title: Rising incidence of second cancers in patients with low-risk (T1N0) thyroid cancer who receive radioactive iodine therapy.
abstract: BACKGROUND
  American Thyroid Association guidelines currently recommend the selective use of radioactive iodine (RAI) therapy in patients with well differentiated thyroid cancer (WDTC). Despite these guidelines, RAI ablation has been used routinely in all but the very lowest risk patients with thyroid cancer over the last 30 years. The objective of this study was to evaluate patterns of RAI use and elevated risk of secondary primary malignancies (SPM) in patients with low-risk (T1N0) WDTC.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results (SEER) database was used to analyze trends in RAI use over time in the United States. To determine the excess risk of SPM, the standardized incidence ratio (SIR) and excess absolute risk (EAR) of various cancers were calculated in the 2 cohorts. Between 1973 and 2007, 37,176 patients with WDTC were followed in the SEER Program, equating to 408,750 person-years at risk (PYR). In total, 14,589 patients received RAI, and SPMs were observed in 3223 patients.
  
  
  RESULTS
  During the study period, the rate of RAI use in patients with low-risk (T1N0) WDTC increased from 3.3% to 38.1%. For low-risk patients, the SIR of SPM was 1.21 (95% confidence interval [CI], 0.93-1.54), and the EAR was 4.6 excess cases per 10,000 PYR. SPM with significantly elevated risk because of RAI were salivary gland malignancies (SIR = 11.13; 95% CI, 1.35-40.2) and leukemia (SIR = 5.68; 95% CI, 2.09-12.37). The excess risk of leukemia was significantly greater in patients aged <45 years (SIR = 5.32; 95% CI, 2.75-9.30) compared with the excess risk in older patients (SIR = 2.26; 95% CI, 1.43-3.39).
  
  
  CONCLUSIONS
  The increased risk of a SPM in patients with low-risk (T1N0) WDTC, along with a lack of data demonstrating improved survival outcomes with adjuvant RAI, provide a compelling argument in favor of rationing the use of RAI in this patient population.
authors: Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
authors: N Gopalakrishna
authors: NG
authors: Iyer
authors: Luc G T
authors: LG
authors: Morris
authors: R Michael
authors: RM
authors: Tuttle
authors: Ashok R
authors: AR
authors: Shaha
authors: Ian
authors: I
authors: Ganly
mesh_terms: D018263:Adenocarcinoma, Follicular / Q000532:radiotherapy*; D002291:Carcinoma, Papillary / Q000532:radiotherapy*; D002454:Cell Differentiation; D005260:Female; D006801:Humans; D015994:Incidence; D007457:Iodine Radioisotopes / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009381:Neoplasms, Radiation-Induced / Q000453:epidemiology / Q000209:etiology*; D016609:Neoplasms, Second Primary / Q000453:epidemiology / Q000209:etiology*; D011379:Prognosis; D012307:Risk Factors; D018426:SEER Program; D015996:Survival Rate; D013964:Thyroid Neoplasms / Q000532:radiotherapy*; D014481:United States / Q000453:epidemiology
chemical_list: D007457:Iodine Radioisotopes