American Thyroid Association 89th Annual Meeting:

ATA Poster Highlights on TED, Hashimoto’s, and Active Surveillance

with Terry J. Smith, MD, and Susan C. Pitt, MD, MPHS

Costs and Opportunity in the Treatment of Active Thyroid Eye Disease

Given the lack of approved therapeutic options to manage thyroid eye disease (TED), there is little known about the usual clinical management practices offered to patients with this Graves’ related condition.

A team of investigators led by Anu Sharma, MD, assistant professor of clinical medicine at the University of Utah School of Medicine in Salt Lake City surveyed endocrinologists (n=73) who saw patients at least 50% of the time and treated at least five patients with a diagnosis of TED in the past year.1

 

Insights on clinical care challenges drawn from poster presentations

In this online survey, clinicians were asked to provide information on comorbidities such as pain, visual symptoms, and orbital-facial changes. Reported severity of the three features of TED were assessed using Fisher’s exact tests to draw categorical differences among the variables, and Student’s T-tests to compare continuous variables. They were than prompted to answer the following question: How would you characterize individual patient responses (for at least four patients) to their current regimen? They were asked to choose from among three options: “Responding really well”, “Responding Somewhat,” and Responding poorly”.1

Declassified data from 282 patients with TED were collected and analyzed. The authors reported no demographic differences within the study cohort, including smoking status: 58.5% never smoked, 28.7% were former smokers and 10.6% were current smokers. The participants were 60% women, mean age was 45.4 +/- 13.6 years, with a disease duration of 3.5 +/- 4.7 years.1

The majority of patients had been using lubricating topical eye drops. In addition, 39.7% of patients overall were receiving oral glucocorticoids and 19.5% were treated with IV glucocorticoids. Those characterized as having severe thyroid eye disease were given prescription ophthalmic drops containing rituximab and/or tocilizumab.

Individuals deemed to have moderate eye disease (60.7%) were receiving on average, 2 therapies, whereas patients (70%) diagnosed with severe TED were being treated with five or more treatments and often orbital radiation and ocular surgery, as well.1

In evaluating patient satisfaction with treatment, about one-third of those with a moderate form of thyroid eye disease and only 22.5% of patient with severe TED were reported to “respond well” to treatment.1

“The active phase of TED typically lasts two to three years but some patients may experience disease activity considerably longer, sometimes many years in duration,” said Terry J. Smith, MD,  Frederick GL Huetwell Professor in Ophthalmology and Visual Sciences at the Kellogg Eye Center at the University of Michigan in Ann Arbor who spoke to EndocrineWeb about the opportunity to finally meet patients’ needs with a single efficacious therapy; not only will patients with Graves' opthalmopoathy finally have a single safe and effective treatment, and by prescribing this emerging monoclononal antibody therapy early in the course of disease will provide maximum symptom reduction.

“Given the promising pooled (phase 2 and phase 3) data on teprotumumab presented at ATA,2 which unambiguously demonstrated that the primary and secondary endpoints were met,” there is reason to believe that these patients will finally have a chance to experience remarkable improvement in double vision (diplopia) and enhanced quality of life,” said Dr. Smith. “The majority of patients treated over a 24-week period responded with a marked reduction in proptosis in the more affected eye of at least 2 mm and a reduction in clinical activity score, in the same eye, of greater than or equal to 2 points on a 7-point scale.”

“The opportunity to treat patients early is important because once the stable or chronic phase has been reached, the patient’s eye manifestations largely stop changing. While many of the superficial inflammatory signs may disappear, the patient is left with the consequences of the disease, which can be viewed as endpoints of severity, such as proptosis and double vision, which in its most severe forms can result in loss of vision. This can occur as a consequence of either compression of the optic nerves,” he said.

“As such, we believe the period during the active phase [of thyroid eye disease] is most likely to yield optimal clinical response to treatment. Thus, we want to stress the importance of recognizing the disease early in disease presentation so as to initiate therapy when there is the best chance to have a favorable impact on disease endpoints,” said Dr. Smith. “It also may be that the active phase of disease may be shortened in duration, sometimes dramatically, as indicated by the very rapid responses seen in the phase 2 and 3 trials that have just been completed.”

Dr. Sharma has no disclosure but the other co-authors are employees of Horizon Therapeutics for the poster survey, and Dr. Smith is a consultant to Horizon, and holds patents in Grave's opthalmology.

