Thyroid Cancer Treatment Choice: A Pilot Study of a Tool to Facilitate Conversations with Patients with Papillary Microcarcinomas Considering Treatment Options

Thyroid Cancer Risk Communication in Patients with Thyroid Nodules

The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.

Operative Management of Thyroid Disease in Older Adults

As the population ages, both domestically and globally, clinicians will increasingly find themselves navigating treatment decisions for thyroid disease in older adults. When considering surgical treatment, individualizing risk assessment is particularly important, as older patients can present with very different health profiles. While fit, independent individuals may benefit from thyroidectomy with minimal risk, those with multiple comorbidities and poor functional status are at higher risk of perioperative complications, which can have adverse health effects and detract from long-term quality of life. In order to optimize surgical outcomes for older adults, strategies for accurate risk assessment and mitigation are being explored. Surgical decision-making also should consider the characteristics of the thyroid disease being treated, given many benign thyroid disorders and some well-differentiated thyroid cancers can be appropriately managed nonoperatively without compromising longevity. Shared decision-making becomes increasingly important to respect the health priorities and optimize outcomes for older adults with thyroid disease. This review summarizes the current knowledge of thyroid surgery in older adults to help inform decision-making among patients and their physicians.

Shared Decision Making in the Care of Patients With Cancer

Shared decision making (SDM) is a method of care that is suitable for the care of patients with cancer. It involves a collaborative conversation seeking to respond sensibly to the problematic situation of the patient, cocreating a plan of care that makes sense intellectually, practically, and emotionally. Genetic testing to identify whether a patient has a hereditary cancer syndrome represents a prime example of the importance for SDM in oncology. SDM is important for genetic testing because not only results affect current cancer treatment, cancer surveillance, and care of relatives but also these tests generate both complex results and psychological concerns. SDM conversations should take place without interruptions, disruptions, or hurry and be supported, where available, by tools that assist in conveying the relevant evidence and in supporting plan development. Examples of these tools include treatment SDM encounter aids and the Genetics Adviser. Patients are expected to play a key role in making decisions and implementing plans of care, but several evolving challenges related to the unfettered access to information and expertise of varying trustworthiness and complexity in between interactions with clinicians can both support and complicate this role. SDM should result in a plan of care that is maximally responsive to the biology and biography of each patient, maximally supportive of each patient's goals and priorities, and minimally disruptive of their lives and loves.

Patient decision aids for patients with differentiated thyroid carcinoma: development process and alpha and beta testing

Background

Patient decision aids (PtDAs) are structured clinical tools that facilitate shared decision-making. Two important treatment decisions for patients with differentiated thyroid cancer (DTC), which could benefit from PtDAs, are as follows (1): the extent of surgery decision in patients with low-risk DTC and (2) the decision to start or delay starting the treatment with tyrosine kinase inhibitors (TKIs) in patients with advanced tumors.

Material and methods

PtDAs for these two decisions were developed using the International Patient Decision Aids Standards (IPDAS) quality criteria in an iterative process of prototype development via alpha and beta testing by patients and physicians. The information content of the PtDAs was based on the available literature, current guidelines, and patient's needs, preferences, and values.

Results

The web-based PtDAs underwent two rounds of alpha testing, revisions, and beta testing. The PtDAs have the same structure, consisting of six steps: a general introduction, information about the treatment options, comparing the treatment options, knowledge questions, a values clarification exercise, and saving the information. The alpha testing (n = 8 patients, n = 10 physicians) showed that the PtDAs were highly acceptable and usable for decision-making. Results of the beta testing in 20 patients showed that two patients did not use the PtDA; the other 18 patients found that the PtDAs were readable (n = 17) and helpful (n = 14) for decision-making. All patients recommend using the PtDAs.

Conclusions

Evidence-based PtDAs were created for patients with DTC for two different treatment decisions. Our final version was judged to be clear, balanced, and helpful in decision-making.

Challenges of Shared Decision-making by Clinicians and Patients With Low-risk Differentiated Thyroid Cancer: A Systematic Review and Meta-Ethnography

Importance

Several international guidelines have endorsed more conservative treatment of low-risk differentiated thyroid cancer (LRDTC), yet patients are facing more treatment options with similar oncologic outcomes and are expressing feelings of confusion, dissatisfaction, and anxiety. Shared decision-making, which considers the patient's values and preferences along with the most reliable medical evidence, has been proposed to optimize patient satisfaction in the context of the current clinical equipoise.

Objectives

To understand key individual and behavioral factors affecting the patient and clinician decision-making process in treatment decision for LRDTC.

Evidence Review

This systematic review and meta-ethnography involved a comprehensive literature search of MEDLINE, Embase, PubMed, and CINAHL databases for qualitative and mixed-method studies on patient and clinician experiences with the decision-making process for LRDTC treatment. The quality of the studies was assessed using the Mixed Methods Appraisal Tool; meta-ethnography was used for data analysis. Primary and secondary themes of the included studies were extracted, compared, and translated across articles to produce a lines-of-argument synthesis.

