Understanding surgical decision-making in older adults with differentiated thyroid cancer: A discrete choice experiment

Controversies in the Management of Intermediate-Risk Differentiated Thyroid Cancer

BACKGROUND

Intermediate-risk thyroid cancer accounts for up to two-thirds of all cases of differentiated thyroid cancer (DTC), yet it is subject to substantial variations in risk stratification and management strategies.

METHODS

This comprehensive review examines the current controversies regarding diagnosis and management of intermediate risk DTC.

RESULTS

The evolution of risk stratification systems is discussed, highlighting limitations such as heterogeneity in patient cohorts, variability in outcome definitions, and the need for more precise risk estimation tools incorporating genetic profiles and individual risk modifiers. The role of radioactive iodine therapy in intermediate-risk DTC is examined, considering evolving evidence, conflicting study results, and the necessity for personalized treatment decisions based on risk modifiers, potential morbidity, and patient preferences. Furthermore, the shift from total thyroidectomy to lobectomy in certain intermediate-risk cases is explored, emphasizing the need for tailored surgical approaches and the impact on long-term outcomes, recurrence rates, and quality of life.

CONCLUSION

Management of intermediate-risk DTC remains controversial. This review summarizes current evidence to aid decision-making. Further research, prospective trials, and collaboration are crucial to address these complexities and personalize care for patients.

Perception of risk and treatment decisions in the management of differentiated thyroid cancer

BACKGROUND AND OBJECTIVES

The recent de-escalation of care for differentiated thyroid cancer (DTC) has broadened the range of initial treatment options. We examined the association between physicians' perception of risk and their management of DTC.

METHODS

Thyroid specialists were surveyed with four clinical vignettes: (1) indeterminate nodule (2) tall cell variant papillary thyroid cancer (PTC), (3) papillary thyroid microcarcinoma (mPTC), and (4) classic PTC. Participants judged the operative risks and likelihood of structural cancer recurrence associated with more versus less aggressive treatments. A logistic mixed effect model was used to predict treatment choice.

RESULTS

Among 183 respondents (13.4% response rate), 44% were surgical and 56% medical thyroid specialists. Risk estimates and treatment recommendation varied markedly in each case. Respondents' estimated risk of 10-year cancer recurrence after lobectomy for a 2.0-cm PTC ranged from 1% to 53% (interquartile range [IQR]: 3%-12%), with 66% recommending lobectomy and 34% total thyroidectomy. Respondents' estimated 5-year risk of metastastic disease during active surveillance of an 0.8-cm mPTC ranged from 0% to 95% (IQR: 4%-15%), with 36% choosing active surveillance. Overall, differences in perceived risk reduction explained 10.3% of the observed variance in decision-making.

CONCLUSIONS

Most of the variation in thyroid cancer treatment aggressiveness is unrelated to perceived risk of cancer recurrence.

Pros and cons of hemi-thyroidectomy for low-risk differentiated thyroid cancer

The debate regarding the surgical management of low-risk differentiated thyroid cancer (DTC) is ongoing. The recommended extent of surgery in DTC is based on an assessment of the predicted risk of recurrence and recent guidelines reflect an evolving philosophy of de-escalation of surgical management, informed by a growing understanding of the determinants of tumour biology and important prognostic factors. However, our current clinical and pathological risk stratification processes are imperfect and hence there is significant variation in clinical practice. Surgeons face the challenge of finding the balance between avoiding overtreatment, minimizing complications and providing adequate oncological management. This article discusses the nuances of the current management guidelines as well as the important considerations in preoperative decision making.