Clinical and professional ethics guidelines for the practice of thyroidology

Active surveillance is a feasible and safe strategy in selected patients with papillary thyroid cancer and suspicious cervical lymph nodes detected after thyroidectomy

Objective

After initial treatment, up to 30% of patients with papillary thyroid cancer (PTC) have incomplete response, mainly cervical lymph node (LN) disease. Previous studies have suggested that active surveillance (AS) is a possible option for these patients. Our aim was to report the results of AS in patients with PTC and cervical LN disease.

Materials and methods

In this retrospective observational study, we included adult patients treated and followed for PTC, who presented with cervical LN disease and were managed with AS. Growth was defined as an increase ≥ 3mm in either diameter.

Results

We included 32 patients: 27 (84.4%) women, age of 39 ± 14 years, all initially treated with total thyroidectomy, and 22 (69%) with therapeutic neck dissection. Cervical LN disease was diagnosed 1 year (0.3-12.6) after initial management, with a diameter of 9.0 mm (6.0-19.0). After a median AS of 4.3 years (0.6-14.1), 4 (12.5%) patients had LNgrowth: 2 (50%) of whom were surgically removed, 1 (25%) was effectively treated with radiotherapy, and 1 (25%) had a scheduled surgery. Tg increase was the only predictive factor of LN growth evaluated as both the delta Tg (p < 0.0366) and percentage of Tg change (p < 0.0140). None of the included patients died, had local complications due to LN growth or salvage therapy, or developed distant metastases during follow-up.

Conclusion

In selected patients with PTC and suspicious cervical LNs diagnosed after initial treatment, AS is a feasible and safe strategy as it allows effective identification and treatment of the minority of patients who progress.

The outcomes and prognostic factors of patients who underwent reoperation for persistent/recurrent papillary thyroid carcinoma

BACKGROUND

While the most suitable approach for treating persistent/recurrent papillary thyroid carcinoma (PTC) remains controversial, reoperation may be considered an effective method. The efficacy of reoperation in patients with locoregional persistent/recurrent PTC, especially those with unsatisfactory radioactive iodine (RAI) ablation results, is still uncertain. This study aimed to clarify the clinical management strategies for locoregional persistent/recurrent PTC and to explore factors that may affect long-term patient outcomes after reoperation.

METHODS

In total, 124 patients who initially underwent thyroidectomy and variable extents of RAI therapy and finally received reoperation for locoregionally persistent/recurrent PTC were included. The parameters associated with recurrence-free survival (RFS) were analysed using a Cox proportional hazards model.

RESULTS

Overall, 124 patients presented with structural disease after initial therapy and underwent secondary surgical resection, of whom 32 patients developed further structural disease during follow-up after reoperation. At the time of reoperation, metastatic lymph nodes with extranodal extension (P = 0.023) and high unstimulated thyroglobulin (unstim-Tg) levels after reoperation (post-reop) (P = 0.001) were independent prognostic factors for RFS. Neither RAI avidity nor the frequency and dose of RAI therapies before reoperation affected RFS.

CONCLUSIONS

Reoperation is an ideal clinical treatment strategy for structural locoregional persistent/recurrent PTC, and repeated empirical RAI therapies performed prior to reoperation may not contribute to the long-term outcomes of persistent/recurrent PTC patients. Metastatic lymph nodes with extranodal extension and post-reop unstim-Tg > 10.1 ng/mL may predict a poor prognosis.

Are American follow-up recommendations in endocrinology actionable? A systematic review of clinical practice guidelines

PURPOSE

Clinical guidelines include recommendations to guide patient's longitudinal care. These recommendations may differ in content and quality of supporting evidence from those guiding diagnosis and treatment. We aimed to identify recommendations guiding the follow-up of patients with endocrine conditions, describe their content and quality of evidence.

METHODS

We systematically assessed the Endocrine Society and the American Thyroid Association clinical guidelines and identified recommendations guiding follow-up strategies to evaluate direction, content, strength, and quality of evidence.