Findings

Of 1081 publications identified, 12 articles met the inclusion criteria. The qualitative synthesis produced 4 themes: (1) a bimodal distribution of patient preferences for treatment decisions; (2) clinician anxiety affected equipoise and biased their recommendations; (3) clinicians struggled to identify patient concerns and preferences; and (4) the clinician-patient relationship and psychosocial support were key to shared decision-making but were frequently overlooked.

Conclusions and Relevance

The findings of this systematic review and meta-ethnography emphasize the need for better patient-clinician communication, particularly with respect to eliciting patient concerns and preferences. With an ever-increasing pool of thyroid cancer survivors, future efforts should be directed at establishing and evaluating tools that will aid in shared decision-making for treatment of patients with LRDTC.

Trial Registration

PROSPERO Identifier: CRD42022286395.

Active Surveillance for Low-Risk Differentiated Thyroid Cancer

Less aggressive treatment options, including hemithyroidectomy and active surveillance, have been accepted as treatment options for low-risk small, differentiated thyroid carcinoma (DTC). Multiple studies have shown a low rate of cancer growth and lymph node metastases and no evidence of distant metastases during active surveillance of low-risk small DTC. However, not all patients with low -risk small DTC are ideal or appropriate candidate for active surveillance. Patients with thyroid cancer adjacent to either the trachea or recurrent laryngeal nerve or those with evidence of extrathyroidal extension, a high-risk molecular profile, lymph node, or distant metastases are considered inappropriate candidates for active surveillance. In addition, there are other essential factors that clinicians should consider while recommending active surveillance, including patient financial and insurance status; availability of high-quality neck ultrasounds and experienced radiologists, endocrinologists, and surgeons; and patient preference, level of anxiety, and willingness to undergo prolonged surveillance and follow-up imaging.

Psychological adjustment to initial treatment for low-risk thyroid cancer: Preliminary study

BACKGROUND

Low-risk papillary thyroid carcinoma (LR-PTC) can be managed by immediate surgery (IS) or active surveillance (AS). We compare the psychological impact of these treatments on patients with LR-PTC.

METHODS

Psychological data were collected over 1 year, with assessments at the time of treatment decision (T1), at 6 months (T2) and 12 months (T3) follow-up. Assessments included 13 validated psychological tools.

RESULTS

Of 27 enrolled patients, 20 chose AS and 7 chose IS. The average times to T2 and T3 were 5.7 and 11.3 months, respectively. For both groups, Impact of Events Scale scores significantly decreased (p = 0.001) at T2, and depressive/anxiety symptoms remained low.

CONCLUSIONS

This study demonstrates the feasibility of assessing psychological outcomes among patients treated for LR-PTC. Further studies are needed to evaluate the impact of AS versus IS on quality of life and changes that patients experience over longer time periods following their treatment decision.

What do patients want to know about surgery for low-risk thyroid cancer? A qualitative study

BACKGROUND

Shared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making.

METHODS

We identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients' questions and surgeon responses.

RESULTS

Overall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0-25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine.

CONCLUSION

Patient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients' questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.

Position paper from the Endocrine Task Force of the European Organisation for Research and Treatment of Cancer (EORTC) on the management and shared decision making in patients with low-risk micro papillary thyroid carcinoma

The incidence of differentiated thyroid cancer (DTC) has been increasing worldwide, mostly, as an increase in the incidental detection of micro papillary thyroid carcinomas (microPTCs), many of which are potentially overtreated, as suggested by the unchanged mortality. Several international guidelines have suggested a less aggressive approach. More recently, it has been shown that active surveillance or minimally invasive treatments (MIT) are good alternatives for the management of these patients. In this context, patient participation in the decision-making process is paramount. The Endocrine Task Force of the European Organisation for Research and Treatment of Cancer (EORTC) has undertaken the task to establish consensus and define its position based on the scientific evidence concerning, 1) the current state of diagnostic and management options in microPTCs, including the current opinion of physicians about shared decision making (SDM), 2) the available evidence concerning patients' needs and the available decision instruments, and 3) to provide practical suggestions for implementation of SDM in this context. To improve SDM and patients' participation, knowledge gaps and research directions were highlighted.

Factors That Inform Individual Decision Making Between Active Surveillance, Hemithyroidectomy and Total Thyroidectomy for Low-Risk Thyroid Cancer: A Scoping Review

Background: Due to the excellent prognosis and relatively high incidence of small low-risk thyroid cancers, more conservative management strategies such as active surveillance (AS) or hemithyroidectomy (HT) may be preferable to total thyroidectomy (TT) for patients seeking to balance long-term survival rates with the potential adverse effects of overtreatment. The aim of this review was to synthesize key factors or variables that inform patient decision making about treatment for low-risk thyroid cancer, from current primary investigations that presented participants with information facilitating this choice. Methods: Studies were identified from the Medline, Cochrane, and Embase databases up until March 2022. Study characteristics were extracted into a pre-piloted form. Factors were hypothesized to include treatment-related risks and possible outcomes and identified from a review of studies with consensus by discussion. Results: The search identified 444 unique studies: 397 were excluded on review of abstract and title with 47 studies undergoing a full text review and 6 studies identified to be eligible. Four were cross-sectional: one a prospective cohort study and one a mixed-methods study with both a prospective observational and qualitative component. The decisions addressed included: the choice between AS versus surgery (HT and/or TT) and HT versus TT and enrolled participants ranging from healthy volunteers to thyroid cancer patients. Treatment choice was the primary outcome in five studies. Across the studies, participants who were given the option of AS or surgery predominately chose the more conservative pathway, with a range of 70-84%. The major factors represented by information provision in the studies were risk of cancer recurrence or spread, need for hormone replacement therapy, and voice change. Conclusions: A framework of key factors informing patient treatment choice may be derived from current studies involving information provision for low-risk thyroid cancer management. Further research evaluating the efficacy and optimal timing for decision support interventions would help inform the design and clinical use of these tools to promote shared decision making.

