of radioactive iodine following total thyroidectomy for primary thyroid cancer, there are still significant variations in use among institutions and across demographically different populations.
That variation, however, doesn’t appear to have had much of an impact on disease severity, according to a study published online Aug. 16 in JAMA.
"The recent increase in the incidence of small, low-risk thyroid cancer mandates an understanding of patterns of care in thyroid cancer," wrote lead author Dr. Megan R. Haymart and her colleagues (JAMA 2011;306:721-8).
Moreover, "the significant between-hospital variation in radioactive iodine use suggests clinical uncertainty about the role of radioactive iodine in thyroid cancer management."
Dr. Haymart, of the University of Michigan, Ann Arbor, and her coauthors analyzed the cases of 189,219 patients with primary thyroid cancer who underwent total thyroidectomy between 1990 and 2008. Data were culled from the National Cancer Database, which captures close to 85% of all thyroid cancers in the United States, according to the investigators.
They found that in 1990, 1,373 of 3,397 patients with the diagnosis received radioactive iodine (40%).
By 2008, that number had jumped to 11,539 of 20,620 cases (56%) – a significant increase (P less than .001).
The authors then conducted a subgroup analysis involving 85,948 patients diagnosed between 2004 and 2008, in order to "define the most contemporary practice patterns." They found that "younger age and absence of comorbidity were associated with a small but significantly greater likelihood of receiving radioactive iodine after total thyroidectomy."
Younger patients (aged 44 years and less) had an odds ratio of 2.15 for receiving the treatment compared with patients aged 60 years and older (95% confidence interval, 2.04-2.26).
Similarly, patients with a Charlson-Deyo comorbidity index score of 0 registered an OR of 1.19 for receiving radioactive iodine following thyroidectomy, compared to patients with scores of 2 or greater (95% CI, 1.07-1.35).
Factors significantly associated with a lower rate of radioactive iodine use were female sex (OR, 0.87; 95% CI, 0.84-0.91), African American race (OR, 0.83; 95% CI, 0.77-0.89), and the absence of private/government insurance (OR, 0.84; 95% CI, 0.81-0.88).
By comparison, disease severity appeared to play less of a role in treatment patterns. There was a significant difference between radioactive iodine use between American Joint Committee on Cancer designation stage I and stage IV (OR for stage I vs. stage IV, 0.34; 95% CI, 0.31-0.37). However, no difference in use existed between stage II and stage IV (OR for stage II vs. stage IV, 0.97; 95% CI, 0.88-1.07). Nor was there a significant difference in use between stage III and stage IV (OR, 1.06; 95% CI, 0.95-1.17).
The number of cases of post-thyroidectomy thyroid cancers seen at a particular institution per year also affected the use of radioactive treatment. Compared with high-volume institutions, defined as treating 35 or more cases per year, there was significantly less use of radioactive iodine at low-volume centers, treating 6 or fewer cases per year (OR, 0.44; 95% CI, 0.33-0.58) and medium-volume centers, treating 7-11 cases per year (OR, 0.62; 95% CI, 0.48-0.80).
According to Dr. Haymart and her colleagues, the conflicting use patterns are not easily explained, although some uncertainty may be due to a lack of clinical trials, as well as previous conflicting, single-institution studies. "Because of limited clinical evidence, clinical guidelines have left radioactive iodine use to physician discretion in many cases," they wrote.
"In the interest of curbing the increasing health care costs and preventing both overtreatment and undertreatment of disease, indications for radioactive iodine should be clearly defined and disease severity should become the primary driver of radioactive iodine use," they said.
The authors reported no potential conflicts of interest. The study was funded by a grant to Dr. Haymart from the National Institutes of Health.
While there does appear to be wide variation in use of radioactive iodine, the conclusion that this variation is inappropriate may not be accurate, wrote Dr. Edward H. Livingston and Dr. Robert A. McNutt in an accompanying editorial.
"There is incomplete knowledge about how and why care was delivered in hospitals showing variation," they wrote.
"If RAI [radioactive iodine] was not given to high-risk patients, the reasons it was not administered (such as patient preferences) are not captured in the database. If RAI was given to low-risk patients, subtle information regarding a clinician’s decision to administer RAI is not captured in these databases."