RESULTS

Out of 1540 recommendations, 138(8.9%) guided follow-up strategies. From these, 109 (79%) recommendations included goal of follow-up, 121(97.7%) suggested follow-up methods, and 56 (40.6%) a specific monitoring frequency. A total of 76 (55.1%) assessed treatment response, 65 (47.1%) disease progression, and 30 (21.7%) side effects. A total of 90 (65.2%) described the use of laboratory studies, 30 (21.7%) clinical exam/history, and 27 (19.6%) imaging studies. Finally, 91 (65.9%) suggested a monitoring time interval and 42 (30.4%) directed an action based on results. Most recommendations [88 (55.3%)] were based on low/very low-quality evidence. A total of 73 (52.9%) recommendations were labeled as strong, from which 12% were based on high-quality evidence.

CONCLUSIONS

One out of ten clinical recommendations for endocrine conditions guide follow-up and their content is variable. More than half of the follow-up recommendations are supported by low/very low-quality evidence and the majority does not provide an action threshold. A specific framework for developing follow-up recommendations can aid guideline panelists and support evidence-based monitoring.

2019 European Thyroid Association Guidelines for the Treatment and Follow-Up of Advanced Radioiodine-Refractory Thyroid Cancer

The vast majority of thyroid cancers of follicular origin (TC) have a very favourable outcome, but 5-10% of cases will develop metastatic disease. Around 60-70% of this subset, hence less than 5% of all patients with TC, will become radioiodine refractory (RAI-R), with a significant negative impact on prognosis and a mean life expectancy of 3-5 years. Since no European expert consensus or guidance for this challenging condition is currently available, a task force of TC experts was nominated by the European Thyroid Association (ETA) to prepare this document based on the principles of clinical evidence. The task force started to work in September 2018 and after several revision rounds, prepared a list of recommendations to support the treatment and follow-up of patients with advanced TC. Criteria for advanced RAI-R TC were proposed, and the most appropriate diagnostic tools and the local, systemic and palliative treatments are described. Systemic therapy with multikinase inhibitors is fully discussed, including recommendations on how to start it and at which dosage, on the duration of treatment, and on the management of side effects. The appropriate relationship between the specialist and the patient/family as well as ethical issues are covered. Based on the available studies and on personal experience, the experts provided 39 recommendations aimed to improve the management of advanced RAI-R TCs. Above all of them is the indication to treat and follow these patients in a specialized setting which allows the interaction between several specialists in a multidisciplinary team.

American Thyroid Association Guidelines and Statements: Past, Present, and Future

BACKGROUND

The American Thyroid Association (ATA) is continually striving to improve the quality of its publications. The ATA Guidelines Policies and Procedures Task Force was active during 2017. It recently recommended convening a formal standing committee to review and update policies and procedures for the development of clinical practice guidelines (CPGs) and Statements on an ongoing basis.

OBJECTIVE

This statement reviews the history of official ATA publications and discusses the challenges and findings identified by the Task Force. We also wish to present our "work in progress" and propose future directions for the new ATA Guidelines and Statements Committee (ATA GSC).

METHODS

Our Task Force reviewed the publication record of the ATA with respect to CPGs. We also reviewed existing ATA policies for CPGs and other official statements, examined policies of other organizations, solicited input from external experts and organizations, and convened five conference calls and two in-person meetings.

RESULTS

The ATA has a rich history of developing official publications that have been influential based on download and citation records as well as changes in practice trends. Key future issues to be further addressed by the ATA GSC include the following: (i) striving to improve the methodologic rigor of development of CPGs while balancing considerations of feasibility and timeliness and the role of transparently communicated expert opinion; (ii) formalizing a framework and process for development of new Statements; (iii) increasing stringency and transparency of management of competing interests of individuals being considered for CPG/Statement panel membership; (iv) encouraging consideration of equity and diversity in CPG/Statement development group composition; (v) increasing relevant stakeholder representation (including patient representatives) in development of CPGs/Statements; and (vi) expanding future guideline implementation strategies.

