Day Case Radioiodine for Thyroid Cancer Safe and Feasible

Liam Davenport

November 12, 2019

BRIGHTON — Patients with thyroid cancer can be treated with radioiodine ablation as day cases and avoid having to stay overnight in hospital, say UK researchers in findings that could reduce bed pressures and offer potentially huge cost savings.

Dr Shazia Hussain, Department of Endocrinology, Barts Health NHS Trust, London, and colleagues developed a protocol for treating patients as day cases to take advantage of lower dose radiation.

Reducing Bed Pressures

Presenting their results at Society for Endocrinology BES 2019, they showed that when carefully selecting the patients, they could threat 37% of thyroid cancer cases with radioiodine ablation as day cases, with no adverse events and high patient satisfaction.

Dr Hussain said that they "believe that day case radioiodine ablation is safe and can reduce hospital bed pressures".

However, some patients said they would have preferred to have been treated as an inpatient, and more patients could have been treated as day cases if the service had been more well known in the hospital.

She and her colleagues therefore "acknowledge that we need to continue to audit our practice, manage our patient expectations, and continue to collect patient feedback".

The poster session was co-chaired by Dr Jacqueline Gilbert, a consultant endocrinologist at King's College Hospital, London.

She told Medscape News UK that the study shows that there is "an opportunity" to manage radioiodine ablation patients differently, with cost savings that are "potentially very interesting".

She added that "there certainly seems to be scope" for treating a wider cohort that, combined with increased awareness among clinicians and "setting the level of patient expectation", could have "a positive impact on acceptance of day case admission versus remaining in hospital for a longer period of time".

Risk Assessment

Presenting the study, Dr Hussain said that, traditionally, patients requiring radioactive iodine ablation have received five doses of I-131 radioiodine at approximately 3000 MBq.

This, she pointed out, "has necessitated a hospital admission to ensure that radioactivity levels fall to a safe level prior to discharge home".

Since the publication of results from the landmark HiLo trial, however, doses have been significantly reduced, to 1100 MBq.

In the meantime, a department audit revealed that 86% of patients undergoing radioiodine ablation waited for at least 3 hours, and 29% waited beyond 5pm for an available bed, which resulted in a late discharge.

Dr Hussain and colleagues therefore conducted an extensive risk assessment, finding that, given the lower radiation doses, they "could potentially discharge many of our patients home safely on the day of treatment".

They developed a treatment strategy that followed strict exclusion criteria for day case treatment. These included incontinent patients or those with a stoma, and those with long commutes, as well as children and pregnant women.

Each patient followed a strict care pathway that emphasised the exclusion criteria and safe day case management. They were monitored for 2 hours after the procedure and returned for post-ablation imaging 48–72 hours later.

No Adverse Effects

Between May 2018 and June 2019, the team administered the lower 1100 MBq dose to 53 patients, of whom 20 (37%) were discharged home on the same day.

"We were pleased to find that there were no adverse effects in any of our patients and, in fact, by adopting this approach, we reduced patient waiting times," Dr Hussain said.

Retrospective analysis suggested that they could have doubled the number of day case treatments through education of the wider care team about its existence.

If that were implemented, the team calculated that, at an estimated admission cost of £340 per patient, they could save approximately £14,000 per year.

In addition, four nuclear medicine physicist work hours would be saved per patient, alongside increases in bed availability, and the potential to treat more than one patient per day.

Of the twenty patients seen as day cases, 11 were seen within 30 minutes of their scheduled appointment time.

Although all of them said they would recommend the service and reported no adverse events, five (45%) would have preferred to have been admitted to hospital, largely for a sense of security.

Managing Patient Expectations

In the post-presentation discussion, session co-chair Dr Carla Moran, a consultant endocrinologist at Beacon Hospital, Dublin, asked how they might try to "allay the fears" of patients wanting inpatient care.

Dr Hussain quipped that the "major issue is maybe we shouldn’t be asking them in our feedback questionnaire whether or not they want inpatient care".

She noted that "the grass is always greener on the other side", as many of their inpatients "said they would prefer to have day case treatment", adding that "it largely falls down to managing patient expectations".

Dr Hussain pointed out that many patients are referred from other clinics, "where they would be admitted for ablation, and so when we offer then day case treatment it’s...a frame shift".

She continued: "Generally I think we need to educate the wider team and make this our local guideline, and make it very clear that, if you don’t fall into these categories, only then are you admitted for treatment."

No conflicts of interest or funding declared.

Society for Endocrinology BES 2019: Abstract OP2.1. Presented 11th November.

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