0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter | Less Is More

Patterns of Use and Cost for Inappropriate Radioactive Iodine Treatment for Thyroid Cancer in the United States Use and Misuse FREE

Paolo Goffredo, MD1; Samantha M. Thomas, MB2; Michaela A. Dinan, PhD1; Jennifer M. Perkins, MD3; Sanziana A. Roman, MD4; Julie A. Sosa, MD1,4
[+] Author Affiliations
1Duke Clinical Research Institute, Durham, North Carolina
2Department of Biostatistics, Duke University, Durham, North Carolina
3Department of Medicine, Duke University, Durham, North Carolina
4Section of Endocrine Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
JAMA Intern Med. 2015;175(4):638-640. doi:10.1001/jamainternmed.2014.8020.
Text Size: A A A
Published online

Based on current guidelines, adjuvant radioactive iodine (RAI) therapy is not recommended for localized papillary thyroid tumors measuring 1 cm or less, medullary thyroid cancer (MTC), and anaplastic thyroid cancer (ATC).13 Nevertheless, previous studies have reported the use of RAI in the treatment of these cancers.

The aim of the current study was to analyze patterns of inappropriate RAI use in the United States to identify potential misuses leading to increased costs for the health care system and unnecessary patient exposure to the risk and potential complications of RAI therapy.4

The National Cancer Data Base was used to identify patients diagnosed with ATC, MTC, and papillary thyroid cancer from 1998 to 2011.5 The Surveillance, Epidemiology, and End Results database was used to cross-validate the National Cancer Data Base patient population.6 The study was granted exempt status by the Duke University Institutional Review Board. Patient consent was not obtained as it was not necessary.

All adult patients with ATC and MTC were included in the analyses. Inclusion criteria for patients with papillary thyroid cancer were the following: papillary thyroid microcarcinoma (PTMC) measuring 1 cm or less, no aggressive histologic variants, no extrathyroidal extension, no regional or distant metastases, and negative margin status.

Estimates of costs were obtained from the 2011 and 2014 Medicare reimbursement schedule and from the US Bureau of Labor Statistics (Table). Costs were estimated only for PTMCs.

Table Graphic Jump LocationTable.  Medicare Reimbursement Rates for RAI Therapy of PTMCs

In the National Cancer Data Base, 49 of 3095 ATCs (1.6%), 217 of 6375 MTCs (3.4%), and 14 146 of 60 586 PTMCs (23.3%) were inappropriately treated with RAI.

In univariate analyses, patients with ATCs who received RAI were younger than those who did not (P < .001), had lower income (P = .01), were from a rural or urban rather than a metropolitan county (P = .04), and had smaller tumors (P = .001). Patients with MTCs whose management included RAI were less likely to be treated in academic facilities (P < .001) and had smaller tumors (P = .02).

Patients with PTMCs treated with RAI were younger, more often white, managed in nonacademic centers, and were more likely to have multifocal and larger tumors (all P < .001). While the overall incidence of PTMC significantly increased over time, the proportion of PTMCs treated with RAI has decreased. When stratified by facility type, the rate of RAI administration showed no change in community hospital programs (P = .26) but decreased at comprehensive and academic hospital programs (P < .001) (Figure).

Place holder to copy figure label and caption
Figure.
Trends of Radioactive Iodine (RAI) Therapy Misuse in Papillary Thyroid Microcarcinomas Over Time, by Facility Type

Misuse of RAI therapy in papillary thyroid microcarcinomas in academic/research programs, comprehensive community programs, and community programs.

Graphic Jump Location

In adjusted analyses, inappropriate RAI therapy was associated with Hispanic origin, low income, receiving care in nonacademic facilities, tumor multifocality, and increasing size. Protective factors included older age, black and other races, more recent year of diagnosis, no insurance or government insurance, and receiving less than a total thyroidectomy.

The average cost per patient ranged between $5587.73 and $8442.11 in 2011 US dollars and $5429.58 and $9105.67 in 2014 US dollars. The average total number of patients was 1768 per year, with a total cost of $9 879 109 to $14 925 650 per year in 2011 US dollars and $9 599 497 to $16 098 824 per year in 2014 US dollars.

