Toro-Tobón, David

This Viewpoint discusses the practice of molecular testing for the classification of thyroid nodules and explores related questions regarding automation, transparency, and clinical reasoning.

Abstract Context Benign thyroid nodules (BTNs) are highly prevalent, and current treatment options are primarily invasive. There is a need for effective, noninvasive alternatives. Objective To systematically evaluate the efficacy of repurposed pharmacologic agents in reducing the size of BTNs. Data Sources MEDLINE, EMBASE, Cochrane databases, and Scopus were searched from inception to December 18, 2024. Study Selection We included preclinical and clinical studies evaluating repurposed drugs for BTNs in adults. Of 1499 records screened, 20 studies met inclusion criteria: 6 randomized controlled trials (RCTs), 6 prospective cohorts, 3 retrospective observational studies, 3 case reports, 1 cross-sectional study, and 1 preclinical study. Data Extraction Data were extracted independently in duplicate using a standardized form. Data Synthesis Narrative synthesis was conducted due to heterogeneity. Metformin was the most frequently evaluated agent (7 studies), with 5 studies (including 2 RCTs) reporting statistically significant reductions in dominant nodule volume. One prospective study demonstrated a reduction in the maximum nodule diameter, which was not statistically significant, and 1 RCT showed no changes in nodule size after intervention. Statins (4 studies) and somatostatin analogues (4 studies) showed mixed results. Myo-inositol with selenium, herbal formulations, and immune checkpoint inhibitors showed promise in single studies or case reports. Conclusion Metformin shows the most consistent potential for noninvasive reduction of BTN size, particularly in patients with metabolic comorbidities. However, current evidence is limited and heterogeneous. Further large-scale studies are needed to confirm efficacy and guide clinical use.

Abstract Disclosure: L. Miller-Wilson: Employee of Immunovant, Inc. N. Princic: Employee of Merative. K. Evans: Employee of Merative. N. Atreja: Employee of Immunovant, Inc. K. Tollefsen: Employee of Immunovant, Inc.. D. Toro-Tobón: None. Objectives: Graves’ disease (GD) is an autoimmune condition responsible for most cases of hyperthyroidism in the United States. An estimated 20%-50% of patients with GD will also develop thyroid eye disease (TED). Current treatments for GD focus on managing hyperthyroidism, but frequent monitoring, dose adjustments, and the high rate of relapse after discontinuation of antithyroid drugs can increase treatment costs and complicate long-term management. This study describes healthcare resource utilization (HCRU) and costs among patients with GD, with and without TED. Methods: This retrospective analysis utilized claims data from the Merative™ MarketScan® Research Databases. Individuals aged ≥18 years with ≥2 claims for a GD diagnosis from January 1, 2017-December 31, 2023 were included (first claim = index). To ensure a newly diagnosed cohort, patients with a history of GD-specific treatment or a GD diagnosis in the 12 months preceding the index were excluded. The final GD cohort was stratified into patients who had evidence of TED at any time during the 12-month pre-index period through 90 days post-index, and those who did not. Propensity score matching was used to balance patients with GD (with and without TED) with non-GD controls (1:3) on demographic and baseline clinical characteristics. Both GD cases (with and without TED) and controls were required to have ≥12 months of post-index follow-up. HCRU and costs were compared between cases and controls during a fixed 12-month post-index period. Categorical outcomes were compared using chi-squared tests, while continuous endpoints were compared using paired t-tests. Results: The analysis included 1,767 GD cases with TED matched with 5,301 controls (mean age, 53.1 years [standardized mean difference (SMD), 0.00]; 77% female [SMD, 0.00]; mean Charlson comorbidity score, 0.9 [SMD, 0.02]) and 43,120 GD cases without TED matched with 129,360 controls (mean age, 49.8 years [SMD, 0.00]; 78% female [SMD, 0.00]; mean Charlson comorbidity score, 0.7 [SMD, 0.01]). Compared with matched controls, patients with GD and TED had 78% more inpatient visits (0.16 vs 0.09), 104% more outpatient visits (65.06 vs 31.86), and 43% more prescriptions (30.21 vs 21.13) during the 12-month post-index period, while patients with GD without TED had 75% more inpatient visits (0.14 vs 0.08), 83% more outpatient visits (52.15 vs 28.48), and 38% more prescriptions (24.27 vs 17.56) (p<0.001 for all). Annual mean healthcare costs were 305% higher ($56,584 vs. $13,981) among GD patients with TED and 65% higher ($19,913 vs $12,076) in those without TED compared with matched controls. Conclusion: Patients with GD had significantly higher HCRU and healthcare costs than matched controls in the 12 months following diagnosis, and this difference was notably greater among GD patients who also had TED. More effective treatments are needed to address the health and financial burden of GD. Presentation: Monday, July 14, 2025

