2019-5-22 PTA - Philippine Thyroid Summit

Global, Regional and
National Prevalence of
Thyroid Disorders
Jeremy F. Robles, MD, FPCP, FPSEDM

2019 Thyroid Summit
“Building Partnerships to Support Thyroid Disorder Prevention and Control in the Philippines”
May 22, 2019 (Wednesday) Diamond Hotel, Manila, Philippines

SPECTRUM OF THYROID DISEASES
Hyperthyroidism Hypothyroidism
Thyroid
Nodules
Thyroid
Malignancy
Pregnancy related
thyroid Disease

The Philippine Thyroid Diseases Study
(PhilTiDeS 1): Prevalence of Thyroid
Disorders Among Adults in the Philippines
The Philippine Thyroid Diseases Study (PhilTiDeS 1) JAFES Vol. 27 No. 1 May 2012
• First national survey in the Philippines on the prevalence
of thyroid disorder based on thyroid function tests.
• Sampling: Stratiﬁed multi-stage sampling design
(17 regions, 80 provinces)

The Philippine Thyroid Diseases Study
(PhilTiDeS 1): Prevalence of Thyroid
Disorders Among Adults in the Philippines
• Philippine Prevalence of thyroid dysfunction = 8.53%.
• Half of the hyperthyroid patients have goiter
• Distribution based on thyroid Function Status
Thyroid Function Status Prevalence, N (%)
Normal 4480 (91.47)
Subclinical Hyperthyroidism 258 (5.33)
Subclinical Hypothyroidism 110 (2.18)
True Hyperthyroidism 30 (0.61)
True Hypothyroidism 19 (0.41)
Total 4897 (100)

Demographic & Biochemical
Characteristics of the Population

Characteristics of the sample population
according to World Health Organization
grading of goiter

• Philippine National Prevalence of thyroid disease 8.53%

• Subclinical Hyperthyroidism (5.33%) and Subclinical
Hypothyroidism (2.18%) are the most common thyroid
dysfunctions

• Hyperthyroidism (0.6%) and Hypothyroidism (0.4%)

• Only half of the patients with hyperthyroidism had goiter

• Among the adult Filipino population, 8.9% have goiters by
physical examination
The Philippine Thyroid Diseases Study (PhilTiDeS 1):
Prevalence of Thyroid Disorders Among Adults in the
Philippines

https://seer.cancer.gov/statfacts/html/thyro.html
Thyroid Cancer

• American Cancer Society’s estimates for thyroid cancer in the
United States for 2019 are:

• 52,070 new cases of thyroid cancer (14,260 in men & 37,810 in
women)

• 2,170 deaths from thyroid cancer (1,020 men and 1,150
women)

• The death rate from thyroid cancer has increased slightly, but
remains very low compared with most other cancers.

• Thyroid cancer is commonly diagnosed at a younger age than
most other adult cancers.

• Women 3X more likely to develop thyroid cancer than men.

• Thyroid cancer is the most rapidly increasing cancer in the US. It
has tripled in the past three decades. (UTZ: detect nodules better)
US Thyroid Cancer Statistics
https://www.cancer.org/cancer/thyroid-cancer/about/key-statistics.html

WHO: International Agency for Research on Cancer
Globocan 2018 (World Incidence)
https://gco.iarc.fr/today/data/factsheets/populations/608-philippines-fact-sheets.pdf
More common in Females
Relatively lower mortality rate

WHO: International Agency for Research on Cancer
Globocan 2018 (Philippine Data)
https://gco.iarc.fr/today/data/factsheets/populations/608-philippines-fact-sheets.pdf
• Thyroid Cancer is the #7 most common cancers reported
in the Philippines. Overall incidence of 4.2 % among
reported cancers.

Clinicopathological, Biochemical, and Sonographic Features of
Thyroid Nodule Predictive of Malignancy among Adult Filipino
Patients in a Tertiary Hospital in the Philippines
Endocrinol Metab (Seoul). 2014 Dec 29;29(4):489-97.
• . . physical findings of firm to hard thyroid nodules, and
sonographic findings of microcalcifications and irregular
margins were significantly predictive of thyroid malignancy.

Well-Differentiated Thyroid Cancer: The Philippine
General Hospital Experience
Endocrinol Metab (Seoul). 2016 Mar;31(1):72-9.
• PTC among Filipinos was associated with a more
aggressive and recurrent behavior. FTC among Filipinos
appeared to behave similarly with other racial groups.

• Papillary Thyroid Cancer among Filipinos occur at a younger
age, with larger tumors, higher degree of distant metastasis at
presentation & higher recurrence rate (aggressive and recurrent)

• Follicular Thyroid Cancer among Filipinos presents at a young
age, with high recurrence rates, behaving similarly to other
racial groups. (recurrent)

• Overall prognosis and survival rates are excellent with well
diﬀerentiated Thyroid Disease.

• Timely diagnosis and treatment of thyroid cancer are therefore
of the utmost importance to reduce recurrence rates.
Well-Differentiated Thyroid Cancer: The Philippine
General Hospital Experience
Endocrinol Metab (Seoul). 2016 Mar;31(1):72-9.

Poorly Differentiated Thyroid Carcinoma: 10-Year
Experience in a Southeast Asian Population
Endocrinol Metab (Seoul). 2017 Jun;32(2):288-295.
• PDTC Filipinos compared with other similar patients showed
higher mean age and larger tumor size at presentation.