CONCLUSIONS

As shown by the completed literature search, the ATA has a long history of producing CPGs and Statements with global impact on informing clinical management, education, and research in thyroid diseases. The ATA remains committed to a process of continual improvement of its publications and to meeting stakeholder information needs. Based on the work of our Task Force, we have identified many elements that are needed to achieve this goal and areas of challenge for our new committee.

Latent Hypothyroidism in Adults

BACKGROUND

The prevalence of latent/subclinical hypothyroidism is between 3% and 10%, according to epidemiologic studies that have been carried out in the USA, the United Kingdom, and Denmark. As persons with latent hypo - thyroidism are often asymptomatic, the diagnosis is often made incidentally in routine laboratory testing.

METHODS

This review is based on a selective search in PubMed for publications on the diagnosis and treatment of latent hypothyroidism. All pertinent articles and guidelines published from 1 January 2000 to 31 July 2016 were included.

RESULTS

The diagnosis of latent hypothyroidism is generally assigned after repeated measurement of a TSH concentration above 4.0 mU/L in a person whose fT4 concentration is in the normal range. The most common cause is autoimmune thyroiditis, which can be detected by a test for autoantibodies. L-thyroxin supplementation is a controversial matter: its purpose is to prevent the development of overt hypothyroidism, but there is a danger of overtreatment, which increases the risk of fracture. To date, no benefit of L-thyroxin supplementation has been demonstrated with respect to morbidity and mortality, health-related quality of life, mental health, cognitive function, or reduction of overweight. There is, however, evidence of a beneficial effect on cardiac function in women, and on the vascular system. At present, treatment is generally considered indicated only if the TSH level exceeds 10.0 mU/L.

CONCLUSION

Limited data are available on the relevant clinical endpoints and undesired side effects of supplementation therapy. Physicians should advise patients about the indications for such treatment on an individual basis after due consideration of the risks and benefits.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

The Ethics of Breast Surgery

Breast surgery has evolved as a subspecialty of general surgery and requires a working knowledge of benign and malignant diseases, surgical techniques, shared decision-making with patients, collaboration with a multi-disciplinary team, and a basic foundation in surgical ethics. Ethics is defined as the practice of analyzing, evaluating, and promoting best conduct based upon available standards. As new information is obtained or as cultural values change, best conduct may be re-defined. In 2014, the Ethics Committee of the ASBrS acknowledged numerous ethical issues, specific to the practice of breast surgery. This independent review of ethical concerns was created by the Ethics Committee to provide a resource for ASBrS members as well as other surgeons who perform breast surgery. In this review, the professional, clinical, research and technology considerations that breast surgeons face are reviewed with guidelines for ethical physician behavior.

The limits of autonomy in thyroid oncology

Abstract: 

It is widely believed that respecting patient autonomy obligates practitioners to accede to all patients’ preferences and requests regardless of potential consequences to their health or to the professional integrity of the practitioner. This is a false belief that misrepresents the basic theoretical concepts surrounding the principles of autonomy and respect for persons, which must be balanced with other core medical ethical principles. There are many situations in which there are limits to autonomy. This clinical ethics article, intended for clinicians, will discuss various conditions in which autonomy-limiting principles and concepts apply, which are specific to the thyroid oncology context. The ethical and legal obligations of thyroid oncologists in such situations will also be explored.

Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance

BACKGROUND

The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for management of recurrent and persistent cervical nodal disease in patients with differentiated thyroid cancer (DTC) and to review the risks and benefits of surgical intervention versus active surveillance.

METHODS

A writing group was convened by the Surgical Affairs Committee of the American Thyroid Association and was tasked with identifying the important clinical elements to consider when managing recurrent/persistent nodal disease in patients with DTC based on the available evidence in the literature and the group's collective experience.

SUMMARY

The decision on how best to manage individual patients with suspected recurrent/persistent nodal disease is challenging and requires the consideration of a significant number of variables outlined by the members of the interdisciplinary team. Here we report on the consensus opinions that were reached by the writing group regarding the technical and clinical issues encountered in this patient population.