For example, "during total thyroidectomy, some surgeons leave a rim of thyroid tissue adjacent to nerves to minimize the risk of nerve injury and rely on RAI to ablate the residual thyroid tissue," they pointed out.
"This procedure is coded as a total thyroidectomy in an administrative database and appears in an analysis of that database to be associated with inappropriate administration of RAI."
Indeed, "without knowing if patients receiving RAI derived benefit or harm, it is difficult to conclude that RAI administration was appropriate or not," they added.
And while the study is telling, its usefulness in setting clinical guidelines is limited.
"For individual patients cared for by individual physicians, variation in care is sometimes desirable. One patient’s chronic illness is not another’s, and treating all patients the same would be clinical nonsense.
"Because of uncertainty in the integrity of most administrative databases and registries and the inherent limitation in the amount of information they contain about patient care, policy should only rarely be made based on findings from these sources," they added.
Dr. Livingston, of the University of Texas Southwestern Medical Center, Dallas, and Dr. McNutt, of the Rush University School of Medicine, Chicago, are both contributing editors to JAMA. Both stated that they had no conflicts of interest related to the editorial (JAMA 2011;306:762-3).
While there does appear to be wide variation in use of radioactive iodine, the conclusion that this variation is inappropriate may not be accurate, wrote Dr. Edward H. Livingston and Dr. Robert A. McNutt in an accompanying editorial.
"There is incomplete knowledge about how and why care was delivered in hospitals showing variation," they wrote.
"If RAI [radioactive iodine] was not given to high-risk patients, the reasons it was not administered (such as patient preferences) are not captured in the database. If RAI was given to low-risk patients, subtle information regarding a clinician’s decision to administer RAI is not captured in these databases."
For example, "during total thyroidectomy, some surgeons leave a rim of thyroid tissue adjacent to nerves to minimize the risk of nerve injury and rely on RAI to ablate the residual thyroid tissue," they pointed out.
"This procedure is coded as a total thyroidectomy in an administrative database and appears in an analysis of that database to be associated with inappropriate administration of RAI."
Indeed, "without knowing if patients receiving RAI derived benefit or harm, it is difficult to conclude that RAI administration was appropriate or not," they added.
And while the study is telling, its usefulness in setting clinical guidelines is limited.
"For individual patients cared for by individual physicians, variation in care is sometimes desirable. One patient’s chronic illness is not another’s, and treating all patients the same would be clinical nonsense.
"Because of uncertainty in the integrity of most administrative databases and registries and the inherent limitation in the amount of information they contain about patient care, policy should only rarely be made based on findings from these sources," they added.
Dr. Livingston, of the University of Texas Southwestern Medical Center, Dallas, and Dr. McNutt, of the Rush University School of Medicine, Chicago, are both contributing editors to JAMA. Both stated that they had no conflicts of interest related to the editorial (JAMA 2011;306:762-3).
While there does appear to be wide variation in use of radioactive iodine, the conclusion that this variation is inappropriate may not be accurate, wrote Dr. Edward H. Livingston and Dr. Robert A. McNutt in an accompanying editorial.
"There is incomplete knowledge about how and why care was delivered in hospitals showing variation," they wrote.
"If RAI [radioactive iodine] was not given to high-risk patients, the reasons it was not administered (such as patient preferences) are not captured in the database. If RAI was given to low-risk patients, subtle information regarding a clinician’s decision to administer RAI is not captured in these databases."
For example, "during total thyroidectomy, some surgeons leave a rim of thyroid tissue adjacent to nerves to minimize the risk of nerve injury and rely on RAI to ablate the residual thyroid tissue," they pointed out.
"This procedure is coded as a total thyroidectomy in an administrative database and appears in an analysis of that database to be associated with inappropriate administration of RAI."
Indeed, "without knowing if patients receiving RAI derived benefit or harm, it is difficult to conclude that RAI administration was appropriate or not," they added.
And while the study is telling, its usefulness in setting clinical guidelines is limited.
"For individual patients cared for by individual physicians, variation in care is sometimes desirable. One patient’s chronic illness is not another’s, and treating all patients the same would be clinical nonsense.
"Because of uncertainty in the integrity of most administrative databases and registries and the inherent limitation in the amount of information they contain about patient care, policy should only rarely be made based on findings from these sources," they added.
