Long-Term Outcomes Following Therapy in Differentiated Thyroid Carcinoma: NTCTCS Registry Analysis 1987-2012

Abstract

Context: Initial treatments for patients with differentiated thyroid cancer are supported primarily by single-institution, retrospective studies, with limited follow-up and low event rates. We report updated analyses of long-term outcomes after treatment in patients with differentiated thyroid cancer.

Objective: The objective was to examine effects of initial therapies on outcomes.

Design/setting: This was a prospective multi-institutional registry.

Patients: A total of 4941 patients, median follow-up, 6 years, participated.

Intervention: Interventions included total/near-total thyroidectomy (T/NTT), postoperative radioiodine (RAI), and thyroid hormone suppression therapy (THST).

Main outcome measure: Main outcome measures were overall survival (OS) and disease-free survival using product limit and proportional hazards analyses.

Results: Improved OS was noted in NTCTCS stage III patients who received RAI (risk ratio [RR], 0.66; P = .04) and stage IV patients who received both T/NTT and RAI (RR, 0.66 and 0.70; combined P = .049). In all stages, moderate THST (TSH maintained subnormal-normal) was associated with significantly improved OS (RR stages I-IV: 0.13, 0.09, 0.13, 0.33) and disease-free survival (RR stages I-III: 0.52, 0.40, 0.18); no additional survival benefit was achieved with more aggressive THST (TSH maintained undetectable-subnormal). This remained true, even when distant metastatic disease was diagnosed during follow-up. Lower initial stage and moderate THST were independent predictors of improved OS during follow-up years 1-3.

Conclusions: We confirm previous findings that T/NTT followed by RAI is associated with benefit in high-risk patients, but not in low-risk patients. In contrast with earlier reports, moderate THST is associated with better outcomes across all stages, and aggressive THST may not be warranted even in patients diagnosed with distant metastatic disease during follow-up. Moderate THST continued at least 3 years after diagnosis may be indicated in high-risk patients.

Figure 1.. A, Product limit estimates (with log-rank statistic) of OS after diagnosis of DTC by registry at entry (P < .0001). B, Product limit estimates (with log-rank statistic) of DFS after diagnosis of DTC by registry at entry (P < .0001).

Figure 2.. A, Product limit estimates (with log-rank statistic) of OS according to mean TSH category among stage I patients (P = .002). B, Product limit estimates (with log-rank statistic) of OS according to mean TSH category among stage II patients (P < .0001). C, Product limit estimates (with log-rank statistic) of OS according to mean TSH category among stage III patients (P < .0001). D, Product limit estimates (with log-rank statistic) of OS according to mean TSH category among stage IV patients (P = .003). E, Product limit estimates (with log-rank statistic) of OS according to mean TSH category after diagnosis of distant metastases (P < .0003).