Year in Thyroidology-Recent Developments and Future Challenges: Clinical Science Review

Background: The 2021 Year in Thyroidology-Recent Developments and Future Challenges: Clinical Science Review featured key clinical research within five categories: Thyroid Nodules and Cancer, Thyroid Function and Thyroid Eye Disease, Thyroid and Pregnancy, Thyroid and Pediatrics, and Disparities in Thyroid. Methods: A literature search of PubMed from November 2019 to August 2021 was performed to identify relevant peer-reviewed articles published in English and with a focus on human subjects. Results: There were three nominees for each of the five categories and one featured article per category. The featured articles had the most potential to change clinical practice, focused on a novel topic, and/or included of strong methodology. Conclusions: There were many strong publications on thyroid between November 2019 and August 2021; the 15 nominees and 5 featured articles span a breadth of topics and methodological approaches. The featured articles all have potential to change practice patterns or to stimulate further research that will ultimately change practice patterns.

Change in worry over time among Hispanic women with thyroid cancer

PURPOSE

The purpose of this study is to assess change in worry over time in Hispanic women with thyroid cancer.

METHODS

Worry about recurrence, quality of life, family at risk, death, and harm from treatments was assessed in 273 Hispanic women with thyroid cancer diagnosed in 2014-2015. Subjects were recruited from Surveillance, Epidemiology, and End Results (SEER) Los Angeles. Participants were surveyed at two points in time (time 1: 2017-2018 and time 2: 2019). Multivariable logistic regression was used to determine correlates with high worry (somewhat, quite a bit, very much) versus low worry (not at all, a little) at time 2.

RESULTS

For the five worry items, 20.1-39.6% had high worry at both time 1 and time 2. An additional 7.6-13.4% had low worry at time 1 that became high worry at time 2. In multivariable logistic regression controlling for age, recurrence status, education level, and number of complications or side effects symptoms, younger age (20-39) as compared to older (40-79) was associated with high worry about thyroid cancer recurrence (OR 2.16, 95% CI 1.12-4.17). History of recurrent or persistent disease was associated with high worry about harms from treatment (OR 2.94, 95% CI 1.29-6.67). Greater number of complications or side effects of symptoms was associated with more worry across all five items.

CONCLUSIONS

Some Hispanic women with thyroid cancer have persistently high worry, with young adult Hispanic women vulnerable to worry about recurrence.

IMPLICATIONS FOR CANCER SURVIVORS

Hispanic women with thyroid cancer may benefit from targeted psychosocial support during survivorship, with interventions informed by patient and cancer characteristics.

Thyroid Hormone Therapy and Incident Stroke

CONTEXT

Stroke is a leading cause of death and disability and there is a need to identify modifiable risk factors.

OBJECTIVE

We aimed to determine the relationship between thyroid hormone treatment intensity and incidence of atrial fibrillation and stroke.

METHODS

We conducted a retrospective cohort study using data from the Veterans Health Administration between 2004 and 2017, with a median follow-up of 59 months. The study population comprised 733 208 thyroid hormone users aged ≥18 years with at least 2 thyroid stimulating hormone (TSH) measurements between thyroid hormone initiation and incident event (atrial fibrillation or stroke) or study conclusion (406 030 thyroid hormone users with at least 2 free thyroxine [T4] measurements).

RESULTS

Overall, 71 333/643 687 (11.08%) participants developed incident atrial fibrillation and 41 931/663 809 (6.32%) stroke. In multivariable analyses controlling for pertinent factors such as age, sex, and prior history of atrial fibrillation, higher incidence of stroke was associated with low TSH or high free T4 levels (ie, exogenous hyperthyroidism; eg, TSH <0.1 mIU/L; OR 1.33; 95% CI, 1.24-1.43; free T4>1.9 ng/dL, OR 1.17, 95% CI 1.06-1.30) and high TSH or low free T4 levels (ie, exogenous hypothyroidism; eg, TSH >5.5 mIU/L; OR 1.29; 95% CI, 1.26-1.33; free T4 <0.7 ng/dL; OR 1.29; 95% CI, 1.22-1.35) compared with euthyroidism (TSH >0.5-5.5 mIU/L and free T4 0.7-1.9 ng/dL). Risk of developing atrial fibrillation and stroke was cumulative over time for both patients with exogenous hyperthyroidism and hypothyroidism.