A Cross-Sectional Survey of Patient Treatment Choice in a Multicenter Prospective Cohort Study on Active Surveillance of Papillary Thyroid Microcarcinoma (MAeSTro)

Background: Active surveillance (AS) is offered as a choice to patients with low-risk papillary thyroid microcarcinoma (PTMC). This study aimed to identify patient and physician factors associated with the choice of AS. Methods: We conducted a cross-sectional survey of patients with low-risk PTMC who were enrolled in a prospective study comparing outcomes following AS and surgery. Patients completed a questionnaire to assess their prior knowledge of the disease, considerations in the decision-making process, and reasons for choosing the treatment. We also surveyed 19 physician investigators about their disease management preferences. Variables affecting the patients' choice of AS, including patients' characteristics and their decision-making process, were analyzed in a multivariable analysis. Results: The response rate of the patient survey was 72.8% (857/1177). Among the patients who responded to the survey, 554 patients (128 male; mean age 49.4 ± 11.6 years; response rate 73.4%) with low-risk PTMC chose AS (AS group), whereas 303 patients (55 male; 46.6 ± 10.7 years; 71.8%) chose immediate surgery (iOP group). In the AS group, 424 patients (76.5%) used a decision aid, and 144 (47.5%) used it in the iOP group. The choice of AS was associated with the following variables: patient age >50 years (odds ratio 1.713 [confidence interval, CI 1.090-2.690], p = 0.020), primary tumor size ≤5 mm (odds ratio 1.960 [CI 1.137-3.379], p = 0.015), and consulting an endocrinologist (odds ratio 114.960 [CI 48.756-271.057], p < 0.001), and use of a decision aid (odds ratio 2.469 [CI 1.320-4.616], p = 0.005). The proportion of patients who were aware of AS before their initial consultation for treatment decision was higher in the AS group than in the iOP group (64.6% vs. 56.8%). Family members were reported to have influenced the treatment decisions more in the iOP group (p = 0.025), whereas the AS group was more influenced by information from the media (p = 0.017). Physicians' attitudes regarding AS of low-risk PTMC tended to be more favorable among endocrinologists than surgeons and all became more favorable as the study progressed. Conclusions: Emerging evidence suggests that physicians' attitudes and communication tools influence the treatment decision of low-risk PTMC patients. Support is needed for patient-centered decision making. (Clinical trial No: NCT02938702).

Active Surveillance Versus Immediate Surgery for Low-Risk Papillary Thyroid Microcarcinoma Patients in South Korea: A Cost-Minimization Analysis from the MAeSTro Study

Background: Active surveillance (AS) has been established as an alternative to immediate surgery for low-risk papillary thyroid microcarcinoma (PTMC). Nonetheless, it remains difficult to decide between AS and immediate surgery, since limited objective evidence exists regarding risks and benefits. The aim of study is to compare the cumulative costs of AS and immediate surgery. Methods: To estimate cumulative costs, a hypothetical model is simulated based on the Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Micro-Carcinoma (MAeSTro) study, a multicenter prospective cohort study of AS for PTMC. Direct and indirect costs are estimated from diagnosis to the treatment decision and follow-up for 10 years and a longer period. In the case of the scenarios, AS, AS to surgery due to changing their mind, and lobectomy (analyzed regardless of levothyroxine [LT4] treatment, as well as subdivided into lobectomy/LT4[-] and lobectomy/LT4[+]) are considered. A sensitivity analysis is performed using different discount rates to address uncertainties in future time costs. To compare the cumulative costs, we referred to previous research conducted in Hong Kong, the United States, and Japan. Results: The initial cost of AS is estimated to be 5.6 times lower than that of lobectomy (regardless of LT4 use), while the 10-year cumulative costs of AS ($2545) and lobectomy regardless of LT4 ($3045) are similar under a discount rate of 3%. However, in the long-term follow-up period, immediate surgery is going to be estimated more economical than AS. The costs of the two management approaches are similar in Hong Kong, but substantially different in the United States and Japan, implying that it could be affected by each country's national health insurance coverage and the thyroid ultrasound interval during follow-up. Conclusion: Considering both direct and indirect costs, the cumulative costs of AS and immediate surgery in low-risk PTMC patients are similar during 10 years, and surgery could be more economical for patients with a life expectancy in long-term follow-up. However, careful interpretation is needed for long-term follow-up and the country's health care system and environment. Nevertheless, considering the representative protocols and objective costs in South Korea, it is expected to be a key to suggest the appropriate treatment for PTMC patients.