CONCLUSIONS

Identification of recurrent/persistent disease requires a team decision-making process that includes the patient and physicians as to what, if any, intervention should be performed to best control the disease while minimizing morbidity. Several management principles and variables involved in the decision making for surgery versus active surveillance were developed that should be taken into account when deciding how best to manage a patient with DTC and suspected recurrent or persistent cervical nodal disease.

Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement

BACKGROUND

A number of recent advances in our understanding of thyroid physiology may shed light on why some patients feel unwell while taking levothyroxine monotherapy. The purpose of this task force was to review the goals of levothyroxine therapy, the optimal prescription of conventional levothyroxine therapy, the sources of dissatisfaction with levothyroxine therapy, the evidence on treatment alternatives, and the relevant knowledge gaps. We wished to determine whether there are sufficient new data generated by well-designed studies to provide reason to pursue such therapies and change the current standard of care. This document is intended to inform clinical decision-making on thyroid hormone replacement therapy; it is not a replacement for individualized clinical judgment.

METHODS

Task force members identified 24 questions relevant to the treatment of hypothyroidism. The clinical literature relating to each question was then reviewed. Clinical reviews were supplemented, when relevant, with related mechanistic and bench research literature reviews, performed by our team of translational scientists. Ethics reviews were provided, when relevant, by a bioethicist. The responses to questions were formatted, when possible, in the form of a formal clinical recommendation statement. When responses were not suitable for a formal clinical recommendation, a summary response statement without a formal clinical recommendation was developed. For clinical recommendations, the supporting evidence was appraised, and the strength of each clinical recommendation was assessed, using the American College of Physicians system. The final document was organized so that each topic is introduced with a question, followed by a formal clinical recommendation. Stakeholder input was received at a national meeting, with some subsequent refinement of the clinical questions addressed in the document. Consensus was achieved for all recommendations by the task force.

RESULTS

We reviewed the following therapeutic categories: (i) levothyroxine therapy, (ii) non-levothyroxine-based thyroid hormone therapies, and (iii) use of thyroid hormone analogs. The second category included thyroid extracts, synthetic combination therapy, triiodothyronine therapy, and compounded thyroid hormones.

CONCLUSIONS

We concluded that levothyroxine should remain the standard of care for treating hypothyroidism. We found no consistently strong evidence for the superiority of alternative preparations (e.g., levothyroxine-liothyronine combination therapy, or thyroid extract therapy, or others) over monotherapy with levothyroxine, in improving health outcomes. Some examples of future research needs include the development of superior biomarkers of euthyroidism to supplement thyrotropin measurements, mechanistic research on serum triiodothyronine levels (including effects of age and disease status, relationship with tissue concentrations, as well as potential therapeutic targeting), and long-term outcome clinical trials testing combination therapy or thyroid extracts (including subgroup effects). Additional research is also needed to develop thyroid hormone analogs with a favorable benefit to risk profile.

Ethical issues in the management of thyroid disease

The focus of this article is on clinical ethics issues in the thyroid disease context. Clinical ethics is a subspecialty of bioethics that deals with bedside ethical dilemmas that specifically involve the provider-patient relationship. Such issues include consent and capacity; weighing therapeutic benefits against risks and side-effects; innovative therapies; end of life care; unintended versus intentional harms to patients or patient populations; and healthcare access. This article will review core ethical principles for practice, as well as the moral and legal requirements of informed consent. It will then discuss the range of unique and universal ethical issues and considerations that present in the management of autoimmune thyroid disease and thyroid cancer.

Identifying predictors of a difficult thyroidectomy

BACKGROUND

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

METHODS

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P<0.05) variables from a univariate analysis.

RESULTS

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P=0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P=0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P=0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23-15.36, P=0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28-9.66, P=0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06-6.42, P=0.037) were independently associated with DT.

CONCLUSIONS

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.