CONCLUSION

Both exogenous hyper- and hypothyroidism were associated with increased risk of stroke, highlighting the importance of patient medication safety.

Progress and Challenges in Thyroid Cancer Management

The state of thyroid cancer in 2021 is reviewed including the prevalence of thyroid cancer, vulnerable patient groups such as women and young adults, and known and hypothesized risk factors for thyroid cancer. Understanding the overdiagnosis and overtreatment of thyroid cancer and recent efforts to reduce harms secondary to overdiagnosis and overtreatment are addressed with optimism that future work will continue to evaluate and improve the care of patients with thyroid cancer.

Thyrotropin Suppression for Papillary Thyroid Cancer: A Physician Survey Study

Background: Current guidelines recommend against thyrotropin (TSH) suppression in low-risk differentiated thyroid cancer patients; however, physician practices remain underexplored. Our objective was to understand treating physicians' approach to TSH suppression in patients with papillary thyroid cancer. Methods: Endocrinologists and surgeons identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles were surveyed in 2018-2019. Physicians were asked to report how likely they were to recommend TSH suppression (i.e., TSH <0.5 mIU/L) in three clinical scenarios: patients with intermediate-risk, low-risk, and very low-risk papillary thyroid cancer. Responses were measured on a 4-point Likert scale (extremely unlikely to extremely likely). Multivariable logistic regressions were performed to determine physician characteristics associated with recommending TSH suppression in each of the aforementioned scenarios. Results: Response rate was 69% (448/654). Overall, 80.4% of physicians were likely/extremely likely to recommend TSH suppression for a patient with an intermediate-risk papillary thyroid cancer, 48.8% for a patient with low-risk papillary thyroid cancer, and 29.7% for a patient with very low-risk papillary thyroid cancer. Surgeons were less likely to recommend TSH suppression for an intermediate-risk papillary thyroid cancer patient (odds ratio [OR] = 0.36 [95% confidence interval, CI, 0.19-0.69]) compared with endocrinologists. Physicians with higher thyroid cancer patient volume were less likely to suppress TSH in low-risk and very low-risk papillary thyroid cancer patients (i.e., >40 patients per year, OR = 0.53 [CI 0.30-0.96]; OR = 0.49 [CI 0.24-0.99], respectively, compared with 0-20 patients per year). Physicians who estimated higher likelihood of recurrence were more likely to suppress TSH in a patient with very low-risk papillary thyroid cancer (OR = 2.34 [CI 1.91-4.59]). Conclusions: Many patients with low-risk thyroid cancer continue to be treated with suppressive doses of thyroid hormone, emphasizing the need for more high-quality research to guide thyroid cancer management, as well as better understanding of barriers that hinder guideline adoption.

Competing Causes of Death in Older Adults with Thyroid Cancer

Background: Understanding the impact of comorbidities and competing risks of death when caring for older adults with thyroid cancer is key for personalized management. The objective of this study was to determine whether older adults with thyroid cancer are more likely to die from thyroid cancer or other etiologies, and determine patient factors associated with each. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients aged ≥66 years diagnosed with thyroid cancer (papillary, follicular, Hürthle cell, medullary, anaplastic, and other) between 2000 and 2015 (median follow-up, 50 months). We analyzed time to event (i.e., death from other causes or death from thyroid cancer) using cumulative incidence functions. Competing risk hazards regression was used to determine the association between patient (e.g., age at diagnosis and specific comorbidities) and tumor characteristics (e.g., SEER stage) with two competing mortality outcomes: death from other causes and death from thyroid cancer. Results: Of 21,509 patients with a median age of 72 years (range 66-106), 4168 (19.4%) died of other causes and 2644 (12.3%) died of thyroid cancer during the study period. For differentiated thyroid cancer patients, likelihood of dying from other causes exceeds likelihood of dying from thyroid cancer, whereas the opposite is true for anaplastic thyroid cancer. For medullary thyroid cancer, after 6.25 years patients are more likely to die from other etiologies than thyroid cancer. Using competing risks hazards regression, male sex (hazards ratio [HR] 1.47; 95% confidence interval [CI 1.37-1.57]), black race (HR 1.30; CI [1.16-1.46]), and comorbidities (e.g., heart disease, HR 1.34; CI [1.25-1.44]; chronic lower respiratory disease, HR 1.25; CI [1.17-1.34]) were associated with death from other causes. Tumor characteristics such as histology, tumor size, and stage correlated with death from thyroid cancer (e.g., distant SEER stage compared with localized, HR 12.65; CI [10.91-14.66]). Conclusions: The clinical context, including patients' specific comorbidities, should be considered when diagnosing and managing thyroid cancer. Our findings can be used to develop decision models that account for competing causes of death, as an aid for clinical decision making.