Has the ATA Annual Meeting Program Covered a Wide Range of Thyroid Topics

While Hashimoto’s hypothyroidism is the most prevalent form of thyroid disease in the United States, affecting more than 14 million people, it may come as a surprise as much to you as it did to ATA Board member Sally E. Carty, MD, professor of surgery and co-director of the University of Pittsburgh Medical Center Hillman Cancer Center Multidisciplinary Thyroid Center, that the annual meeting topics have addressed this common thyroid condition in less than 5% of all presentation topics (P < 0.05).1

In fact, the program agenda over the past five years have consistently skewed in favor of presentations on thyroid cancer, according to a research team from the Charleston Thyroid Center and Hashimoto’s Foundation of American who conducted a survey of all lectures and poster topics featured at American Thyroid Association annual meetings held between 2015-2019.

Topical content was grouped into six categories: thyroid cancer, hypothyroidism, hyperthyroidism/Graves’ disease, and Hashimoto’s disease, and then analyzed using both descriptive and statistical analysis, as presented in this poster abstract.3

“Hashimoto’s disease was the focus of only 5% of the lectures presented over the past five years,” according to the authors. The focus on thyroid cancer captured the greatest time, representing 45% of the lecture time, followed by thyroid hormone activity at 19%, and Graves’ hyperthyroidism at 10%   

While there was a slight uptick in presentations addressing hypothyroidism this year— 14.3% sessions focusing on the diagnosis and management addressing disease, which more is more than double the 5-year average (6%). Yet, content specific to Hashimoto’s thyroiditis at 5.1% in 2019, remaining unchanged from past years in which this was a lecture topic, ranging from 4.1% to 6.4% during the annual meetings in the last five year.3

The takeaway from this poster: These authors raise a valid point that deserves consideration by next year’s planning committee as they plan the program topics and speakers.

When You Patient Chooses Active Surveillance, What Will Your Response Be?

While active surveillance has been recognized as an appropriate therapeutic choice for patients with asymptomatic, very low-risk papillary thyroid cancer of no more than 1 cm, there is little data on the level of adoption since publication of the 2015 ATA guideline.4

To evaluate how closely American Medical Association members have adopted active surveillance,5 a team of investigators in the department of surgery at the University of Wisconsin School of Medicine and Public Health conducted a mail survey to assess implementation of this clinical practice recommendation.

A random sample of 1,500 practitioners who specialize in endocrinology and surgery from across the United States were presented with two case scenarios: a 45-year old female with a single node-negative PTC (< 0.8 cm), and the same patient profile but she indicated a preference for active surveillance.5

From the 464 returned surveys analyzed by the team led by Susan C. Pitt, MD, MPHS, assistant professor of (endocrine) surgery, the practitioners were grouped based on their responses as follows:

  • Full adopters (ie, yes for both cases) – 12%
  • Partial adopters (yes for the first case only) – 42%
  • Non-adopters (didn’t recommend AS for either scenario) – 46%

Not surprisingly, respondents (88%) who indicated that they closely followed the ATA guidelines were most likely to select active surveillance in both cases. However, 64% of full adopters and less than half (46%) of partial adopters indicated that they did not have sufficient resources to comfortably perform active surveillance.5

When asked if they felt that they should implement active surveillance more often, 80% of full adopters, and 93% of the partial adopters felt there was no reason increase use of this watchful waiting beyond their current frequency.5

The ATA guideline recommends active surveillance or lobectomy for the patient with very low-risk papillary thyroid microcarcinomas which were described in the case scenarios and does not mandate active surveillance as the only option. 

“We intentionally chose ‘adoption’ of the guideline as opposed to ‘adherence’ because adherence implies that these practitioners are not doing something they are supposed to be doing; rather, they are choosing not to adopt active surveillance into their practice even if the patient prefers active surveillance over surgery,” Dr. Pitt told EndocrineWeb.

“Non-adopters mostly practiced in a non-academic setting and saw 25 of fewer new patients with thyroid cancer per year,” she said, “whereas non-adopters were less likely to be aware that active surveillance is an option and less likely to use American Thyroid Association guidelines.”

One possible intervention might be to increase awareness through greater efforts to more widely disseminate the guidelines, such as making the articles free access or mailing practitioners a notice about new guidelines, said Dr. Pitt. “The other major barriers to these practitioners not adopting active surveillance included knowledge about how to appropriately surveil patients, resources, and concerns about outcomes.

Additionally, patients are usually not aware of surveillance as a recommended option, she said. “These barriers can be addressed by providing guidelines and resources on optimal surveillance strategies, identifying centers with appropriate resources, and studying and publishing patient outcomes (both cancer-related outcomes like progression and psychological and quality of life related outcomes).  Fortunately, many of these studies are already underway.” 

“Lastly, increasing patient awareness with media campaigns and internet resources will be key to wider adoption of active surveillance,” Dr. Pitt said. “Our group recently showed that most websites about thyroid cancer treatment do not include information about active surveillance.”

Next Summary:
Thyroid Cancer Treatment—New Approaches to Improve Patient Outcomes
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