Patients' experiences of diagnosis and management of papillary thyroid microcarcinoma: a qualitative study

Disease Experience of Patients With Differentiated Thyroid Cancer at Different Phases Based on Timing It Right Framework: A Qualitative Longitudinal Study

BACKGROUND

As the incidence of differentiated thyroid cancer (DTC) continues to rise globally, it is important to gain insight into the disease experience of cancer patients at different phases of the disease. However, surveys addressing the longitudinal disease experience and specific needs of this population are lacking.

OBJECTIVE

The aim of this study was to explore the disease experience of people with DTC at key time points in their cancer trajectory so support can be rendered for "patient-centered" supportive care services.

METHODS

On the basis of the Timing It Right framework, a semistructured in-depth interview was conducted with 14 patients with DTC at 5 key phases from initial diagnosis to 6 months postoperatively, and data were analyzed using the Colaizzi 7-step analysis.

RESULTS

The themes of disease experience at different phases were as follows: (1) diagnostic phase: differences in acceptance; (2) perioperative phase: physical and mental distress; (3) discharge preparation phase: anxiety and helplessness, and gap of disease knowledge; (4) discharge adjustment phase: fear of recurrence and proactive health; and (5) discharge adaptation phase: multiple needs.

CONCLUSION

The experience, care needs, and nature of the needs of patients with DTC change dynamically with the different phases of the disease. Capturing the most appropriate time throughout the continuum of care to implement supportive care that patients need most will help to improve the continuity and precision of cancer care.

IMPLICATIONS FOR PRACTICE

Healthcare providers should provide a continuum of dynamic care by scientifically and systematically assessing the actual supportive care needs of patients with DTC according to their different phases of disease.

Patient Experiences of Symptoms and Coping Strategies in the Early Postoperative Phase Following Hemithyroidectomy: A Qualitative Interview Study

The aim was to explore patients' early experiences of symptoms after hemithyroidectomy and how these symptoms influenced their daily lives. An inductive explorative qualitative research design was performed. Sixteen patients from two hospitals were interviewed between two-three weeks after the surgery. All the patients experienced compression symptoms before the surgery. The study was analyzed with conventional manifest content analysis. The inductive analysis yielded two main categories and one subcategory. The two main categories were: Early postoperative symptoms that caused disadvantage in daily life and Early postoperative symptoms and coping strategies. The subcategory was: Early postoperative experiences of concerns about the future. Key points: 1. Patients experienced early postoperative symptoms that affected their lives in multiple levels, making them develop coping strategies and awaking concerns about remaining symptoms in the future. 2. The effect of hemithyroidectomy influenced patients' daily life in the early postoperative phase considerably. 3. The study shows that tailored preoperative patient information is important. The findings may guide professionals to tailored preoperative information to optimize the care for this patient group.

The impact of delayed diagnosis and treatment due to COVID-19 on Australian thyroid cancer patients: a qualitative interview study

OBJECTIVES

The study aims to investigate the perceptions of patients with thyroid cancer on the potential impact of diagnosis and treatment delays during the COVID-19 pandemic.

DESIGN

This study involved qualitative semi-structured telephone interviews. The interviews were transcribed verbatim, analysed using the thematic framework analysis method and reported using the Consolidated Criteria for Reporting Qualitative Research.

SETTING

Participants in the study were treated and/or managed at hospital sites across New South Wales and Victoria, Australia.

PARTICIPANTS

17 patients with thyroid cancer were interviewed and included in the analysis (14 females and 3 males).

RESULTS

The delays experienced by patients ranged from <3 months to >12 months. The patients reported about delays to diagnostic tests, delays to surgery and radioactive iodine treatment, perceived disease progression and, for some, the financial burden of choosing to go through private treatment to minimise the delay. Most patients also reported not wanting to experience delays any longer than they did, due to unease and anxiety.

CONCLUSIONS

This study highlights an increased psychological burden in patients with thyroid cancer who experienced delayed diagnosis and/or treatment during COVID-19. The impacts experienced by patients during this time may be similar in the case of other unexpected delays and highlight the need for regular clinical review during delays to diagnosis or treatment.

Hearing the Voices of Australian Thyroid Cancer Survivors: Qualitative Thematic Analysis of Semistructured Interviews Identifies Unmet Support Needs

Background: Most thyroid cancer survivors regain their physical health-related quality of life, but psychological and social deficits persist. The nature of these detriments remains poorly understood and they are insufficiently captured by survey data alone. To address this, qualitative data exploring the breadth and depth of thyroid cancer survivors' experiences and priorities for supportive care are required. Methods: Twenty semistructured interviews were undertaken with a purposive, maximum variation sample of thyroid cancer survivors. Interviews were transcribed verbatim and coded independently by two researchers. A hybrid model of inductive and realistic codebook analysis was undertaken with themes developed. Results: Patient experiences centered around three themes: (1) impact of diagnosis and treatment, (2) thyroid cancer does not happen in isolation, and (3) role of clinicians and formalized support structures. The word "cancer" had negative connotations, but for many, the reality of their experience was more positive. Despite feeling "lucky" at the relative low-risk nature of thyroid cancer, many patients reported fatigue, weight gain, and difficulty returning to usual activities; concerns that were largely dismissed or minimized by clinicians. Few were offered any support beyond their treating doctors; where patients attempted to access formalized supportive care, little was available or appropriate. Life stage and concurrent family and social stressors greatly impacted patients' ability to cope with diagnosis and treatment. Addressing thyroid cancer in isolation felt inappropriate without appreciating the broader context of their lives. Interactions with clinicians were largely positive, particularly where information was communicated as a means of empowering patients to participate in shared decision-making and where clinicians "checked in" emotionally with patients. Information about initial treatments was largely adequate but information on longer term effects and follow-up was lacking. Many patients felt that clinicians focused on physical well-being and scan results, missing opportunities to provide psychological support. Conclusions: Thyroid cancer survivors can struggle to navigate their cancer journey, particularly with regard to psychological and social functioning. There is a need to acknowledge these impacts at the time of clinical encounters, as well as develop information resources and support structures that can be individualized to optimize holistic well-being for those in need.