To our knowledge, this is the first study to demonstrate that 23.3% of PTMCs, 3.4% of MTCs, and 1.6% of ATCs undergo unnecessary adjuvant RAI therapy, with an estimated cost burden of $9 599 497 to $16 098 824 per year for PTMC management alone. This cost is likely an underestimation given the fact that we could not include costs associated with complications from RAI therapy and quality of life changes and that our reported costs are based on Medicare reimbursements, which are lower than private insurance rates.

In our cohort, the rate of unnecessary RAI treatment decreased overall; however, no change was observed during the past decade at community hospitals. This emphasizes the need to educate health care professionals regarding evidence-based practice guidelines and disseminate those guidelines in areas that may serve vulnerable populations.

In conclusion, our study demonstrates that nearly one-fourth of patients with thyroid cancer may receive unnecesary RAI treatment. Ongoing efforts should be undertaken to educate health care professionals in the appropriate use of RAI therapy to optimize patient care.

Corresponding Author: Sanziana A. Roman, MD, Section of Endocrine Surgery, Department of Surgery, Duke University School of Medicine, DUMC #2945, Durham, NC 27710 (sanziana.roman@dm.duke.edu).

Published Online: February 16, 2015. doi:10.1001/jamainternmed.2014.8020.

Author Contributions: Dr Sosa had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Goffredo, Dinan, Roman, Sosa.

Acquisition, analysis, or interpretation of data: Goffredo, Thomas, Dinan, Perkins.

Drafting of the manuscript: Goffredo, Dinan, Perkins, Roman.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Goffredo, Thomas, Dinan, Roman.

Obtained funding: Goffredo.

Administrative, technical, or material support: Dinan, Roman, Sosa.

Study supervision: Perkins, Roman, Sosa.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Goffredo is supported by the Fondazione Italiana per la Ricerca sul Cancro (Italian Foundation for Cancer Research).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Some of the data used in the study are derived from a deidentified National Cancer Data Base file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methods used, or the conclusions drawn from these data by the investigators.

Additional Contributions: Mohamed Abdelgadir Adam, MD, Section of Endocrine Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, and Linda Youngwirth, MD, Duke Clinical Research Institute, and Section of Endocrine Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, assisted with data acquisition and statistical work. They were not compensated for their contributions.

Cooper  DS, Doherty  GM, Haugen  BR,  et al.  Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1167-1214.
PubMed   |  Link to Article
Smallridge  RC, Ain  KB, Asa  SL,  et al.  American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012;22(11):1104-1139.
PubMed   |  Link to Article
Kloos  RT, Eng  C, Evans  DB,  et al.  Medullary thyroid cancer: management guidelines of the American Thyroid Association. Thyroid. 2009;19(6):565-612.
PubMed   |  Link to Article
Lee  SL.  Complications of radioactive iodine treatment of thyroid carcinoma. J Natl Compr Canc Netw. 2010;8(11):1277-1287.
PubMed
National Cancer Data Base. 2014.https://www.facs.org/quality%20programs/cancer/ncdb/puf. Accessed May 1, 2014.
National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER) Program. http://seer.cancer.gov/data/. Published 2014. Accessed June 1, 2014.

Figures

Place holder to copy figure label and caption
Figure.
Trends of Radioactive Iodine (RAI) Therapy Misuse in Papillary Thyroid Microcarcinomas Over Time, by Facility Type

Misuse of RAI therapy in papillary thyroid microcarcinomas in academic/research programs, comprehensive community programs, and community programs.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Medicare Reimbursement Rates for RAI Therapy of PTMCs

References

Cooper  DS, Doherty  GM, Haugen  BR,  et al.  Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1167-1214.
PubMed   |  Link to Article
Smallridge  RC, Ain  KB, Asa  SL,  et al.  American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012;22(11):1104-1139.
PubMed   |  Link to Article
Kloos  RT, Eng  C, Evans  DB,  et al.  Medullary thyroid cancer: management guidelines of the American Thyroid Association. Thyroid. 2009;19(6):565-612.
PubMed   |  Link to Article
Lee  SL.  Complications of radioactive iodine treatment of thyroid carcinoma. J Natl Compr Canc Netw. 2010;8(11):1277-1287.
PubMed
National Cancer Data Base. 2014.https://www.facs.org/quality%20programs/cancer/ncdb/puf. Accessed May 1, 2014.
National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER) Program. http://seer.cancer.gov/data/. Published 2014. Accessed June 1, 2014.

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,449 Views
0 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs