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Introduction To minimize recurrence risk in differentiated thyroid cancer (DTC), TSH is usually lifelong suppressed with levothyroxine. A common consequence of this treatment is subclinical hyperthyroidism which can induce cardiovascular disease (CV). This study’s aim was to compare CV incidence in DTC patients with the general population in Sweden. Materials and methods All Swedish patients diagnosed with DTC in 1987–2013 were included in the cohort study. Lifelong TSH suppression treatment was assumed to be administered to patients in compliance with prevalent national guidelines. Patients were followed from 1 year after DTC diagnosis until December 31, 2014, death, or migration. The event of interest was hospitalization due to any of the following diseases: atrial fibrillation (AF), cerebrovascular disease, cerebral infarction, ischemic heart disease, ischemic heart attack, and heart failure. Standardized incidence ratios (SIRs) were calculated to compare CV incidence between DTC patients and the general population. Results The cohort consisted of 6900 patients with DTC. Hospitalization was increased among DTC patients for AF (SIR 1.66, CI 95% 1.41–1.94), and women faced increased hospitalization for cerebrovascular disease (SIR 1.20 CI 95% 1.04–1.38). Regarding the remaining CV diseases, no consistent difference in SIR between the groups was observed. Conclusion Compared to the general population, DTC patients have a higher incidence in AF, and female face a slightly higher incidence in cerebrovascular disease. However, there was no difference in hospitalization for other studied CV diseases between DTC patients and the general population.

BackgroundDifferentiated thyroid cancer (DTC) accounts for over 90% of all thyroid malignancies, and is typically treated with a total thyroidectomy and radioactive iodine (RAI) to eliminate both macro- and microscopic cancer tissue. After these procedures, patients require levothyroxine to substitute for loss of thyroid hormones. Thyroid stimulating hormone (TSH) stimulates proliferation of both healthy and malignant thyroid cells and is suppressed by high doses of levothyroxine. Therefore, levothyroxine is administered in suppressive doses, which by definition induces a state of subclinical hyperthyroidism. This condition, when present in thyroid diseases other than DTC, is associated with negative health outcomes including cardiovascular disease. Furthermore, cancer patients are in general more susceptible to mental health challenges, such as anxiety disorders. Additionally, the TSH suppression treatment can cause symptoms, such as heart palpitations among others, which are also common in anxiety disorders. One specific form of anxiety, called health anxiety, involves an excessive preoccupation with interpreting bodily signals and connecting them to somatic illness. Therefore, it is plausible that DTC patients may be more vulnerable to this type of anxiety, however no previous research has investigated this question.This thesis investigated cardiovascular disease and health anxiety in patients with DTC, placing a particular emphasis on providing explanations on how the TSH suppression treatment can affect these outcomes.Study 1 and Study 2In Study 1 and Study 2, we analysed cardiovascular mortality and incidence by investigating individuals diagnosed with DTC in Sweden between 1987 and 2013. Patients were followed from one year after DTC diagnosis until death, migration or December 31, 2014 (last study date). The data were obtained from nationwide healthcare registries that included information on hospitalization, cancer disease, causes of death, as well as data on migration. DTC patients were identified from the Swedish Cancer Registry and were assumed to be on lifelong TSH suppression treatment as according to prevalent guidelines during the study period. Six cardiovascular endpoints were considered separately (atrial fibrillation, cerebral infarction, cerebrovascular disease, ischemic heart attack, ischemic heart disease, and heart failure) as well as all the six endpoints combined. Only individuals who remained in the cohort for at least one year after DTC diagnosis were included in the final study cohort. The mortality (incidence) rates in the DTC cohort were compared to the ones of the general population by calculating standardized mortality ratios (SMRs) and standardized incidence ratios (SIRs), respectively.We identified 6900 patients that were diagnosed with DTC, survived, and did not emigrate for at least one year after diagnosis. Study 1 did not find differences in mortality rates in the DTC cohort as compared to the rates found in the general population, when considering all cardiovascular endpoints combined. However, a gender difference was observed, with DTC males having a slightly elevated mortality rate compared to males in the general population (SMR 1.16 CI, 95% 1.02-1.31). When investigating specific cardiovascular endpoints, the whole DTC cohort displayed an increased mortality rate of atrial fibrillation (AF) in comparison to the general population (SMR 1.36, CI 95% 1.12-1.64). In study 2, analyses of SIRs revealed a higher incidence rate of AF for the entire DTC cohort as compared to the rate of the general population (SIR 1.66, CI 95% 1.41–1.94).

Differentiated thyroid cancer (DTC) has a good prognosis; however, patients often need lifelong follow up, and they face potential side effects. The aim of this study was to investigate health anxiety among DTC patients and its relationship to TSH suppression. In 2020, patients from a previous cohort who were from Stockholm completed the 14-item Short Health Anxiety Inventory (SHAI-14; 0–42; 18 being the threshold for clinical significance) and a study-specific questionnaire. Clinical information was also retrieved from medical records. Linear regression was used to investigate the relationship between the TSH levels and the SHAI-14, while adjusting for potential confounders. In total, 146 (73%) patients were included. A total of 24 respondents (16%) scored 18 or more on the SHAI-14, and the mean score was 11.3. Patients with TSH levels of 0.1–0.5 (mE/L) scored, on average, 3.28 points more (p-value 0.01) on the SHAI-14 compared to patients with TSH levels > 0.5. There was no statistically significant difference between patients with TSH levels < 0.1 and TSH levels > 0.5. Thus, we found no linear relationship between the TSH values and health anxiety. Clinically significant levels of health anxiety are slightly higher than those in the general population, but do not appear to be a major psychiatric comorbidity among patients with DTC.