Assessment of surveillance versus etiologic factors in the reciprocal association between papillary thyroid cancer and breast cancer

BACKGROUND

Mutually increased risks for thyroid and breast cancer have been reported, but the contribution of etiologic factors versus increased medical surveillance to these associations is unknown.

METHODS

Leveraging large-scale US population-based cancer registry data, we used standardized incidence ratios (SIRs) to investigate the reciprocal risks of thyroid and breast cancers among adult females diagnosed with a first primary invasive, non-metastatic breast cancer (N = 652,627) or papillary thyroid cancer (PTC) (N = 92,318) during 2000-2017 who survived ≥1-year.

RESULTS

PTC risk was increased 1.3-fold [N = 1434; SIR = 1.32; 95 % confidence interval (CI) = 1.25-1.39] after breast cancer compared to the general population. PTC risk declined significantly with time since breast cancer (Poisson regression = P_trend <0.001) and was evident only for tumors ≤2 cm in size. The SIRs for PTC were higher after hormone-receptor (HR)+ (versus HR-) and stage II or III (versus stage 0-I) breast tumors. Breast cancer risk was increased 1.2-fold (N = 2038; SIR = 1.21; CI = 1.16-1.26) after PTC and was constant over time since PTC but was only increased for stage 0-II and HR + breast cancers.

CONCLUSION

Although some of the patterns by latency, stage and size are consistent with heightened surveillance contributing to the breast-thyroid association, we cannot exclude a role of shared etiology or treatment effects.

Unmet Information Needs Among Hispanic Women with Thyroid Cancer

CONTEXT

Thyroid cancer is the second most common cancer in Hispanic women.

OBJECTIVE

To determine the relationship between acculturation level and unmet information needs among Hispanic women with thyroid cancer.

DESIGN

Population-based survey study.

PARTICIPANTS

Hispanic women from Los Angeles Surveillance Epidemiology and End Results registry with thyroid cancer diagnosed in 2014-2015 who had previously completed our thyroid cancer survey in 2017-2018 (N = 273; 80% response rate).

MAIN OUTCOME MEASURES

Patients were asked about 3 outcome measures of unmet information needs: (1) internet access, (2) thyroid cancer information resources used, and (3) ability to access information. Acculturation was assessed with the Short Acculturation Scale for Hispanics (SASH). Health literacy was measured with a validated single-item question.

RESULTS

Participants' median age at diagnosis was 47 years (range 20-79) and 48.7% were low-acculturated. Hispanic women were more likely to report the ability to access information "all of the time" if they preferred thyroid cancer information in mostly English compared to mostly Spanish (88.5% vs 37.0%, P < 0.001). Low-acculturated (vs high-acculturated) Hispanic women were more likely to have low health literacy (47.2% vs 5.0%, P < 0.001) and report use of in-person support groups (42.0% vs 23.1%, P = 0.006). Depending on their level of acculturation, Hispanic women accessed the internet differently (P < 0.001) such that low-acculturated women were more likely to report use of only a smartphone (34.0% vs 14.3%) or no internet access (26.2% vs 1.4%).

CONCLUSIONS

Low-acculturated (vs high-acculturated) Hispanic women with thyroid cancer have greater unmet information needs, emphasizing the importance of patient-focused approaches to providing medical information.

Multilevel Factors Associated With More Intensive Use of Radioactive Iodine for Low-Risk Thyroid Cancer

CONTEXT

The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs.

OBJECTIVE

To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer.

METHODS

This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer.

RESULTS

Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67).

CONCLUSIONS

Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.

Interfering Medications in Older Adults on Thyroid Hormone Replacement: Who Is at Risk?

