Guideline Updates on Hormones, CKD-MBD; Meeting Report on Thyroid Cancer

Brief overview of revised recommendations on use of hormones in postmenopausal women, and on care of chronic kidney disease-mineral bone disorder, and lifestyle factors your patients still need to hear.

with Marcia S. Brose, MD PhD 

Promising First-Line Treatment for Advanced RIA-Resistant Thyroid Cancer

Most cases of differentiated thyroid cancer are treated with radioactive iodine (RAI) therapy. However, an estimated 15% of these patients are resistant to treatment with RAI.

In a phase II trial,1 cabozantinib, a kinase inhibitor, was given as first-line therapy to 35 patients with metastatic, radioactive iodine-resistant thyroid cancer. Thirty-four of 35 patients experienced tumor shrinkage, with 54 percent showing at least a partial response defined as a reduction in tumor size of at least 30 percent.1 Patients were followed for an average of 35 weeks with16 patients still being followed

The results as reported offer promise to patients with metastatic, radioactive iodine-resistant thyroid cancer, extending patients’ progression-free period,1 as reported by the researchers at the Abramson Cancer Center and the University of Pennsylvania Perelman School of Medicine in Philadelphia. 

These findings were presented at the 2018 Multidisciplinary Head and Neck Cancers Symposium in Scottsdale, Arizona.

"Our trial shows that cabozantinib is an active agent for patients with RAI-refractory thyroid cancer and may be able to significantly improve the care of patients who are at this advanced stage of their disease," said lead author Marcia S. Brose, MD PhD, an associate professor of Otorhinolaryngology: Head and Neck Surgery and director of the Center for Rare Cancers and Personalized Therapy at UPenn.

However, 23 the 35 patients required dose interruptions or adjustments during the trial. Common drug side effects included: hyperglycemia (80%), diarrhea (7%), fatigue (74%), and unintended weight loss (71%).1 Plans for a large, multicenter study is underway.  The study received financial support from Exelixis, a manufacturer of cabozantinib.

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Updated Recommendations for Management of Chronic Kidney Disease-Mineral Bone Disorder

The newest guidelines for the prevention, diagnosis, and treatment of chronic kidney disease-mineral bone disorder (CKP-MBD) emphasize the need to make clinical decisions based on trends in serial values of serum parathyroid hormone (PTH), phosphate, and calcium rather than on a single abnormal laboratory finding,2 published in the Annals of Internal Medicine.

According to the senior author, Mary Leonard, MD, professor, and chair of the department of pediatrics at Stanford University in Palo Alto, California, the first revision concerns the use of bone mineral density (BMD) testing to assess fracture risk.

“It is apparent that therapeutic maneuvers aimed at improving one variable often have unintended effects on others,” the authors wrote in explaining this change. They said it may be beneficial to focus on preventing hyperphosphatemia and to treat patients with elevated phosphate levels, rather than adjusting for calcium, although further research in the area is needed.2

While many of the recommendations remain the same, there were 15 notable changes that reflect evidence garnered since the 2009 guidelines were issued,2 according to members of the Kidney Disease: Improving Global outcomes 2017 Work Group.

Another notable change occurred for the recommendation against routinely performing bone mineral density (BMD) in patients with CKD stage G3a to G5D and CKD-MBD, to recommending the use of dual-energy xray absorptiometry testing and bone biopsy to differentiate types of renal osteodystrophy as “reasonable” so that findings of low or declining BMD may prompt active management aimed at reducing risk of falls and treating for osteoporosis.2

Similarly, “when PTH trends are inconsistent, it is reasonable to perform a bone biopsy if the results could lead to changes in therapy,” the authors reported. However, bone biopsy is now contraindicated before introducing antiresorptive therapy in patients with CKD stage G4 to G5D, as the earlier guidelines recommended; Evidence now supports the effectiveness of antiresorptive treatment in patients with CKD stage 3a to G4.2

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Revised Guidance on Hormone Therapy for Primary Prevention, Issued by USPSTF

The US Preventive Services Task Force (USPSTF) recommends against the use of combined estrogen and progestin for primary prevention of common chronic diseases (eg, cardiovascular disease, stroke, fractures, dementia, and breast cancer) in postmenopausal women.3

Similarly, the USPSTF issued guidance against prescribing estrogen alone for women who had a hysterectomy in postmenopause; this statement updates the 2012 USPSFT recommendation on menopausal hormone therapy to reflect evidence amassed over the past 3 years,3,4 and was published in JAMA.

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Lifestyle Factors Worth Reinforcing with Your Patients

Consuming Highly Processed Foods Increases Cancer Risk

Findings from the large prospective NutriNet-Santé study (n = 104,980) revealed that for every 10% increase in a diet containing sugary cereals, packaged snacks, and other significantly manufactured food products, individuals were at a 12% increase in overall risk for cancer, and 11% elevated risk for breast cancer.5   The data was assessed using multivariable Cox proportional hazard models adjusted for known risk factors.

The study, published online in the British Medical Journal, was based on 24-hour consumption recall for participants completing at least two online questionnaires.5

Excessive early TV exposure tied to adverse outcomes in adolescence but may be reversed with regular physical activity in adulthood

For every hour that a two-year-olds sat in front of the television (TV), the Canadian researchers noted an 8% increased risk for developing unhealthy eating habits, as well as  a 10% higher likelihood of skipping breakfast, 10% higher body mass index, as well as an increase in screen time and reduced engagement in school work in their teens years.6 These findings, reported in Preventive Medicine,6 were based nearly 2,000 Canadian children born between 1997 and 1998, and followed for 13 years.

However, physical activity was shown to attenuate the negative effects of TV watching,7 according to a team of researchers from Spain and Portugal. This cross-sectional survey of time spent watching television and doing some form of physical activity among 32,931 adult men and women from 18 European countries.7 The data was obtained from the European Social Survey database.7

The researchers confirmed an association between increase disease multimorbidity and time in front of the TV.

The level of activity had a different impact on the sexes:

  • For men, more than 3 hours of TV daily over 2-3 days, and no more than 1 hour of physical activity weekly increased risk of comorbidity
  • In women with the same hours of TV watching, but when physical activity was limited to 30 minutes over 2-3 days/week, the risk of disease increased. 
  • For adults who were active at least five times weekly, there was no negative effect from TV watching.   
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Effectiveness of Osteoporosis Medications: Can They Help Prevent Fractures?
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