Dr. Livingston, of the University of Texas Southwestern Medical Center, Dallas, and Dr. McNutt, of the Rush University School of Medicine, Chicago, are both contributing editors to JAMA. Both stated that they had no conflicts of interest related to the editorial (JAMA 2011;306:762-3).
Despite an overall increase in the use of radioactive iodine following total thyroidectomy for primary thyroid cancer, there are still significant variations in use among institutions and across demographically different populations.
That variation, however, doesn’t appear to have had much of an impact on disease severity, according to a study published online Aug. 16 in JAMA.
"The recent increase in the incidence of small, low-risk thyroid cancer mandates an understanding of patterns of care in thyroid cancer," wrote lead author Dr. Megan R. Haymart and her colleagues (JAMA 2011;306:721-8).
Moreover, "the significant between-hospital variation in radioactive iodine use suggests clinical uncertainty about the role of radioactive iodine in thyroid cancer management."
Dr. Haymart, of the University of Michigan, Ann Arbor, and her coauthors analyzed the cases of 189,219 patients with primary thyroid cancer who underwent total thyroidectomy between 1990 and 2008. Data were culled from the National Cancer Database, which captures close to 85% of all thyroid cancers in the United States, according to the investigators.
They found that in 1990, 1,373 of 3,397 patients with the diagnosis received radioactive iodine (40%).
By 2008, that number had jumped to 11,539 of 20,620 cases (56%) – a significant increase (P less than .001).
The authors then conducted a subgroup analysis involving 85,948 patients diagnosed between 2004 and 2008, in order to "define the most contemporary practice patterns." They found that "younger age and absence of comorbidity were associated with a small but significantly greater likelihood of receiving radioactive iodine after total thyroidectomy."
Younger patients (aged 44 years and less) had an odds ratio of 2.15 for receiving the treatment compared with patients aged 60 years and older (95% confidence interval, 2.04-2.26).
Similarly, patients with a Charlson-Deyo comorbidity index score of 0 registered an OR of 1.19 for receiving radioactive iodine following thyroidectomy, compared to patients with scores of 2 or greater (95% CI, 1.07-1.35).
Factors significantly associated with a lower rate of radioactive iodine use were female sex (OR, 0.87; 95% CI, 0.84-0.91), African American race (OR, 0.83; 95% CI, 0.77-0.89), and the absence of private/government insurance (OR, 0.84; 95% CI, 0.81-0.88).
By comparison, disease severity appeared to play less of a role in treatment patterns. There was a significant difference between radioactive iodine use between American Joint Committee on Cancer designation stage I and stage IV (OR for stage I vs. stage IV, 0.34; 95% CI, 0.31-0.37). However, no difference in use existed between stage II and stage IV (OR for stage II vs. stage IV, 0.97; 95% CI, 0.88-1.07). Nor was there a significant difference in use between stage III and stage IV (OR, 1.06; 95% CI, 0.95-1.17).
The number of cases of post-thyroidectomy thyroid cancers seen at a particular institution per year also affected the use of radioactive treatment. Compared with high-volume institutions, defined as treating 35 or more cases per year, there was significantly less use of radioactive iodine at low-volume centers, treating 6 or fewer cases per year (OR, 0.44; 95% CI, 0.33-0.58) and medium-volume centers, treating 7-11 cases per year (OR, 0.62; 95% CI, 0.48-0.80).
According to Dr. Haymart and her colleagues, the conflicting use patterns are not easily explained, although some uncertainty may be due to a lack of clinical trials, as well as previous conflicting, single-institution studies. "Because of limited clinical evidence, clinical guidelines have left radioactive iodine use to physician discretion in many cases," they wrote.
"In the interest of curbing the increasing health care costs and preventing both overtreatment and undertreatment of disease, indications for radioactive iodine should be clearly defined and disease severity should become the primary driver of radioactive iodine use," they said.
The authors reported no potential conflicts of interest. The study was funded by a grant to Dr. Haymart from the National Institutes of Health.
Despite an overall increase in the use of radioactive iodine following total thyroidectomy for primary thyroid cancer, there are still significant variations in use among institutions and across demographically different populations.
That variation, however, doesn’t appear to have had much of an impact on disease severity, according to a study published online Aug. 16 in JAMA.