Background: Thyroid hormone prescriptions have steadily increased in the past few years with levothyroxine being one of the most frequently prescribed medications in the United States. Population-based studies have shown that older age is a significant predictor for thyroid hormone initiation, with use continuing long-term. Thyroid hormone management in older adults is complicated by the presence of comorbidities and polypharmacy, particularly due to medications that can interfere with thyroid function tests. However, the prevalence of concurrent use of thyroid hormone and interfering medications in older adults and patient characteristics associated with this practice remain unknown. Methods: We conducted a population-based, retrospective cohort study of 538,137 thyroid hormone users aged ≥65 years from the Corporate Data Warehouse of the Veterans Health Administration (2004-2017). First, we described the prevalence of concurrent use of thyroid hormone and medications that commonly interfere with thyroid function tests (i.e., prednisone, prednisolone, carbamazepine, phenytoin, phenobarbital, amiodarone, lithium, interferon-alpha, tamoxifen). Then, we performed a multivariable logistic regression analysis to determine patient characteristics associated with concurrent use of thyroid hormone and at least one interfering medication during the study period. Covariates included in the model were patient age, sex, race, ethnicity and number of comorbidities. Results: Overall, 170,261 (31.6%) of patients were on at least one interfering medication while on thyroid hormone during the study period (median follow up 56 months). Non-white race [odds ratio (OR) 1.18, 95% confidence interval (CI) 1.15-1.21], compared to white race), Hispanic ethnicity (OR 1.11, 95% CI 1.08-1.14, compared to non-Hispanic), female sex (OR 1.12, 95% CI 1.08-1.15, compared to male sex), and presence of comorbidities (e.g. Charlson-Deyo Comorbidity Score ≥2, OR 2.47, 95% CI 2.43-2.52, compared to zero) were more likely to be associated with concurrent use of thyroid hormone and interfering medications. Older age (e.g., ≥85 years, OR 0.47, 95% CI 0.46 - 0.48, compared to age 65-74 years) was less likely to be associated with concurrent use of thyroid hormone and interfering medications. Conclusions: Almost one-third of older adults on thyroid hormone were taking medications that have been known to interfere with thyroid function tests. Our study highlights the complexity of managing thyroid hormone replacement in older patients, many of whom are at risk for adverse effects in the context of polypharmacy and comorbidities.

Unmet Information Needs Among Hispanic Women With Thyroid Cancer

Background: Despite thyroid cancer being the second most common cancer in Hispanic women, little is known about access to and utilization of medical information resources by Hispanic women with thyroid cancer. Methods: Hispanic women who had diagnoses of thyroid cancer reported to the Los Angeles Surveillance Epidemiology and End Results (SEER) registry in 2014-2015, and who had previously completed our thyroid cancer survey in 2017-2018, were offered follow-up surveys in both English and Spanish (N=273; 80% response rate). Acculturation, which is the process by which individuals adopt the language, values, attitudes, and behaviors of a different culture, was assessed with the Short Acculturation Scale for Hispanics (SASH). Health literacy was assessed with the validated single-item question of “How confident are you filling out medical forms by yourself?” with response categories based on a five-point Likert scale from “extremely” to “not at all”. Patients were also asked about their internet access, information resources used, and ability to access medical information about thyroid cancer in their preferred language. We generated descriptive statistics for all categorical variables and used Rao-Scott adjusted chi-square tests to test for a relationship between level of acculturation and the following variables: health literacy, internet access, information resources used, and ability to access information. Results: Participants’ median age at diagnosis was 47 years (range 20-79); 49% were low-acculturated, 25% had low health literacy, and 14% reported no internet access at home. Low-acculturated Hispanic women reported using information resources in both English and Spanish whereas high-acculturated women used resources in English only. Hispanic women were more likely to report the ability to access medical information about thyroid cancer all of the time if they preferred information in English compared to if they preferred it in Spanish (89% vs 37%, P<0.001). Low-acculturated (vs high-acculturated) Hispanic women were more likely to have low health literacy (47% vs 5%, P<0.001) and to report use of in-person support groups (42% vs 23%, P=0.006). Depending on their level of acculturation, Hispanic women accessed the internet differently (P<0.001) such that low-acculturated women were more likely to use only a smartphone (34% vs 14%) or have no internet access (26% vs 1%), and less likely to use both a smartphone and home computer/tablet (28% vs 58%) or use only a home computer/tablet (10% vs 21%). Conclusion: Our findings demonstrate that low-acculturated Hispanic women with thyroid cancer have greater unmet information needs and access information differently compared to high-acculturated Hispanic women. This study emphasizes the importance of a patient-focused tailored approach to providing medical information to this understudied population.

Financial Hardship Among Hispanic Women with Thyroid Cancer

Background: Little is known about financial hardship among Hispanic women with thyroid cancer. The goal of this study was to determine the prevalence of financial hardship and to identify correlates of financial hardship in this understudied patient group. Methods: We surveyed Hispanic women who had diagnoses of thyroid cancer reported to the Los Angeles Surveillance Epidemiology and End Results (SEER) registry in 2014-2015, and who had previously completed our thyroid cancer survey in 2017-2018 (N = 273; 80% response rate). Acculturation was assessed with the Short Acculturation Scale for Hispanics (SASH). Patients were asked about three outcome measures since their thyroid cancer diagnosis: (i) financial status, (ii) insurance status, and (iii) material measures of financial hardship, collapsed into a single composite measure of financial hardship. We used multivariable logistic regression to identify correlates of financial hardship. Results: Patients' median age at diagnosis was 47 years (range 20-79 years); 49% were low-acculturated and 47% reported financial hardship. Since their thyroid cancer diagnosis, 31% and 12% of the cohort reported being worse off regarding financial and insurance status, respectively. In multivariable analysis, high-acculturated older women were less likely to experience financial hardship compared with high-acculturated 20-year-old women. While financial hardship decreased with age for high-acculturated women (p = 0.002), financial hardship remained elevated across all age groups for low-acculturated women (p = 0.54). Conclusions: Our findings suggest that across all age groups, low-acculturated Hispanic women with thyroid cancer are vulnerable to financial hardship, emphasizing the need for tailored patient-focused interventions.

Physician Confidence in Neck Ultrasonography for Surveillance of Differentiated Thyroid Cancer Recurrence

IMPORTANCE

Neck ultrasonography, a mainstay of long-term surveillance for recurrence of differentiated thyroid cancer (DTC), is routinely used by endocrinologists, general surgeons, and otolaryngologists; however, physician confidence in their ability to use ultrasonography to identify lymph nodes suggestive of cancer recurrence remains unknown.

OBJECTIVE

To evaluate physicians' posttreatment surveillance practices for DTC recurrence, specifically their use of and confidence in ultrasonography.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 448 physicians in private and academic hospitals who completed a survey on DTC posttreatment practices from October 2018 to August 2019 (response rate, 69%) and self-reported involvement in long-term surveillance for thyroid cancer recurrence. Physicians were identified by patients affiliated with the Surveillance, Epidemiology, and End Results Program registries in Georgia State and Los Angeles County. Of the respondents, 320 physicians who reported involvement with DTC surveillance were included in the analysis.

MAIN OUTCOMES AND MEASURES

Physician-reported long-term surveillance practices for DTC, including frequency of use and level of confidence in ultrasonography for detecting lymph nodes suggestive of cancer recurrence.

RESULTS

In the cohort of 320 physicians who reported involvement with DTC surveillance, 186 (60%) had been in practice for 10 years to less than 30 years; 209 (68%) were White; and 212 (66%) were men. The physicians included 170 (56%) endocrinologists, 67 (21%) general surgeons, and 75 (23%) otolaryngologists. Just 84 (27%) physicians reported personally performing bedside ultrasonography. Only 57 (20%) had high confidence (rated quite or extremely confident) in their ability to use bedside ultrasonography to identify lymph nodes suggestive of recurrence; 94 (33%) did not report high confidence in either their ability or a radiologist's ability to use ultrasonography to detect recurrence. Higher confidence in ultrasonography was associated with the general surgery subspecialty (odds ratio [OR], 5.7; 95% CI, 2.2-14.4; reference endocrinology) and with treating a higher number of patients per year (>50 patients: OR, 14.4; 95% CI, 4.4-47.4; 31-50 patients: OR, 8.4; 95% CI, 2.6-26.7; 11-30 patients: OR, 4.3; 95% CI, 1.5-12.1; reference 0-10 patients).

CONCLUSIONS AND RELEVANCE

Given the importance of neck ultrasonography in long-term surveillance for thyroid cancer, these findings of physicians' low confidence in their own ability and that of radiologists to use ultrasonography to detect recurrence point to a major obstacle to standardizing long-term DTC surveillance practices.

Understanding Osteoporosis Screening Practices in Men: A Nationwide Physician Survey

OBJECTIVE

To understand osteoporosis screening practices, particularly in men, by a diverse cohort of physicians, including primary care physicians, endocrinologists, and geriatricians.

