Endocrine Insights

By Denise Armellini, MD

 To my patients and friends,

It’s hard to believe we’re already in the second month of 2020…I hope you’re off to a healthy start.  I have much to share with you as there’s been a tremendous amount of valuable research published in the last few months. Below are highlights from studies and articles that I believe will be of particular interest to my patients and their families. If you’re interested in reading the entire study, please click on the link included with each article.

Patient-perceived lack of choice in receipt of radioactive iodine for treatment of differentiated thyroid cancer.

J Clin Oncol. 2019 Aug 20 Wallner LP¹, Reyes-Gastelum D¹, Hamilton AS², Ward KC³, Hawley ST¹, Haymart MR¹.

Background: A total of 2,632 patients diagnosed with thyroid cancer in 2014-2015 in Georgia and Louisiana were enrolled in the study. All were asked if they had the choice of receiving Radioactive Iodine (RAI) therapy, how strongly their physician recommended RAI therapy, if they received RAI therapy, and how satisfied they were with their decision. More than half (55.8%) perceived they did not have an RAI choice, and the majority of patients (75.9%) received RAI.

Results: Patients who perceived they did not have the choice to receive RAI therapy were more likely to receive it. They also had a much lower satisfaction in terms of treatment.

My perspective:  More patient-doctor communication is needed to thoroughly discuss treatment options, impact of therapy and prognosis when managing a medical condition, particularly thyroid cancer. Patient education is key to the shared decision-making process and reducing overtreatment.

Abdominal obesity and the risk of recurrent atherosclerotic cardiovascular disease after myocardial infarction.

Eur J Prev Cardiol. 2020. Mohammadi H, Ohm J, Discacciati A, et al

Background: Many studies have shown abdominal obesity is an important risk factor for developing a first heart attack but there has been no data to prove that abdominal obesity increases the risk for subsequent heart attacks or strokes. This large study recruited more than 22,000 patients from Sweden’s national SWEDEHEART registry, who had a previous heart event, and were followed for a median 3.8 years afterward. Three times as many men enrolled in the study compared to women.

About 78% of the men and 90% of the women in the study had abdominal obesity categorized as a waist circumference of >94 cm in men and >80 cm in women.

Results: It is well accepted that an increase in abdominal fat is associated with increased risk for conditions that raise the risk of atherosclerosis (clogging of arteries). These conditions are elevated blood pressure, high blood sugar, insulin resistance with diabetes, and elevated blood lipids. In this study, increased abdominal obesity was associated with an increased risk of fatal and non-fatal heart attacks and stroke, regardless of other cardiovascular risks including smoking, diabetes, hypertension, blood lipids, Body Mass Index (BMI) and secondary prevention treatment. Waist circumference was a more important marker of recurrent events than overall obesity. The relationship between waist circumference and recurrent events was stronger and linear in men.

My perspective: Keeping a healthier waist circumference may help prevent heart attacks and strokes. To further minimize risk, it’s important to control other risk factors such as elevated blood pressure and blood cholesterol levels and diabetes.

Investigating the Effect of Thyroid Nodule Location on the Risk of Thyroid Cancer.

Sina Jasim, Thomas J Baranski, Sharlene A Teefy, William D Middleton

Background: This retrospective study explored if the location of a thyroid nodule was useful in helping determine the risk of thyroid cancer. A total of 3,313 adult patients from 6 U.S. referral centers were studied from the years 2006 to 2020.

The mean age was 54 (18-97), 80% of patients were women.  A total of 3,241 nodules were analyzed; 10.3% were malignant.  Data was analyzed using a model that adjusted for age, sex and family history of thyroid cancer, radiation exposure, nodule size and followed the American College of Radiology’s Thyroid Imaging Reporting and Data System.

Results: Isthmic nodules (located between the right and left lobe) had the highest risk for malignancy, followed by upper thyroid nodules, middle thyroid nodules, with the lowest risk seen for lower thyroid nodules. Isthmic nodules were overall smaller in size compared to middle and lower pole nodules.

My perspective: Since graduating from fellowship, I have had the impression that nodules in the isthmus, which represents a very small part of thyroid tissue, are unusual. For that reason, I biopsied these nodules and found the majority were cancerous. This new evidence confirms my belief that extra attention should be taken to carefully evaluate nodules found in the isthmus.

Environmental Hazards

Finally, I want to share information from an editorial written by Dr. Leonardo Trasande, Professor of Pediatrics at the NYU Center for the Investigation of Environmental Hazards. He offers five tips on avoiding endocrine-disrupting chemicals which are particularly noteworthy because, as he states, while we have no medication or treatment to counteract past exposures, we do have a significant opportunity for prevention. Many of these exposures have been proven to dissipate within one to three days if certain measures are taken.

My advice: Trying to follow all these tips at once can be overwhelming. Prioritize the first two tips and add others when you’re ready.

Background: It is well studied that the endocrine system is exquisitely vulnerable to the effects of chemicals commonly used in furniture, agriculture, cookware, food packaging, cosmetics, and personal care products. Different entities describe many ways to avoid these exposures which can lead to a variety of chronic conditions such as cognitive deficits and developmental disabilities, obesity, diabetes, fibroids, birth defects, and even cardiovascular disease.

1. Mind your cookware, Nonstick pans have perfluoroalkyl substances (best known as PFAS). These chemicals slow metabolic rate and promote the return of weight after successful dietary intervention. Cast iron and stainless steel cookware are good alternatives.
2. Open your windows and use a wet mop. Flame retardants, organic pollutants used in electronics and other products accumulate in household dust and can impair thyroid function. Using a wet mop can help eliminate these pollutants. Note: a new law in California requires disclosure if flame retardants are added to upholstery.
3. Eat organic. Organophosphates pesticides are well-known thyroid disruptors, and many studies show an effect on cognition; some research also suggests associations with increased risk for cancer.
4. Avoid canned foods. Bisphenols are estrogenic and antagonize adiponectin which makes fat cells larger. Stopping canned food consumption can decrease bisphenol levels in urine by close to 90%. Even if cans are labeled as BPA-free, this can be misleading, as there are 40 or more replacement bisphenols. Studies suggest a twofold increase in risk for diabetes type 2, as well as toxicity to embryos.
5. Don’t microwave or machine wash plastics. Phthalates are commonly found in food packaging and may negatively influence lipid and carbohydrate metabolism, as exposure to them has been linked to an increase in weight gain over the years. Polymers can break down at microscopic levels and get into food.