Association of Radioactive Iodine Treatment With Cancer Mortality in Patients With Hyperthyroidism

Key Points

Question

Is radioactive iodine absorbed dose associated with overall and site-specific cancer mortality in patients with hyperthyroidism?

Finding

In this cohort study of 18 805 patients with hyperthyroidism treated with radioactive iodine, a statistically significant positive dose-response relationship for risk of death was observed for all solid cancers (6% increase in risk per 100-mGy dose to the stomach), breast cancer (12% increase in risk per 100-mGy dose to the breast), and all solid cancers excluding breast (5% increase in risk per 100-mGy dose to the stomach).

Meaning

This study’s findings suggest a modest positive association between greater organ-absorbed doses of radioactive iodine and risk of solid cancer death; additional studies are needed to fully weigh the risks and advantages of radioactive iodine and other treatment options for patients with hyperthyroidism.

Abstract

Importance

Radioactive iodine (RAI) has been used extensively to treat hyperthyroidism since the 1940s. Although widely considered a safe and effective therapy, RAI has been associated with elevated risks of total and site-specific cancer death among patients with hyperthyroidism.

Objective

To determine whether greater organ- or tissue-absorbed doses from RAI treatment are associated with overall and site-specific cancer mortality in patients with hyperthyroidism.

Design, Setting, and Participants

This cohort study is a 24-year extension of the multicenter Cooperative Thyrotoxicosis Therapy Follow-up Study, which has followed up US and UK patients diagnosed and treated for hyperthyroidism for nearly 7 decades, beginning in 1946. Patients were traced using records from the National Death Index, Social Security Administration, and other resources. After exclusions, 18 805 patients who were treated with RAI and had no history of cancer at the time of the first treatment were eligible for the current analysis. Excess relative risks (ERRs) per 100-mGy dose to the organ or tissue were calculated using multivariable-adjusted linear dose-response models and were converted to relative risks (RR = 1 + ERR). The current analyses were conducted from April 28, 2017, to January 30, 2019.

Exposures

Mean total administered activity of sodium iodide I 131 was 375 MBq for patients with Graves disease and 653 MBq for patients with toxic nodular goiter. Mean organ or tissue dose estimates ranged from 20 to 99 mGy (colon or rectum, ovary, uterus, prostate, bladder, and brain/central nervous system), to 100 to 400 mGy (pancreas, kidney, liver, stomach, female breast, lung, oral mucosa, and marrow), to 1.6 Gy (esophagus), and to 130 Gy (thyroid gland).

Main Outcomes and Measures

Site-specific and all solid-cancer mortality.

Results

A total of 18 805 patients were included in the study cohort, and the mean (SD) entry age was 49 (14) years. Most patients were women (14 671 [78.0%]), and most had a Graves disease diagnosis (17 615 [93.7%]). Statistically significant positive associations were observed for all solid cancer mortality (n = 1984; RR at 100-mGy dose to the stomach = 1.06; 95% CI, 1.02-1.10; P = .002), including female breast cancer (n = 291; RR at 100-mGy dose to the breast = 1.12; 95% CI, 1.003-1.32; P = .04) and all other solid cancers combined (n = 1693; RR at 100-mGy dose to the stomach = 1.05; 95% CI, 1.01-1.10; P = .01). The 100-mGy dose to the stomach and breast corresponded to a mean (SD) administered activity of 243 (35) MBq and 266 (58) MBq in patients with Graves disease. For every 1000 patients with hyperthyroidism receiving typical doses to the stomach (150 to 250 mGy), an estimated lifetime excess of 19 (95% CI, 3-40) to 32 (95% CI, 5-66) solid cancer deaths could occur.

Conclusions and Relevance

In RAI-treated patients with hyperthyroidism, greater organ-absorbed doses appeared to be modestly positively associated with risk of death from solid cancer, including breast cancer. Additional studies are needed of the risks and advantages of all major treatment options available to patients with hyperthyroidism.

Abstract

This cohort study evaluates the level of ionizing radiation exposure and risk of cancer death from a common treatment for hyperthyroidism in a large and longest-running cohort of patients with hyperthyroidism.