METHODS

We surveyed randomly selected members of the American Academy of Family Practice, Endocrine Society, and American Geriatrics Society. Respondents were asked to rate how often they would screen for osteoporosis in four different clinical scenarios by ordering a bone density scan. Multivariable logistic regression analyses were conducted to determine factors associated with offering osteoporosis screening in men in each clinical scenario. Physicians were also asked to note factors that would lead to osteoporosis screening in men.

RESULTS

Response rate was 63% (359/566). While 90% respondents reported that they would always or frequently screen for osteoporosis in a 65-year-old post-menopausal woman, only 22% reported they would screen a 74-year-old man with no significant past medical history. Endocrinologists were more likely to screen a 74-year-old man compared to primary care physicians (odds ratio, 2.32; 95% confidence interval, 1.10 to 4.88). In addition to chronic steroid use (94%), history of nontraumatic fractures (88%), and androgen-deprivation therapy for prostate cancer (82%), more than half the physicians reported suppressive doses of thyroid hormone (64%) and history of falls (52%) as factors leading to screening for osteoporosis in men.

CONCLUSIONS

Our survey results highlight heterogeneity in osteoporosis screening in men, with underscreening in some scenarios compared to women, and identify factors that lead to screening in men. These findings can help design interventions to improve osteoporosis screening in men.

Physician management of thyroid cancer patients' worry

PURPOSE

The purpose of this study is to understand physician management of thyroid cancer-related worry.

METHODS

Endocrinologists, general surgeons, and otolaryngologists identified by Surveillance, Epidemiology, and End Results (SEER) patients were surveyed 2018-2019 (response rate 69% (448/654)) and asked to rate in general their patients' worry at diagnosis and actions they take for worried patients. Multivariable-weighted logistic regressions were conducted to determine physician characteristics associated with reporting thyroid cancer as "good cancer" and with encouraging patients to seek help managing worry outside the physician-patient relationship.

RESULTS

Physicians reported their patients as quite/very worried (65%), somewhat worried (27%), and a little/not worried (8%) at diagnosis. Half of the physicians tell patients their thyroid cancer is a "good cancer." Otolaryngology (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.08-3.21, versus endocrinology), private practice (OR 2.48, 95% CI 1.32-4.68, versus academic setting), and Los Angeles (OR 2.24, 95% CI 1.45-3.46, versus Georgia) were associated with using "good cancer." If patients are worried, 97% of physicians make themselves available for discussion, 44% refer to educational websites, 18% encourage communication with family/friends, 13% refer to support groups, and 7% refer to counselors. Physicians who perceived patients being quite/very worried were less likely to use "good cancer" (OR 0.54, 95% CI 0.35-0.84) and more likely to encourage patients to seek help outside the physician-patient relationship (OR 1.82, 95% CI 1.17-2.82).

IMPLICATIONS FOR CANCER SURVIVORS

Physicians perceive patient worry as common and address it with various approaches, with some approaches of unclear benefit. Efforts are needed to develop tailored interventions targeting survivors' psychosocial needs.

Primary Care Provider Involvement in Thyroid Cancer Survivorship Care

CONTEXT

While prior research has examined how primary care providers (PCPs) can care for breast and colon cancer survivors, little is known about their role in thyroid cancer survivorship.

OBJECTIVE

To understand PCP involvement and confidence in thyroid cancer survivorship care.

DESIGN/SETTING/PARTICIPANTS

We surveyed PCPs identified by thyroid cancer patients from the Georgia and LA SEER registries (n = 162, response rate 56%). PCPs reported their involvement in long-term surveillance and confidence in handling survivorship care (role of random thyroglobulin levels and neck ultrasound, and when to end long-term surveillance and refer back to the specialist). We examined: 1) PCP-reported factors associated with involvement using multivariable analyses; and 2) bivariate associations between involvement and confidence in handling survivorship care.

MAIN OUTCOME MEASURES

PCP involvement (involved vs not involved) and confidence (high vs low).

RESULTS

Many PCPs (76%) reported being involved in long-term surveillance. Involvement was greater among PCPs who noted clinical guidelines as the most influential source in guiding treatment (OR 4.29; 95% CI, 1.56-11.82). PCPs reporting high confidence in handling survivorship varied by aspects of care: refer patient to specialist (39%), role of neck ultrasound (36%) and random thyroglobulin levels (27%), and end long-term surveillance (14%). PCPs reporting involvement were more likely to report high confidence in discussing the role of random thyroglobulin levels (33.3% vs 7.9% not involved; P < 0.01).