• Filipino PDTC median age was 62 years old, with the majority
being females, goiter on presentation, and most were stage
IV at the time of diagnosis.

• 5-year survival rate was 83%. Surgery provided excellent 5-
year survival rates, but the role of adjuvant therapy remains
unclear.

• Behavior of PDTC in this Southeast Asian population was
found to be similar to patterns observed in other regions, and
exhibited intermediate features between WDTC and ATC.
Poorly Differentiated Thyroid Carcinoma: 10-Year
Experience in a Southeast Asian Population
Endocrinol Metab (Seoul). 2017 Jun;32(2):288-295.

• Recommended patient profiles for targeted thyroid disease case
finding in women seeking pregnancy or newly pregnant

• Women over age 30 yr ; Women with a goiter ; Women with infertility

• Familial history or autoimmune thyroid disease or hypothyroidism

• With thyroid antibodies, primarily thyroid peroxidase antibodies

• With symptoms or clinical signs suggestive of thyroid hypofunction

• With type 1 DM or other autoimmune disorders

• With a prior history of miscarriage or preterm delivery

• With prior therapeutic head or neck irradiation or prior thyroid surgery

• Women currently receiving levothyroxine replacement

• Women living in a region with presumed iodine deficiency
Management of Thyroid Dysfunction during Pregnancy and
Postpartum: An Endocrine Society Clinical Practice Guideline
The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 8, 1 August 2012, Pages 2543–2565

• Thyroid problems during pregnancy
• Management of hypothyroidism: maternal and fetal aspects

• Management of hyperthyroidism: maternal and fetal aspects

• Gestational hyperemesis and hyperthyroidism

• Autoimmune thyroid disease and miscarriage

• Thyroid nodules and cancer

• Iodine nutrition during pregnancy

• Postpartum thyroiditis

• Screening for thyroid dysfunction during pregnancy

• Overt hypothyroidism occurs in 0.3–0.5% of pregnancies,
and SCH occurs in 2–3%.

• The prevalence of hyperthyroidism in pregnancy ranges from
0.1 to 0.4%, with Graves' disease accounting for 85% of
cases.

• A 2- to 5-fold increased risk of miscarriage has been found
in unselected populations of euthyroid women with
autoimmune thyroid disease.

• Thyroid nodule in pregnancy with limited data suggest that
the malignancy rate is either similar to or possibly greater
than that seen in the general population.

• Overt hyperthyroidism is relatively uncommon during
pregnancy, occurring in 0.1 to 0.4 percent of all pregnancies.
Most common cause is Grave’s Disease.

• Clinical manifestations similar to non pregnant hyperthyroid.

• Transient subclinical hyperthyroidism in the first trimester of
pregnancy is considered a normal physiologic finding.

• Need to differentiate Graves' disease from hCG-mediated
hyperthyroidism in the first Trimester (self-limiting).

• PTU preferred for 1st trimester then shift to Methimazole.
Thyroid Disease in Pregnancy - Hyperthyroidism
Uptodate 2019

• Iodine nutrition needs to be adequate.

• Most common cause of hypothyroidism is Chronic Thyroiditis.

• Universal screening of asymptomatic pregnant women for
hypothyroidism during the ﬁrst trimester of pregnancy is
controversial. (Consider cost, Medical History)

• TPO antibodies in euthyroid pregnant treatment with
levothyroxine remain controversial. (No consensus)

• Treat overt hypothyroidism in Pregnancy to prevent maternal
and fetal complications.
Thyroid Disease in Pregnancy - Hypothyroidism
Uptodate 2019

• 12.5% of the patients had subclinical hypothyroidism (N=101)

• No statistically signiﬁcant diﬀerence among the group of
levothyroxine treated hypothyroid patients versus euthyroid
women in documented complications of pregnancy.

• Preterm delivery occurred in 2 (10%) patients with TSH > 4
mIU/L and post-term delivery in 2 (2.5%) patients with TSH
2.5-4.0 mIU/L (p=0.010)

• Seven (8.6%) small for gestational age (SGA) infants and
two (2.5%) large for gestational age (LGA) infants were also
delivered in patients with TSH 2.5-4.0 mIU/L
Maternal and Perinatal Outcomes of Levothyroxine Treatment in
Pregnant Patients with Subclinical Hypothyroidism: A Single-
Center, Prospective Cohort Study (Unpublished)
Lim-Pacoli M, et. Al. Maternal and Perinatal Outcomes of Levothyroxine Treatment in Pregnant Patients with
Subclinical Hypothyroidism: A Single-Center, Prospective Cohort Study

Pregnancy Related Thyroid Disease

Philippine Thyroid Disease Key Points
• Thyroid Disease Prevalence 8.53%, Goiter Prevalence 8.9%.

• Subclinical Thyroid Disease are more common than overt.

• Thyroid nodules with high risk of malignancy are generally
asymptomatic with firm or hard nodule, imaging with
microcalcifications and irregular borders

• Papillary Thyroid Cancer more aggressive among Filipinos.
Differentiated thyroid cancer with excellent prognosis and
survival rate when managed accordingly.

• Poorly Differentiated Thyroid Cancer larger with higher mean
age of presentation. 5 year survival rate >80%.

• Thyroid Disease in Pregnancy are a significant subset of
patients that require follow up and appropriate treatment.

2019-5-22 PTA - Philippine Thyroid Summit

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