The role of microbiota in colorectal cancer

Cancer is one of the most important causes of death throughout the world, and the mortality rate is increasing significantly due to the aging of the population. One of the most common types of cancer is colorectal cancer (CRC). Human microbial ecosystems use metabolism to make important impacts on the body physiology. An intensive literature review was made to investigate the correlations between human gut microbiota and the incidence of CRC. The results of these studies show that there are differences in the composition of microbiota between CRC patients and normal people and the microorganisms in CRC patients are very different from healthy individuals. Therefore, changes in the microbiome can be used as a biomarker for the early detection of CRC. On the other hand, the intestinal flora is may be act as a powerful weapon against CRC in the future.

Development and pilot testing of a conversation aid to support the evaluation of patients with thyroid nodules

OBJECTIVE

To support patient-centred care and the collaboration of patients and clinicians, we developed and pilot tested a conversation aid for patients with thyroid nodules.

DESIGN, PATIENT AND MEASUREMENTS

We developed a web-based Thyroid NOdule Conversation aid (TNOC) following a human-centred design. A proof of concept observational pre-post study was conducted (TNOC vs. usual care [UC]) to assess the impact of TNOC on the quality of conversations. Data sources included recordings of clinical visits, post-encounter surveys and review of electronic health records. Summary statistics and group comparisons are reported.

RESULTS

Sixty-five patients were analysed (32 in the UC and 33 in the TNOC cohort). Most patients were women (89%) with a median age of 57 years and were incidentally found to have a thyroid nodule (62%). Most thyroid nodules were at low risk for thyroid cancer (71%) and the median size was 1.4 cm. At baseline, the groups were similar except for higher numeracy in the TNOC cohort. The use of TNOC was associated with increased involvement of patients in the decision-making process, clinician satisfaction and discussion of relevant topics for decision making. In addition, decreased decisional conflict and fewer thyroid biopsies as the next management step were noted in the TNOC cohort. No differences in terms of knowledge transfer, length of consultation, thyroid cancer risk perception or concern for thyroid cancer diagnosis were found.

CONCLUSION

In this pilot observational study, using TNOC in clinical practice was feasible and seemed to help the collaboration of patients and clinicians.

Trends in the Management of Localized Papillary Thyroid Carcinoma in the United States (2000-2018)

Background: In response to evidence of overdiagnosis and overtreatment of papillary thyroid carcinoma (PTC), the 2009 and 2015 American Thyroid Association (ATA) adult guidelines recommended less extensive surgery (lobectomy vs. total thyroidectomy) and more restricted use of postsurgical radioactive iodine (RAI) in management of PTC at low risk of recurrence. In 2015, active surveillance was suggested as a viable option for some <1-cm PTCs, or microcarcinomas. The 2015 ATA pediatric guidelines similarly shifted toward more restricted use of RAI for low-risk PTCs. The impact of these recommendations on low-risk adult and pediatric PTC management remains unclear, particularly after 2015. Methods: Using data from 18 Surveillance, Epidemiology, and End Results (SEER) U.S. registries (2000-2018), we described time trends in reported first-course treatment (total thyroidectomy alone, total thyroidectomy+RAI, lobectomy, no surgery, and other/unknown) for 105,483 patients diagnosed with first primary localized PTC (without nodal/distant metastases), overall and by demographic and tumor characteristics. Results: The declining use of RAI represented the most pronounced change in management of PTCs <4 cm (44-18% during the period 2006-2018), including microcarcinomas (26-6% during the period 2007-2018). In parallel, an increasing proportion of PTCs were managed with total thyroidectomy alone (35-54% during the period 2000-2018), while more subtle changes were observed for lobectomy (declining from 23% to 17% during the period 2000-2006, stabilizing, and then rising from 17% to 24% during the period 2015-2018). Use of nonsurgical management did not meaningfully change over time, impacting <1% of microcarcinomas annually during the period 2000-2018. Similar treatment trends were observed by sex, age, race/ethnicity, metropolitan vs. nonmetropolitan residence, and insurance status. For pediatric patients (<20 years), use of RAI peaked in 2009 (59%), then decreased markedly to 11% (2018), while use of total thyroidectomy alone and, to a lesser extent, lobectomy increased. No changing treatment trends were observed for ≥4-cm PTCs. Conclusions: The declining use of RAI in management of low-risk adult and pediatric PTC is consistent with changing recommendations from the ATA practice guidelines. Post-2015 trends in use of lobectomy and nonsurgical management of low-risk PTCs, particularly microcarcinomas, were more subtle than expected; however, these trends may change as evidence regarding their safety continues to emerge.

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.

Comparison of Thermal Ablation and Surgery for Low-Risk Papillary Thyroid Microcarcinoma: A Systematic Review and Meta-Analysis

Objective

Although thermal ablation is effective in treating low-risk papillary thyroid microcarcinomas (PTMCs), comparison of treatment outcomes between thermal ablation and surgery has not yet been systematically evaluated. This study aimed to compare the efficacy and safety of thermal ablation and surgery for the treatment of low-risk PTMCs.

Materials and Methods

Ovid-MEDLINE and EMBASE databases were searched for studies reporting comparisons of treatment results between thermal ablation and surgery for patients with low-risk PTMC published up to April 6, 2020. The analysis evaluated the efficacy (local tumor recurrence, occurrence of new tumor, metastasis, and rescue surgery) and safety (complication rate) of thermal ablation and surgery.