CONCLUSIONS

While PCPs reported being involved in long-term surveillance, gaps remain in their confidence in handling survivorship care. Thyroid cancer survivorship guidelines that delineate PCP roles present one opportunity to increase confidence about their participation.

Patient Report of Recurrent and Persistent Thyroid Cancer

Background: Despite the excellent survival of most patients with differentiated thyroid cancer (DTC), recurrent and persistent disease remain major concerns for physicians and patients. However, studies on patient report of recurrent and persistent disease are lacking. Methods: Between February 1, 2017, and October 31, 2018, we surveyed eligible patients who were diagnosed with DTC between 2014 and 2015 from the Georgia and Los Angeles Surveillance, Epidemiology, and End Results cancer registries (N = 2632; response rate, 63%). Patients who reported current disease status were included in this study (n = 2454). Patient-reported data were linked to registry data. A multivariable, multinomial logistic regression analysis was conducted to determine patient and tumor characteristics associated with recurrent and persistent thyroid cancer. Quality of life was evaluated using the Patient-Reported Outcomes Measurement Information System-Global Health v1.2 questionnaire. Meaningful change in global health was defined as a minimal difference of a half standard deviation or 5 points compared with the mean (T score = 50) of a sample population matching the United States 2000 General Census. Results: Of the 2454 patients completing the survey, 95 (4.1%) reported recurrent disease and 137 (5.8%) reported persistent disease. In multinomial analyses, T3/T4 classification and cervical lymph node involvement (N1) were associated with both report of recurrent (adjusted relative risk ratio [RRR] 1.99, 95% confidence interval [CI 1.16-3.42]; adjusted RRR 2.03 [CI 1.29-3.21], respectively) and persistent disease (adjusted RRR 3.48 [CI 1.96-6.20]; adjusted RRR 3.56 [CI 2.41-5.24], respectively). Additionally, Hispanic ethnicity was associated with report of recurrent disease (adjusted RRR 1.99 [CI 1.23-3.24]). Regarding quality of life, the median scores in patients with persistent disease met criteria for meaningful change in global physical health (T-score = 44.9) and global mental health (T-score = 43.5) when compared with the general population norms. Median scores in patients with cured or recurrent disease did not meet criteria for meaningful change. Conclusions: Patient report is a reasonable method of assessing recurrent and persistent disease. Impact on quality of life is more marked for patients with reported persistent disease. Our findings will help personalize treatment and long-term follow-up in these patients.

Disparities Research in Thyroid Cancer: Challenges and Strategies for Improvement

Until recently, thyroid cancer was one of the most rapidly increasing cancers in the United States. Disparities exist in many aspects of thyroid cancer care as a result of the multifactorial interplay of systemic, patient, and physician factors. To better understand the management of thyroid cancer in populations at risk for health disparities and subsequently implement changes that will lead to health equity for all patients with thyroid cancer, health services research with innovative approaches is necessary.

Thyroid nodules and cancer during pregnancy, post-partum and preconception planning: Addressing the uncertainties and challenges

Thyroid nodules and thyroid cancer have become increasingly common worldwide. When discovered during pregnancy, they pose unique diagnostic and therapeutic challenges for both the treating physician and the patient. The benefits of treatment should be carefully weighed against risks that may adversely impact maternal and fetal health. In this review, we present current knowledge and controversies surrounding the management of thyroid nodules and thyroid cancer in pregnancy, in the post-partum period and during preconception planning.

OR21-06 Physician Management of Thyroid Cancer Patients’ Worry: Is It “Good” Enough?

Introduction: Despite the excellent prognosis of most thyroid cancer patients, cancer-related worry is common. Additionally, patients report that being told by physicians that they have a “good cancer” invalidates their fears of having cancer and creates mixed and confusing emotions. However, it is not known what proportion of physicians try to reassure patients with the description “good cancer”.

