Hyperparathyroidism in the Elderly Appears Undertreated

By David Douglas

January 15, 2021

NEW YORK (Reuters Health) - Fewer than a third of elderly Medicare beneficiaries who may benefit from parathyroidectomy because of primary hyperparathyroidism (PHPT) actually receive such treatment, according to a population-based cohort study.

As Dr. Carolyn D. Seib told Reuters Health by email, "in the United States the majority of older adults with primary hyperparathyroidism, including those who meet evidence-based operative guidelines, are not undergoing parathyroidectomy to provide a definitive cure for the condition and prevent associated health problems, such as osteoporosis, kidney stones, and declining kidney function."

Dr. Seib of Stanford University School of Medicine, in California, and colleagues examined data on more than 210,000 patients with a mean age of 76 years who had an incident diagnosis of PHPT between 2006 and 2016. More than three-quarters were women.

Thirty percent underwent parathyroidectomy within one year of diagnosis, the authors report in JAMA Surgery. Of the subset of 131,723 patients who met at least one consensus guideline criterion for surgical management, only 30% were treated with parathyroidectomy within that period.

Among factors associated with a higher likelihood of being treated operatively were being younger, being white and having fewer comorbidities.

On multivariable analysis, increasing age had a strong and significant inverse association with parathyroidectomy. For example, compared to those aged 66 to 75 years, the odds ratio in those aged 76 to 85 years was 0.68. It was 0.27 in older patients.

Thus, continued Dr. Seib, "We found that older age, frailty, and comorbidity are strongly associated with non-operative management of primary hyperparathyroidism, suggesting providers or patients may be concerned about the surgical risks of parathyroidectomy; however, our findings were unchanged when we excluded patients who died within 5 years of diagnosis of primary hyperparathyroidism, suggesting a number of the patients who aren't getting surgery would likely have lived long enough to benefit from surgical cure."

She concluded, "We need to do a better job of educating patients and providers about the indications for and benefits of parathyroidectomy, which is in general a low-risk, outpatient procedure when performed by experienced surgeons. My research group is working on developing tools that will help patients and providers weigh the risks of parathyroidectomy to improve how we make treatment decisions for primary hyperparathyroidism, which is becoming more common in an aging U.S. population."

Dr. Martin Almquist of Skaane University Hospital, in Lund, Sweden, co-author of an accompanying editorial, told Reuters Health by email, "Primary hyperparathyroidism, a common endocrine disorder mostly affecting postmenopausal women, is according to this large, well-designed study vastly undertreated. Only a third of all patients with clear indications for surgery end up receiving an operation, denying them a potential cure and putting them at risk for future complications of the disease, such as fractures and renal stones."

As he and co-author Dr. Martin Nilsson point out in their editorial, "barriers to treatment need to be identified to start treating patients with PHPT according to guidelines. This would decrease suffering and complications from PHPT and ultimately save lives."

SOURCE: https://bit.ly/3qhikVP and https://bit.ly/3q9DuoW JAMA Surgery, online January 6, 2021.