Results

This systematic review included four studies with a total of 339 PTMCs in 339 patients who underwent thermal ablation and 320 PTMCs in 314 patients who underwent surgery. There was no local tumor recurrence or distant metastasis in either group. There was no significant difference in the pooled proportion of lymph node metastasis (2.6% with thermal ablation vs. 3.3% with surgery, p = 0.65), occurrence of new tumors (1.4% with thermal ablation vs. 1.3% with surgery, p = 0.85), or rescue surgery (2.6% with thermal ablation vs. 1.6% with surgery, p = 0.62). However, the pooled complication rate was significantly higher in the surgery group than in the ablation group (3.3% with thermal ablation vs. 7.8% with surgery, p = 0.03).

Conclusion

Both thermal ablation and surgery are effective and safe options for the management of low-risk PTMCs, with thermal ablation achieving a lower complication rate. Therefore, thermal ablation may be considered as an alternative treatment option for low-risk PTMC in patients who refuse surgery and active surveillance or are ineligible for surgery.

Psychological Distress and Sleep Disturbance Throughout Thyroid Nodule Screening, Diagnosis, and Treatment

CONTEXT

Many controversies exist regarding screening and treatment of thyroid cancer (TC), especially papillary thyroid microcarcinoma (PTMC).

OBJECTIVE

The aim of this study was to evaluate patients' psychological distress and sleep disturbance throughout thyroid nodule (TN) screening, diagnosis, and treatment.

METHODS

A total of 2834 participants (1153 participants with TNs) were enrolled during the screening phase, and 1105 individuals with TNs (87 individuals with TC) were enrolled during the diagnosis phase. Of the 87 TC patients, 66 underwent immediate operation (OP), and 21 patients with PTMC opted for active surveillance (AS). Four validated scales were applied to quantify the outcome indicators at prescreening, postscreening, postdiagnosis, and posttreatment.

RESULTS

Higher psychological distress and sleep disturbance were found postscreening than prescreening in subjects with TNs, but no differences in those without nodules. Compared with postscreening, higher scores of psychological distress and sleep disturbance were identified in patients with suspicious TC treated with fine needle aspiration (FNA) or with AS. Lower psychological distress and sleep disturbance were noted for patients with benign nodules than for TC patients. OP for TC, especially PTMC, did not alleviate psychological distress or sleep disturbance compared with the same parameters in patients who underwent AS.

CONCLUSION

Based on the findings of impaired psychological health and sleep quality, screening for TNs in adults who show no symptoms should be performed with caution. Psychological distress and sleep disturbance should also be taken into consideration when FNA is performed for suspected TC or OP for papillary thyroid cancer, especially PTMC.

Development of a Shared Decision-Making Tool for Adolescents With Scoliosis to Decide Between Observation Versus Fusion Surgery

BACKGROUND

Adolescent patients with moderate to severe idiopathic scoliosis who have completed their skeletal growth face a significant choice in their treatment path: watchful waiting or spinal fusion. Shared decision making (SDM) assists patients and clinicians to find treatments that make intellectual, practical and emotional sense. Our objective was to develop a tool that supports SDM for patients with scoliosis and their families.

METHODS

We used a user-centered design approach that included collaboration between patients, surgeons and SDM experts, observation of clinician encounters, and literature review. We focused on adolescent idiopathic scoliosis patients 13 or more years of age with less than 1 year of growth remaining (Risser stage 3 or greater) and curves between 40 and 65 degrees.

RESULTS

We included 22 patients, and collected 22 video recordings. From these videos, we identified salient patient priorities for decision making including treatment benefits, surgical complications, pain, scheduling and recovery, and cost. For each theme, we conducted a focused review to obtain the best estimate of effect. Then, an expert SDM designer developed an electronic prototype called Scoliosis Choice.

CONCLUSIONS

The initial prototype of the scoliosis SDM was finalized and is currently being field tested in clinic. Scoliosis Choice may help patients and surgeons better understand the potential risks and benefits of spinal fusion vs. observation for scoliosis treatment and improve validated measures of quality in patient-parent-surgeon communication.

Active surveillance for thyroid Cancer: a qualitative study of barriers and facilitators to implementation

BACKGROUND

The 2015 American Thyroid Association guidelines supported active surveillance (AS) as a strategy for managing select low-risk thyroid cancers. Data examining physicians' attitudes about the acceptability of this option are limited. This study aimed to characterize the barriers and facilitators to implementing AS as perceived by practicing endocrinologists and surgeons in the United States.

METHODS

We conducted 24 semi-structured interviews probing physicians' attitudes toward AS for patients with small, low-risk thyroid cancer. We used deductive content analysis guided by a well-known model of guideline implementation. Analysis characterized concepts and themes related to AS implementation as physician, guideline, or external factors. We performed member checking to validate results.

RESULTS

The most prominent barriers to AS were related to physician factors, although guideline-specific and external barriers were also observed. Physician attitudes towards AS comprised the majority of physician-related barriers, while lack of knowledge about the guideline was also discussed. Participants' concerns about the potential negative outcomes resulting from observing a cancer were notable as were the lack of confidence in performing and offering surveillance. Beliefs about patient expectations and lack of knowledge about the guideline were also identified as barriers to offering surveillance. Guideline-specific and external barriers included the vagueness of surveillance protocols, lack of data supporting active surveillance, and societal beliefs about cancer. Facilitators of active surveillance included patients' desire to avoid surgery and shared decision-making.

