Endocrine Insights – October 2020 |

Dear Valued Patient,

As fall approaches and as we adapt more and more to COVID-19 best practices, I wanted to take a break to discuss some interesting new endocrine articles that have recently been published.

These articles cover different endocrine conditions that I see in my office, although not all may be relevant to you. I have summarized the study findings below, and the complete studies can be found by visiting the corresponding websites:

·     Onset Age of Menstruation and Cardiovascular Health

·     Thyroid Cancer: 2015 American Thyroid Association Risk Stratification Accurately Predicts 1-Year Risk of Recurrent/Persistent Thyroid Cancer

·     Thyroid Nodules: A Cohort Analysis of Clinical and Ultrasound Variables Predicting Cancer Risk in 20,001 Consecutive Thyroid Nodules

·     Selenium Supplements and Pregnancy: Thyroid Autoimmunity during Pregnancy

·     My Life Check – At Home Health Assessment Survey

Onset Age of Menstruation and Cardiovascular Health

Facts: This study analyzed data from 1999-2016, obtained from the National Health and Nutrition Examination Survey (NHANES).

·     Study included 20,447 women age at least 18 years with information on the onset of menarche.

·     The cardiovascular health scores were given based on answers to questions regarding smoking, physical activity, diet, blood pressure readings, cholesterol and glucose readings and BMI (body mass index) measurements. The score was defined by Life’s Simple 7 (LS7). 

·     Scores ranged from 0 to 14, with 0 a poor score and 14 an ideal score.

·     Definition for normal age of menarche was around ages 12 -13, early menarche between ages 6-11 and late menarche at ages 14 or older.

Results: The statistic model they used was adjusted for age, race/ethnicity, education, poverty income status, marital status and birth year.

·     The results showed that CVH (Cardiovascular Health) was worse in patients who had an early menarche versus late menarche patients.

·     Age does affect the results, meaning that late menarche was associated with ideal CVH among patients aged 25-34 and 35-44, while the association for early menarche and worse CVH was observed only among those women 25-34 years old.

·     One possible explanation of this finding is that over time, there may be other competing factors among older women that can potentially mitigate the associations seen. 

If you have specific questions on how this study

may affect your health, please give me a call.

Thyroid Cancer

2015 American Thyroid Association Risk Stratification Accurately Predicts 1-Year Risk of Recurrent/Persistent Thyroid Cancer

Facts: There is a big debate in the thyroid cancer world as to how aggressive we need to be when dealing with a suspicious thyroid nodule and thyroid cancer. One of the major reasons for this controversy, given the low mortality rate in this group, is we are trying to minimize overtreatment of low risk thyroid cancer patients.

·     The investigators used the recent 2015 modified American Thyroid Association (ATA) guidelines and its updated stratification systems in trying to identify patients at low versus high risk of disease recurrence at 1 year of diagnosis and therapy.

·     This modified risk stratification system added specific thyroid cancer tumor subtypes, extent of vascular invasion, multifocal tumors, lymph node status and molecular markers as well as response to therapy.

·     The study analyzed 2,071 patients from 40 Italian institutions. Patients’ median age was 48 years old, 75% of them female. Size of the tumor at the time of diagnosis was 11 mm average (6-18 mm) and about a third of patients (77%) had no evidence for lymph node involvement at the time of initial surgery. About 4% of patients underwent lobectomy, 39% underwent total thyroidectomy alone or followed by radioactive iodine therapy (57%). The rate of structurally incomplete response increased with the level of ATA risk: 2% in the low risk group, 6% in the intermediate risk group and 15% in the high-risk group.

Results: Authors concluded that the updated ATA risk stratification system reliably estimated the risk of persistent or recurrent disease in patients with differentiated thyroid cancer at 1 year follow-up.

·     One of the limitations of the study was follow-ups were done at one year, which is considered the earliest relevant time to determine disease recurrence. May need to do a long-term follow up study up to 5 years to determine durability of the initial ATA risk stratification.

·     A few patients, who were low risk, only underwent lobectomy instead of total thyroidectomy, and some patients also had total thyroidectomy without radioactive iodine ablation.

·     More long-term response to treatment tools may be needed when considering these modalities of treatment for patients who are low risk. 

If you have specific questions on how this study

may affect your health, please give me a call.

Thyroid Nodules

A Cohort Analysis of Clinical and Ultrasound Variables Predicting Cancer Risk in 20,001 Consecutive Thyroid Nodules

Facts: The study was investigating potential factors associated with a missed occult thyroid malignancy in nodules that were previously cytologically benign.

