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Principal Investigator, Massachusetts General HospitalAssistant Professor of Surgery, Harvard Medical SchoolSenior Scientist, Institute for Technology Assessment, Massachusetts General HospitalAssistant Surgeon, Division of Surgical Oncology, Department of General Surgery, Massachusetts General Hospital
Principal Investigator: Carrie C. Lubitz, MD, MPH
Research Assistant: Laura Benitez
Thyroid cancer is common and is increasing in incidence, prevalence, and societal cost. Yet, the effects of current clinical practice are unknown. Moreover, most of the increased incidence is in low-risk smaller tumors and in younger patients, making the potential for consequences of overtreatment greater. Our group is in the process of developing a comprehensive, dynamic computer simulation model of the U.S. population to evaluate the impact of current interventions and future advancements in the diagnosis, treatment, and surveillance strategies on patients with PTC. We aim to identify those strategies that have the most promise for increasing both length and quality of life. Ultimately, our work can aid in the appropriate allocation of resources while optimizing care and minimizing harm to our patients. Additionally, we plan to integrate our own primary data on risk-stratified treatment strategies and patient-reported quality of life measures into the work.
After surgery for papillary thyroid carcinoma, the most common type of thyroid cancer, up to 15% of patients develop recurrent disease, requiring high-risk reoperations. The ability to predict tumor behavior is a crucial part of planning the extent of initial surgery, the post-operative medical therapy, and developing a tailored-approach to the frequency and intensity of surveillance for tumor recurrence. Most conventional risk-stratification systems aim to predict overall survival instead of recurrence and depend on post-operative clinical and pathologic data. Our preliminary data have shown that BRAFV600E positivity, present in 45% of PTC tumors, is an independent predictor of PTC recurrence. We are currently developing a prediction model that includes mutational status of BRAF and histological subtype.
Given the longevity of the vast majority of patients with thyroid cancer, addressing patient quality of life is essential in assessing treatment and surveillance strategies. Complications of diagnosis and therapy for thyroid cancer have significant impact on patients. These include anxiety, recurrent laryngeal nerve injury (causing permanent hoarseness), hypoparathyroidism (causing parasthesias and need for lifelong calcium/vitamin D supplementation), salivary and lacrimal dysfunction and secondary malignancies from radioactive iodine. We are in the process of surveying thyroid cancer patients on various aspects of their quality of life as they proceed through treatment.
Hypertension affects 1 in 4 adults and is the leading cause of heart disease, stroke, and death. Resistant hypertensive patients are a subset of patients who remain above target blood pressure on three antihypertensive medications – placing them at an even higher risk. While the majority of patients have primary or “essential” hypertension, there are also secondary, potentially curable, causes, the most common of which is primary hyperaldosteronism (PA). PA, seen in up to 23% of resistant hypertensive patients, is caused by excess aldosterone released from one or both adrenal glands. Guidelines vary on who and how to screen patients for PA. Our group has developed a decision-analytic model to compare the costs and effectiveness of screening strategies to identify surgically correctable disease in this population. We are currently expanding the model to explore the lifetime secondary differential effects of continued hypertension in primary aldosteronism versus essential hypertension.
Primary hyperparathyroidism affects approximately 1% of the population. Parathyroidectomy is accepted as the most durable and cost-effective treatment, with reported cure rates over 97%, preventing complications, such as nephrolithiasis and neurocognitive symptoms, all of which contribute to decreased quality of life. The majority of affected patients have single-gland disease, which has led to a shift from traditional, bilateral four-gland exploration to minimally-invasive parathyroidectomy requiring imaging to identify the enlarged parathyroid. Our group developed a decision-analytic model to comprehensively evaluate short-term costs of eight common parathyroid localization strategies for patients with primary hyperparathyroidism.
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