"The recent increase in the incidence of small, low-risk thyroid cancer mandates an understanding of patterns of care in thyroid cancer," wrote lead author Dr. Megan R. Haymart and her colleagues (JAMA 2011;306:721-8).
Moreover, "the significant between-hospital variation in radioactive iodine use suggests clinical uncertainty about the role of radioactive iodine in thyroid cancer management."
Dr. Haymart, of the University of Michigan, Ann Arbor, and her coauthors analyzed the cases of 189,219 patients with primary thyroid cancer who underwent total thyroidectomy between 1990 and 2008. Data were culled from the National Cancer Database, which captures close to 85% of all thyroid cancers in the United States, according to the investigators.
They found that in 1990, 1,373 of 3,397 patients with the diagnosis received radioactive iodine (40%).
By 2008, that number had jumped to 11,539 of 20,620 cases (56%) – a significant increase (P less than .001).
The authors then conducted a subgroup analysis involving 85,948 patients diagnosed between 2004 and 2008, in order to "define the most contemporary practice patterns." They found that "younger age and absence of comorbidity were associated with a small but significantly greater likelihood of receiving radioactive iodine after total thyroidectomy."
Younger patients (aged 44 years and less) had an odds ratio of 2.15 for receiving the treatment compared with patients aged 60 years and older (95% confidence interval, 2.04-2.26).
Similarly, patients with a Charlson-Deyo comorbidity index score of 0 registered an OR of 1.19 for receiving radioactive iodine following thyroidectomy, compared to patients with scores of 2 or greater (95% CI, 1.07-1.35).
Factors significantly associated with a lower rate of radioactive iodine use were female sex (OR, 0.87; 95% CI, 0.84-0.91), African American race (OR, 0.83; 95% CI, 0.77-0.89), and the absence of private/government insurance (OR, 0.84; 95% CI, 0.81-0.88).
By comparison, disease severity appeared to play less of a role in treatment patterns. There was a significant difference between radioactive iodine use between American Joint Committee on Cancer designation stage I and stage IV (OR for stage I vs. stage IV, 0.34; 95% CI, 0.31-0.37). However, no difference in use existed between stage II and stage IV (OR for stage II vs. stage IV, 0.97; 95% CI, 0.88-1.07). Nor was there a significant difference in use between stage III and stage IV (OR, 1.06; 95% CI, 0.95-1.17).
The number of cases of post-thyroidectomy thyroid cancers seen at a particular institution per year also affected the use of radioactive treatment. Compared with high-volume institutions, defined as treating 35 or more cases per year, there was significantly less use of radioactive iodine at low-volume centers, treating 6 or fewer cases per year (OR, 0.44; 95% CI, 0.33-0.58) and medium-volume centers, treating 7-11 cases per year (OR, 0.62; 95% CI, 0.48-0.80).
According to Dr. Haymart and her colleagues, the conflicting use patterns are not easily explained, although some uncertainty may be due to a lack of clinical trials, as well as previous conflicting, single-institution studies. "Because of limited clinical evidence, clinical guidelines have left radioactive iodine use to physician discretion in many cases," they wrote.
"In the interest of curbing the increasing health care costs and preventing both overtreatment and undertreatment of disease, indications for radioactive iodine should be clearly defined and disease severity should become the primary driver of radioactive iodine use," they said.
The authors reported no potential conflicts of interest. The study was funded by a grant to Dr. Haymart from the National Institutes of Health.
FROM JAMA
Major Finding: Patient demographics and a hospital’s annual volume of thyroidectomy procedures – and not disease severity – are some of the biggest predictors of radioactive iodine use following total thyroidectomy. Factors significantly associated with a lower rate of radioactive iodine use were female sex (OR, 0.87; 95% CI, 0.84-0.91), African American race (OR, 0.83; 95% CI, 0.77-0.89), and the absence of private/government insurance (OR, 0.84; 95% CI, 0.81-0.88).
Data Source: A study of 189,219 patients registered in the National Cancer Database with primary thyroid cancer who underwent total thyroidectomy in the United States between 1990 and 2008.
Disclosures: The authors reported no potential conflicts of interest. The study was funded by a grant to Dr. Haymart from the National Institutes of Health.