CONCLUSIONS

Barriers and facilitators of active surveillance for low-risk thyroid cancers exist at multiple levels. Strategies to increase adoption of active surveillance should focus on physicians' attitudes, patient expectations, data supporting surveillance outcomes, and promoting societal-level acceptance of surveillance.

Management of Sonographically Suspicious Thyroid Nodules 1 cm or Smaller and Candidacy for Active Surveillance: Experience of a Tertiary Center in China

OBJECTIVE

Our objective was to investigate the management of patients with asymptomatic suspicious thyroid nodules ≤1 cm.

METHODS

We retrospectively reviewed medical records of patients with sonographically suspicious thyroid nodules ≤1 cm and without distant metastases, suspicious lymph node metastasis (LNM), or extrathyroidal extension (ETE).

RESULTS

Of the 386 enrolled patients, 174 (45.1%) had immediate surgery (IS), while 212 (54.9%) underwent active surveillance (AS). In the IS group, 166 (95.4%) patients were confirmed as having papillary thyroid microcarcinoma. LNM and ETE were observed in 24.7% and 2.4% cases, respectively. In the AS group, nodule size increased by ≥3 mm in 11 (5.2%) patients and 39 (18.4%) had a >50% increase in nodule volume after a median follow-up of 12 months. Nodules with smaller volume at diagnosis were more likely to increase in volume later. Newly suspicious LNM was detected in 23 (10.8%) patients. Delayed surgery (DS) was performed in 101 patients, with 27 showing disease progression. ETE and LNM were detected in 3% and 36%, respectively, of patients with papillary thyroid microcarcinoma. Compared with IS, tumors in the DS group more frequently showed lateral LNM and capsular invasion (P < .05). No patient had recurrence or died of thyroid cancer during postoperative follow-up (median 26 [4-60] months).

CONCLUSIONS

IS or DS of patients with asymptomatic suspicious thyroid nodules ≤1 cm was relatively high in China. The inertia of low-risk nodules and the effectiveness of DS for those that progressed make AS a feasible strategy.

Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer

BACKGROUND

The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC.

METHODS

We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS).

RESULTS

The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS.

CONCLUSIONS

Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.

Thyroid nodules 1 cm or less are related to Bethesda System nondiagnostic and suspicious for malignancy categories

OBJECTIVE

To compare the frequency of fine needle aspiration (FNA) cytological results between nodules 1 cm or less and nodules greater than 1 cm.

METHODS

All FNAs performed between January 2016 and December 2019 at an institute in Brazil were analysed. For each nodule, at least two conventional slides were produced (one stained by Giemsa and the other by hematoxylin and eosin). All cases were reviewed by two cytopathologists and were reported following the Bethesda System. Clinical information (gender and age) and ultrasound data (nodule size and location) were collected. The magnitude of association was measured using the prevalence ratio (PR) with 95% confidence intervals (CIs) considering two groups of nodules: 1.0 cm or less, and greater than 1 cm.

RESULTS

A total of 3703 nodules were analysed from 3265 patients (2906 women [88.48%], 359 men [11.51%], with a combined mean age of 52 years). Considering the prevalence ratio of Bethesda categories between these two groups of nodules, the nondiagnostic or unsatisfactory category (PR: 3.0, 95% CI: 2.2-4.2) and the suspicious for malignancy category (PR: 1.6, 95% CI: 1.1-2.4) were significantly associated with nodules measuring 1 cm or less.

CONCLUSION

Our results demonstrated that nodules 1 cm or less are significantly associated with the nondiagnostic and suspicious for malignancy categories of the Bethesda System when compared to nodules greater than 1 cm.

Active surveillance of low-risk papillary thyroid microcarcinomas

In 1993, active surveillance of low-risk papillary thyroid microcarcinomas (PTMCs) started in Kuma Hospital, Kobe, Japan. It has spread globally after the publishing of American Thyroid Association (ATA) guidelines. During our hospital's active surveillance program, few patients (8.0%) showed tumor size enlargement ≥3 mm or the new appearance of node metastasis (3.8%) at 10-year follow-up. Conversion surgery was recommended for patients with disease progression. To date, no patients showed significant recurrence or metastasis or died with thyroid carcinoma when patients underwent active surveillance or after surgery due to PTMC progression. Unlike clinical papillary thyroid carcinoma (PTC), elderly patients' PTMCs were less progressive compared to those of young and middle-aged patients, indicating that elderly patients are strong candidates for the active surveillance of their PTMC. Although young patients' PTMCs are the most progressive, >50% and >75% of patients in their 20s and 30s would avoid conversion surgical treatment in their lifetime, respectively (according to estimated lifetime probability), indicating that such young patients are still candidates for active surveillance. It can thus be concluded that active surveillance is appropriate to be first management for PTMCs, based on the accumulation of favorable outcomes of PTMC patients who have undergone active surveillance, as well as the lower incidences of unfavorable events and lower medical cost than immediate surgery.