·     Evaluating thyroid nodules includes a careful medical history and physical examination followed by ultrasound. Many factors such as age, sex, and more recently sonographic features of the nodule such as hypoechogenicity, presence of calcifications, irregular borders are associated with increased risk for malignancy disease but there is a significant variability among physicians interpreting neck ultrasound images.

·     This was a cohort study of adult patients age >18 years old, who were evaluated in the thyroid nodule clinic at Brigham and Women’s Hospital, with fine needle aspiration (FNA) biopsy of nodules >1 cm in size between 1995-2017. Study included nodule location, if nodule was solid or had cystic component, and size in 3 dimensions. Ultrasound guidance FNA of a nodule <1 cm with high sonographic suspicion rate patients were excluded from the study.

·     Between 1995-2017, 9,967 patients with 20,001 nodules >1 cm in size were evaluated with ultrasound guidance FNA. 84% were women, median age 53 years old, with median nodule size of 1.7 cm in largest dimension with 83% under 3 cm. About 74% of nodules were solid.

·     Patient age, sex, nodule size, degree of multinodularity (counting nodules ≥1 cm), and degree of cystic content were all highly important predictors of thyroid cancer. 

·     Increasing age has been associated with lower risk of malignancy in adults due to accumulation of benign nodules with aging or greater incidental detection of lower risk nodules in this population.

Results: This study confirms that the younger patient’s age is a predictor of malignancy, and defines age cut off at 52 years old as the best discriminating cut off. Using this age range, the risk of malignancy is 1.8 times higher in younger patients than for those over the age of 52.

·     The study concurs previous data that men with thyroid nodules have higher risk for malignancy compared to women.

·     Another factor that increases thyroid cancer risk is enlarging nodules from 1-4 cm have higher risk for malignancy – if nodules enlarges from 1 to 2 cm or 2-3 cm over time – there is a higher chance of malignancy.

·     On the other hand, a decrease risk of malignancy was observed in patients with more nodules and in nodules which fluid or cystic component is more (<25% vs <75%).

·     One limitation of the study is that it was only done at one center, and it is based on their experience, and may not reflect all the population.

If you have specific questions on how this study

may affect your health, please give me a call.

Selenium Supplements & Pregnancy

Thyroid Autoimmunity during Pregnancy

Facts: Selenium is widely use in nutraceuticals for its role during pregnancy and patients with autoimmune thyroiditis. It claims to have some benefits with fertility, thyroid function and immunity. However, most of the evidences comes from non-controlled studies. In medicine, the best study design to assess whether a drug or supplement is beneficial is with a randomized controlled trial. This study was performed in the attempt to evaluate the protective effects of selenium in regards to thyroid autoimmunity during and after pregnancy.

·     Study was done at ten endocrine and obstetric centers in Italy. Women between 18-45 years of age, between 4-8 weeks of pregnancy, all had positive thyroid Ab titers.

·     About 71% of women were taking thyroid replacement therapy prior to the study and 7% were started on therapy at the start of the study, as thyroid levels were above target for pregnancy. (TSH was >2.7)

·     The women were randomized to take selenium, 83 micrograms a day or non-selenium pill (placebo). They continued therapy until 6 months after delivery. Thyroid Ab titers (TPO) decreased over the course of pregnancy in both groups (selenium and non-selenium treated patients).

·     At the end of pregnancy, TPO Ab increased in the placebo group, but decreased in the selenium group. Thyroid function test did not differentiate between the groups at baseline or over the course of the study.

·     Thyroid appearance and volume did not change among both groups.

·     There were no differences between health-related quality of life in both groups at baseline or during follow up.

Results: This study concluded that selenium supplementation during and after pregnancy was not associated with changes in thyroid function, thyroid volume or health related quality of life. American Thyroid Association recommends against selenium supplementation during pregnancy.

If you have specific questions on how this study

may affect your health, please give me a call.

My Life Check – At Home Health Assessment Survey

I want to share with you an at home online health assessment tool, “My Life Check” by the American Heart Association. This tool encourages patients to take action to increase their good habits with a goal of achieving a healthy heart. It is important to recognize that ideal heart health has been linked with a much lower risk for cancer, depression, diabetes, and improvement in cognitive function.

Directions:

1.       Website: https://mlc.heart.org/

2.       Click “Get Started”

3.       Register: Enter your first name, last name, email and password

4.       Enter your data: profile, age, gender, height, weight, and physical activity

5.       Answer questions about your diet (veggies, protein, carbs, and fat intake).

6.       Answer questions about your glucose, cholesterol, medical history of stroke, heart attack, etc.

7.       Get your score.

Give it a try! If you click in each individual link, you can see a video with information about each topic.

I hope you enjoy these readings … until the next blog.

Stay safe, stay well.

Dr. Armellini