Abstract Purpose Overuse of thyroid ultrasound (TUS) has contributed to rising thyroid cancer diagnoses and is projected to increase US healthcare costs from $1.5 billion to $3.5 billion by 2030. This study evaluated the healthcare cost of inappropriately ordered TUS in a national multicenter academic system. Methods This is a secondary cost analysis of a retrospective cohort study across 4 Mayo Clinic sites (Rochester, MN; Jacksonville, FL; Scottsdale, AZ; and the Midwest Mayo Clinic Health System). Adult patients (≥18 years) undergoing their first TUS between January 1, 2017, and December 31, 2021, with at least 1 year of follow-up were included. TUS indications were classified as appropriate or inappropriate using a guideline-based natural language processing algorithm. The primary outcome was a comparison of adjusted 1-year all-cause healthcare costs. A secondary analysis calculated the direct procedural costs of the inappropriate TUS cascade. Results Among 6984 patients (mean age 56 [SD 16.4]; 76.2% female; 90.9% White), 546 (7.8%) underwent TUS for inappropriate indications. These patients were younger (mean age 53.0 vs 56.3 years, P < .0001) but otherwise demographically similar. Adjusted total healthcare costs over 90 days and 1 year were comparable: $4842 vs $5794 and $13 748 vs $14 257 for inappropriate vs appropriate TUS, respectively. The inappropriate TUS cascade, including an estimated 56 subsequent biopsies and 22 thyroidectomies, resulted in a minimum of $576 134 in direct procedural costs. Conclusion While adjusted total costs were similar, inappropriate TUS represents potentially avoidable spending and remains a viable target for cost-reduction strategies. Reducing low-value imaging remains a critical target for cost-saving interventions.

ImportanceThyroid cancer incidence has tripled in the past 3 decades, largely driven by increased detection of small, indolent papillary thyroid cancers. Overuse of thyroid ultrasonography (TUS) contributes to overdiagnosis, leading to unnecessary biopsies, procedures, and potential patient harm.ObjectiveTo evaluate the frequency of and factors associated with inappropriate TUS (iTUS) orders and assess related clinical outcomes.Design, Setting, and ParticipantsThis retrospective cohort study analyzed adult patients 18 years and older who underwent their first TUS from January 1, 2017, to December 30, 2021, at 4 Mayo Clinic sites. Patients with previous thyroid nodule, thyroid cancer, thyroid surgery, or TUS were excluded. Based on documented clinical indications, a validated natural language processing model classified TUS orders as appropriate or inappropriate. Data were analyzed from April 2024 to May 2025.ExposuresBaseline characteristics of patients, clinicians, and clinical encounters investigated for their association with an iTUS order.Main Outcomes and MeasuresThe primary outcome was the proportion of iTUS orders. Secondary outcomes included factors associated with iTUS (sociodemographic, clinical, order-specific, and clinician-related factors) and clinical outcomes following iTUS, including the detection of thyroid nodules, thyroid procedures, and thyroid cancer diagnoses.ResultsOf 11 442 included patients, 8422 (73.6%) were female, and the mean (SD) age was 57.3 (15.8) years with a mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 29.7 (7.0). Among 11 442 TUS orders, 866 (7.6%) were classified as inappropriate. In multivariable analysis, younger age (age of 18 to 54 years vs older than 65 years; odds ratio [OR], 1.86; 95% CI, 1.56-2.22), hyperthyroidism (OR, 9.04; 95% CI, 6.75-12.11), ordering by nonendocrinology specialties (eg, oncology/hematology; OR, 3.43; 95% CI, 2.47-4.76), and orders not linked to an in-person appointment (eg, portal messages; OR, 2.42; 95% CI, 2.08-2.82) were strongly associated with increased odds of iTUS. Compared with appropriate TUS, iTUS led to lower rates of thyroid nodule detection (202 of 866 [23.3%] vs 6885 of 10 576 [65.1%]; OR, 0.16; 95% CI, 0.14-0.19), biopsies (89 [10.3%] vs 2647 [25.0%]; OR, 0.34; 95% CI, 0.27-0.43), partial thyroidectomies (14 [1.6%] vs 424 [4.0%]; OR, 0.39; 95% CI, 0.23-0.67), and confirmed thyroid cancer cases (16 [1.8%] vs 425 [4.0%]; OR, 0.45; 95% CI, 0.27-0.74).Conclusions and RelevanceIn this cohort study, approximately 1 in 13 TUS orders were inappropriate. iTUS was more common in younger patients, those with thyroid dysfunction, those not seen in person, and in those referred by nonendocrinology specialties. These findings highlight the need for targeted strategies to optimize TUS use and mitigate overdiagnosis and overtreatment.