Updates on the Management of Thyroid Cancer

The diagnostic modalities, stratification tools, and treatment options for patients with thyroid cancer have rapidly evolved since the development of the American Thyroid Association (ATA) guidelines in 2015. This review compiles newer concepts in diagnosis, stratification tools and treatment options for patients with differentiated thyroid cancer (DTC), medullary thyroid carcinoma (MTC) and anaplastic thyroid cancer (ATC). Newer developments apply precision medicine in thyroid cancer patients to avoid over-treatment in low risk disease and under-treatment in high risk disease. Among novel patient-tailored therapies are selective RET inhibitors that have shown efficacy in the treatment of MTC with limited systemic toxicity compared with non-specific tyrosine kinase inhibitors. The combination of BRAF and MEK inhibitors have revolutionized management of BRAF V600E mutant ATC. Several immunotherapeutic agents are being actively investigated in the treatment of all forms of thyroid cancer. In this review, we describe the recent advances in the diagnosis and management of DTC, MTC, and ATC, with an emphasis on novel treatment modalities.

Interventions that Facilitate Shared Decision-Making in Cancers with Active Surveillance as Treatment Option: a Systematic Review of Literature

PURPOSE OF REVIEW

Medical decisions concerning active surveillance are complex, especially when evidence on superiority of one of the treatments is lacking. Decision aids have been developed to facilitate shared decision-making on whether to pursue an active surveillance strategy. However, it is unclear how these decision aids are designed and which outcomes are considered relevant. The purpose of this study is to systematically review all decision aids in the field of oncological active surveillance strategies and outcomes used by authors to assess their efficacy.

RECENT FINDINGS

A search was performed in Embase, Medline, Web of Science, Cochrane, PsycINFO Ovid and Google Scholar until June 2019. Eligible studies concerned interventions aiming to facilitate shared decision-making for patients confronted with several treatment alternatives, with active surveillance being one of the treatment alternatives. Twenty-three eligible articles were included. Twenty-one articles included patients with prostate cancer, one with thyroid cancer and one with ovarian cancer. Interventions mostly consisted of an interactive web-based decision aid format. After categorization of outcomes, seven main groups were identified: knowledge, involvement in decision-making, decisional conflict, treatment preference, decision regret, anxiety and health-related outcomes. Although active surveillance has been implemented for several malignancies, interventions that facilitate shared decision-making between active surveillance and other equally effective treatment alternatives are scarce. Future research should focus on developing interventions for malignancies like rectal cancer and oesophageal cancer as well. The efficacy of interventions is mostly assessed using short-term outcomes.

Low-risk papillary thyroid microcarcinoma: Optimal management toward a more conservative approach

The incidence of papillary thyroid microcarcinoma (microPTC) has dramatically increased in the last decades. Most of these tumors remain small and clinically "silent", only small number progress. Although thyroid surgery used to be the only therapeutic approach, recent guidelines now consider active surveillance for low-risk microPTC. For this reason, more accurate risk stratification of microPTC is needed. The optimal management of low-risk microPTC through accurate risk stratification represents a major clinical issue.

Active surveillance of low-risk papillary thyroid microcarcinomas in Japan and other countries: a review

Introduction: Active surveillance of low-risk papillary thyroid microcarcinomas (PTMCs) was initiated in Japan in 1993 and has since been adopted in many countries, especially after its approval by the American Thyroid Association in 2015.Areas covered: We performed a literature review in Medline/PubMed to identify studies that used active surveillance for PTMCs. Moreover, we performed a literature review about the increased incidence of thyroid microcarcinomas in relation to the relative stability of deaths due to thyroid carcinomas.Expert opinion: No patients showed life-threatening metastasis/recurrence or died of thyroid carcinoma during active surveillance or after conversion surgery following PTMC progression. Thus, active surveillance should be the first-line management of PTMCs without high-risk features. In the future, molecular testing of actively growing PTMCs using cytology specimens could be useful to guide the treatment plan.

Early Diagnosis of Low-Risk Papillary Thyroid Cancer Results Rather in Overtreatment Than a Better Survival

We are witnessing a rapid worldwide increase in the incidence of papillary thyroid carcinoma (PTC) in the last thirty years. Extensive implementation of cancer screening and wide availability of neck ultrasound or other imaging studies is the main reason responsible for this phenomenon. It resulted in a detection of a growing number of clinically asymptomatic PTCs, mainly low-risk tumors, without any beneficial impact on survival. An indolent nature of low-risk PTC, particularly papillary thyroid microcarcinoma (PTMC), and the excellent outcomes raise an ongoing discussion regarding the adequacy of treatment applied. The question of whether PTMC is overtreated or not is currently completed by another, whether PTMC requires any treatment. Current ATA guidelines propose less extensive preoperative diagnostics and, if differentiated thyroid cancer is diagnosed, less aggressive surgical approach and limit indications for postoperative radioiodine therapy. However, in intrathyroidal PTMCs in the absence of lymph node or distant metastases, active surveillance may constitute alternative management with a low progression rate of 1%-5% and without any increase in the risk of poorer outcomes related to delayed surgery in patients, in whom it was necessary. This review summarizes the current knowledge and future perspectives of active surveillance in low-risk PTC.