Methods: Patients diagnosed with differentiated thyroid cancer in 2014–2015 from the Surveillance, Epidemiology and End Results Program (SEER) registries of Georgia and Los Angeles County were asked to identify endocrinologists and surgeons involved in managing their thyroid cancer. Physicians were surveyed using the modified Diliman method. They were asked to describe their thyroid cancer patients’ worry at time of diagnosis and what they tell them if worried. A multivariable logistic regression was conducted to identify physician characteristics associated with reporting thyroid cancer as a “good cancer”.

Results: Response rate was 69% (448/654). Overall, 40% were endocrinologists, 30% were general surgeons and 30% were otolaryngologists. A total of 8% of physicians reported that their patients are not worried or are a little worried at diagnosis, 27% that they are somewhat worried and 65% that they are quite or very worried. Ninety-one percent of physicians reported providing details on prognosis including information on death and recurrence to worried patients, 61% tell them their physicians are experienced in managing thyroid cancer, and 50% tell them that thyroid cancer is a “good cancer”. Factors associated with report of telling patients they have a “good cancer” included otolaryngology specialty [odds ratio (OR) 1.84, 95% confidence interval (CI) 1.07–3.17, compared to endocrinology), private practice setting (OR 2.57, 95% CI 1.42–4.75, compared to academic setting) and Los Angeles site (OR 2.23, 95% CI 1.46–3.45, compared to Georgia site). Physicians who perceived that their patients were quite or very worried at time of diagnosis were less likely to use this terminology (OR 0.55, 95% CI 0.35–0.84) and more likely to encourage patients to seek help outside of the physician-patient relationship (OR1.82, 95% CI 0.35–0.84), compared to patients not to somewhat worried.

Conclusion: Most physicians in our sample from two diverse geographic areas report perceiving patient worry as common at time of thyroid cancer diagnosis. They report addressing this worry with different strategies, including telling patients they have a “good cancer”. The benefit of such strategies on patient outcomes still needs further investigation.

MON-501 Physician-Reported Misuse of Thyroid Ultrasound

BACKGROUND: Over the past four decades, there has been a substantial increase in the incidence of thyroid cancer with studies suggesting that greater use of thyroid ultrasound contributes to the rise in incidence. However, little is known about physician reported practice patterns on ultrasound use.

Methods: Patients diagnosed with differentiated thyroid cancer in 2014–15 from the Surveillance, Epidemiology and End Results registries of Georgia and Los Angeles were surveyed and asked to identify the surgeon who performed their thyroid surgery, and the endocrinologist and other doctors most involved in their thyroid cancer treatment decision making. We surveyed all physicians identified by more than one patient, and a random sample of physicians identified by one surveyed patient (N=610; 65% response rate). Surveyed physicians were asked to identify the clinical scenarios in which they would schedule a thyroid or neck ultrasound. We generated descriptive statistics for all categorical variables and used multivariable logistic regression to identify factors associated with thyroid ultrasound misuse.

Results: The cohort consisted of primary care physicians (PCPs; N=162), endocrinologists (N=176), otolaryngologists (N=130), and general surgeons (N=134). In addition to physicians reporting ultrasound use for accepted reasons such as palpable nodule on exam (98%), large goiter (92%), and nodule seen on other imaging test (88%), a substantial number of physicians endorsed ultrasound use for clinically unsupported reasons: patient request (33%); abnormal thyroid function tests (28%); and positive thyroid antibodies (22%). In multivariable analysis, compared to PCPs, endocrinologists, otolaryngologists, and general surgeons were significantly more likely to schedule an ultrasound in response to patient request (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.27–5.11; OR 2.98, 95% CI 1.57–5.79; OR 2.14, 95% CI 1.17–3.97, respectively). Physicians in private practice were more likely to schedule an ultrasound for abnormal thyroid function tests (OR 2.44, 95% CI 1.33–4.73) and positive thyroid antibodies (OR 2.47, 95% CI 1.27–5.21) compared to those in academic medical centers. Physicians who managed ten patients or less, compared to more than 50 patients, with thyroid nodules in the past 12 months were less likely to schedule an ultrasound for positive thyroid antibodies (OR 0.43, 95% CI 0.19–0.95).

Conclusion: Physicians report scheduling thyroid ultrasound for reasons not supported by clinical guidelines and in conflict with the Choosing Wisely recommendations. Understanding why physicians use thyroid ultrasound and factors that correlate with clinically unsupported reasons is essential to creating targeted educational interventions to improve physician adherence to guidelines, reduce unnecessary imaging, and curb the overdiagnosis of low-risk thyroid cancer.