Abstract Thyroid eye disease (TED) is a complex ocular autoimmune disorder primarily associated with Graves’ disease. It leads to significant morbidity due to orbital inflammation, fibrosis, and tissue expansion. While corticosteroids have been the traditional mainstay of therapy, recent advancements in understanding TED pathophysiology have driven the development of targeted treatments. Notably, inhibition of the insulin-like growth factor-1 receptor with teprotumumab has revolutionized TED management, demonstrating efficacy in reducing proptosis and disease severity. Additional emerging therapies, including neonatal Fc receptor inhibitors, thyroid-stimulating hormone receptor blockers, and interleukin-6 receptor antagonists, offer promising alternatives for patients with active and refractory disease. Despite these advancements, challenges remain in disease classification and outcome assessment. As the landscape of TED management continues to evolve, this review provides a comprehensive overview of current and emerging therapies for TED, critically examines gaps in disease evaluation, and highlights the evolving paradigm of patient-centered care. Future efforts should focus on optimizing therapeutic algorithms, refining risk stratification models, guiding personalized treatment, and promoting a multidisciplinary approach, which remain essential in improving outcomes and quality of life for affected individuals.

Importance The increasing use of glucagon-like peptide-1 receptor agonists (GLP-1RA) demands a better understanding of their association with thyroid cancer. Objective To estimate the risk of incident thyroid cancer among adults with type 2 diabetes being treated with GLP-1RA vs other common glucose-lowering medications. Design, Setting, and Participants This was a prespecified secondary analysis of a target trial emulation of a comparative effectiveness study using claims data for enrollees in commercial, Medicare Advantage, and Medicare fee-for-service plans across the US. Eligible participants were adults with type 2 diabetes at moderate risk for cardiovascular disease and without history of thyroid cancer who had newly filled prescriptions for GLP-1RA, sodium-glucose cotransporter 2 inhibitor (SGLT2i), dipeptidyl peptidase-4 inhibitor (DPP4i), or sulfonylurea from January 1, 2014, to December 31, 2021. Data were analyzed February 1 to October 31, 2024. Main Outcomes and Measures Overall and piecewise (<1, 1-2, and ≥2 years since treatment initiation) hazard ratios (HRs) for thyroid cancer with use of GLP-1RA vs the other 3 drug classes were estimated using inverse propensity score weighted Cox proportional hazards models. Modified intention-to-treat (mITT) (primary) and as-treated (sensitivity) analyses were performed. Results Of 351 913 patients (mean [SD] age, 65.3 [8.5] years; 173 391 [49.3%] females and 178 522 [50.7%] males), 41 112 started treatment with GLP-1RA; 76 093, with DPP4i; 43 499, with SGLT2i; and 191 209, with sulfonylurea therapy. The numbers of patients diagnosed with thyroid cancer were 69 (0.17%) in the GLP-1RA group, 172 (0.23%) in the DPP4i group, 72 (0.17%) in the SGLT2i group, and 381 (0.20%) in the sulfonylurea group. In the mITT analysis, GLP-1RA initiation was not significantly associated with increased overall risk for thyroid cancer compared to the other 3 diabetes drugs (HR, 1.24; 95% CI, 0.88-1.76). However, the risk for thyroid cancer was significantly higher within the first year after GLP-1RA initiation (HR, 1.85; 95% CI, 1.11-3.08) and was amplified in the overall as-treated analysis that censored patients when therapy was discontinued or another medication was added (HR, 2.07; 95% CI, 1.10-3.95). Conclusions and Relevance This secondary analysis of a target trial emulation of a comparative effectiveness study found that despite the low absolute risk of thyroid cancer among patients receiving GLP-1RA therapy, there was an increased risk of new thyroid cancer diagnoses within the first year of GLP-1RA initiation compared to 3 other diabetes drugs. This finding may have been due to enhanced early detection; therefore, further research is necessary to understand the underlying causes of this association.

Abstract Context Literature suggests patients with thyroid cancer have unmet informational needs in many aspects of care. Patients often turn to online resources for their health-related information, and generative artificial intelligence programs such as ChatGPT are an emerging and attractive resource for patients. Objective To assess the quality of ChatGPT's responses to thyroid cancer-related questions. Methods Four endocrinologists and 4 endocrine surgeons, all with expertise in thyroid cancer, evaluated the responses to 20 thyroid cancer-related questions. Responses were scored on a 7-point Likert scale in areas of accuracy, completeness, and overall satisfaction. Comments from the evaluators were aggregated and a qualitative analysis was performed. Results Overall, only 57%, 56%, and 52% of the responses “agreed” or “strongly agreed” that ChatGPT's answers were accurate, complete, and satisfactory, respectively. One hundred ninety-eight free-text comments were included in the qualitative analysis. The majority of comments were critical in nature. Several themes emerged, which included overemphasis of diet and iodine intake and its role in thyroid cancer, and incomplete or inaccurate information on risks of both thyroid surgery and radioactive iodine therapy. Conclusion Our study suggests that ChatGPT is not accurate or reliable enough at this time for unsupervised use as a patient information tool for thyroid cancer.