Active Surveillance for Small Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis

Background: The rapid increase in the incidence of small papillary thyroid carcinoma (PTC) appears to be caused by the detection of small thyroid cancers. Active surveillance (AS) was therefore suggested to overcome this problem. As the results were favorable with low rates of size enlargement and lymph metastasis, the 2015 American Thyroid Association Management Guidelines endorsed AS as an alternative to immediate surgery. As the clinical value of AS is a subject of ongoing active discussions and surveys, we considered a systematic review and meta-analysis to be timely and necessary. Methods: Ovid-MEDLINE and EMBASE databases were searched up to January 5, 2019, for studies reporting patients who were followed up with AS for PTC. Data extraction and methodological quality assessment were performed independently by two radiologists. The primary outcomes were to identify the annual pooled proportions of size enlargement of 3 mm or more and the detection of lymph node metastases at a 5-year follow-up period. These were calculated using an inverse-variance weighting model. An additional outcome was evaluation of the reasons for surgery during AS. Results: The pooled proportion of size enlargement occurring at 5 years was 5.3% [95% confidence interval (CI), 4.4-6.4%], and the pooled proportion of 5-year lymph node metastasis was 1.6% [CI, 1.1-2.4%]. In many subjects undergoing delayed operations, the reasons for operation were often other than those of size enlargement or lymph node metastasis. Conclusions: AS is effective for the management of small PTC, with a low proportion of size enlargement or lymph node metastasis occurring at 5 years. However, a substantial proportion of the causes of delayed surgery were other than size enlargement or lymph node metastasis, and these situations need to be optimally managed.

Active surveillance of low-risk papillary thyroid carcinoma: a promising strategy requiring additional evidence

PURPOSE

Papillary thyroid carcinoma (PTC), the most common malignant tumor of the thyroid, has been criticized as overtreated by some researchers in recent years. Active surveillance (AS) was first proposed at Kuma Hospital in 1993, and popularized in other institutes ever since. We provide a brief review of low-risk PTC active monitoring studies to date, and discuss the advantages of AS and limitations of existing studies.

RESULTS

Most papillary thyroid microcarcinomas do not show significant growth or new lymph node metastasis in a 10-year AS period. Patients who undergo delayed surgery during AS generally have a good prognosis. Tumor progression correlates with age, calcification pattern, and Ki-67 positivity. Serum thyroid stimulating hormone concentration and pregnancy might also influence tumor progression in some studies.

CONCLUSION

Active surveillance for low-risk PTC has shown its safety and feasibility in certain populations. In the future, it is warranted to determine valuable tumor progression predictors and most suitable PTC patients for AS.

Active surveillance in papillary thyroid carcinoma: not easily accepted but possible in Latin America

OBJECTIVES

To determine the percentage of patients with papillary thyroid carcinoma (PTC) who accepted active surveillance as an alternative to surgery in our clinical practice and to describe the clinical characteristics and outcomes of patients with Bethesda category V and VI thyroid nodules who chose active surveillance.

SUBJECTS AND METHODS

We included 136 PTC patients from the Hospital de Clínicas, University of Buenos Aires without (i) US extrathyroidal extension, (ii) tumors adjacent to the recurrent laryngeal nerve or trachea, and/or (iii) US regional lymph-node metastasis or clinical distant metastasis. PTC progression was defined as the presence of i) a tumor larger than ≥ 3 mm, ii) novel appearance of lymph-node metastasis, and iii) serum thyroglobulin doubling time in less than one year. For patients with these features, surgery was recommended.

RESULTS

Only 34 (25%) of 136 patients eligible for active surveillance accepted this approach, and around 10% of those who accepted abandoned it due to anxiety. The frequency of patients with tumor enlargement was 17% after a median of 4.6 years of follow-up without any evidence of nodal or distant metastases. Ten patients who underwent surgical treatment after a median time of 4 years of active surveillance (AS) had no evidence of disease after a median of 3.8 years of follow-up after surgery.

CONCLUSION

Although not easily accepted in our cohort of patients, AS would be safe and easily applicable in experienced centers.

Management of Papillary Thyroid Microcarcinoma

The worldwide incidence of thyroid cancer is increasing. A third of new thyroid cancer cases are papillary thyroid microcarcinoma (PTM), which are 1 cm or less. These tumors are mostly indolent with excellent prognosis. Although thyroid surgery is the most common management option for patients with PTM, new management options demand that treatment decisions must be individualized and based on patient's preference, context, and biology. This article describes management options for PTM patients and shared decision-making as a novel method for individualizing care.

Conservative Surveillance Management of Low-Risk Papillary Thyroid Microcarcinoma

Most low-risk papillary thyroid microcarcinomas are indolent. Ten years of active surveillance at Kuma Hospital revealed that only 8.0% of patients showed enlargement of 3 mm or greater, whereas only 3.8% showed nodal metastasis. None, including those who underwent rescue surgery after the detection of progression, showed life-threatening recurrence or distant metastasis, and none died of thyroid carcinoma. Adverse events were significantly more frequent in patients who underwent immediate surgery than in those who had active surveillance. Medical costs were significantly higher. Therefore, active surveillance ought to be the primary method of low-risk papillary thyroid microcarcinoma management.