An Individualized Approach to Thyroid Hormone Replacement in Thyroid Cancer Patients
Kaniksha Desai, MD, FACE
Palo Alto, CA
August 24, 2021
Thyroid hormone replacement is a critical element in the overall management of patients with thyroid cancer. For a long period of time, aggressive TSH suppression with long-term high doses of thyroid hormone was advocated for all thyroid cancer patients to prevent cancer recurrence by reducing the stimulation of cancer cells. Recently, a growing body of evidence has suggested a limited benefit to aggressive TSH suppression in many patients. In addition, there appears to be significant risks of long-term TSH suppression to cardiovascular health, bone health, and mental health including the development of osteoporosis, atrial fibrillation, and mood disorders, which can significantly impact Quality of Life in thyroid cancer patients. Benefits of preventing cancer recurrence should be balanced with risks of excessive thyroid hormone replacement. Therefore, thyroid hormone replacement should be tailored to provide appropriate levels of TSH suppression based on a dynamic risk stratification in thyroid cancer patients.
Currently best practice for the management of thyroid cancer patients determines individualized thyroid hormone replacement therapy based on risk stratification of cancer recurrence following initial surgery and the patient’s response to subsequent treatment.
After initial surgery, patients are risk-stratified based upon their surgical pathology and extent of tumor metastasis. They are categorized into three groups for their risk of recurrence: low (<5%), intermediate (5-30%) and high (30-50+%). Thyroid hormone replacement is initiated with TSH goals based upon this risk stratification. Low risk patients that have had their cancer completely resected, including lobectomy patients, are given replacement doses to make them euthyroid with a TSH goal of 0.5 to 2.0 mu/L. Intermediate risk patients, often with lymph node involvement, have mild suppression of their TSH with thyroid hormone replacement dosed to a TSH goal of 0.1 to 0.5 mu/L. High risk patients including those who have extensive metastatic disease or incomplete resection are given higher doses of thyroid hormone with a TSH goal of <0.1 mu/L to prevent cancer recurrence.
At subsequent follow up visits, patients are evaluated for their response to overall cancer treatment and are categorized into four groups: 1) excellent response to treatment (no evidence of cancer recurrence), 2) biochemical incomplete response (elevations in thyroglobulin tumor marker levels), 3) structural incomplete response (local or metastatic disease present) or 4) indeterminate response (nonspecific imaging findings or slight elevations in tumor marker levels). Patients with high risk of recurrence, as well as those with structural incomplete response benefit the most from aggressive TSH suppression and are treated accordingly. In patients with excellent response to treatment with no evidence of disease, thyroid hormone treatment can be decreased, even in initially high-risk patients after 5 years. If a patient has a recurrence, then a higher dose of thyroid hormone treatment may be recommended in the future.
In summary, thyroid hormone replacement should be tailored to patients individually based on their initial risk for thyroid cancer recurrence as well as their response to treatment over time to avoid under treatment of high-risk patients and overtreatment of low risk patients. Risk of thyroid cancer growth and recurrence should be balanced with risk of long-term side effects of over-suppression.
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