Subcentimetric Papillary Thyroid Carcinoma: Does the Diagnosis Kind Impact Prognosis?

INTRODUCTION

Subcentimetric papillary thyroid carcinoma (SPTC) (papillary thyroid carcinoma with less than 10 mm in size) usually presents an excellent prognosis, with few aggressive reported cases. Given the globally increased incidence of SPTC, physicians are struggling with the need to identify prognostic factors to stratify SPTC. The aim was to compare clinicopathological variables and prognosis between clinically and incidentally diagnosed SPTC. Materials and methodsː This is a retrospective observational study on patients with SPTC who underwent thyroidectomy between 2002 and 2015. Two groups were considered: G1 (n=60 (61.9%)), clinical diagnosis (Bethesda III-VI cytology in the thyroid tumor/in cervical lymphadenopathies) and G2 (n=37 (38.1%)), incidental diagnosis (thyroidectomy for benign thyroid pathology). The histological material was reviewed, and molecular analysis of the BRAF, RAS, and TERT promoter (TERTp) genes was performed. Resultsː Ninety-seven individuals were included, 60 (61.9%) of which were from G1, with a predominance of female sex (n=83 (85.6%)). Individuals of G1 were younger (53.0±14.2 versus 59.3±13.9 years; p=0.035), were more frequently treated with 131-iodine (39.2% versus 13.4%; p=0.007), had the largest diameter (8 (p25-p75: 7-9) versus 5 (p25-p75: 4-6.5) mm; p<0.001), and higher frequency of minimal extracapsular invasion (45% versus 24.3%; p=0.041). Increased tumor size was the only independent predictor of a clinical diagnosis (p<0.001). Conclusionsː Clinically and incidentally diagnosed SPTC showed excellent medium- to long-term prognosis. A larger SPTC was more likely a driver of clinical detection than a marker of tumor aggressiveness, but caution should be taken as contradictory data persists.

The Size of a Thyroid Nodule with ACR TI-RADS Does Not Provide a Better Prediction of the Nature of the Nodule: A Single-Center Retrospective Real-Life Observational Study

We investigated if thyroid nodule size has a predictive value of malignancy on a par with composition, echogenicity, shape, margin, and echogenic foci, and what would be the consequence of observing the rule of the American College of Radiology (ACR) to perform a fine-needle aspiration biopsy (FNAB). We conducted a retrospective real-life observational study on 86 patients who underwent surgery after a standardized diagnostic protocol. We divided the TR3, TR4, and TR5 classes into sub-classes according to the size threshold indicating FNAB (a: up to the threshold for no FNAB; b: over the threshold for FNAB suggested). We computed sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for the different sub-classes and Youden's index (Y) for the different possible cutoffs. Each sub-class showed the following PPV (0.67, 0.68, 0.70, 0.78, 0.72), NPV (0.56, 0.54, 0.51, 0.52, 0.59), and Y (0.20, 0.20, 0.22, 0.31, 0.30). In this real-life series, we did not find a significant difference in prediction of malignancy between the sub-categories according to the size threshold. All nodules have a pre-evaluation likelihood of being malignant, and the impact and utility of size thresholds may be less clear than suggested by the ACR TIRADS guidelines in patients undergoing standardized thyroid work up.

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.

Current patterns of care in low-risk thyroid cancer-A national cross-sectional survey of Australian thyroid clinicians

INTRODUCTION

De-escalated treatment of hemithyroidectomy without radioactive iodine (RAI) is now accepted for patients with low-risk, well-differentiated thyroid cancer (WDTC). The benefit of long-term follow-up care remains controversial. This study aims to describe parameters associated with less than total thyroidectomy, and discharge from specialist follow-up in patients with low-risk WDTC in Australia.

METHODS

An online survey was distributed to Australian members of Endocrine Society of Australia, Australian and New Zealand Endocrine Surgeons, and Australian Society of Otolaryngology, Head and Neck Surgery. Clinicians completed a survey of management and follow-up care preferences for four clinical vignettes (all low-risk WDTC).

RESULTS

119 clinicians (48% endocrinologists, 55% male) answered at least one question. The majority (59%) of respondents recommended less than total thyroidectomy and omission of RAI in patients with WDTC <2 cm. Most (62%) would discharge a patient with micropapillary thyroid cancer within 1 year following total thyroidectomy. In contrast, for WDTC 1-4 cm, >90% of clinicians would continue specialist follow-up for at least 5 years. The majority of clinicians felt that patients experienced disproportionate fear of recurrence and were reassured by follow-up. After multivariable analysis, clinicians who participated in multidisciplinary teams (MDTs) were more likely to choose de-escalated care for both initial treatment (p = .005) and follow-up care (>5 years, p = .05).

CONCLUSION

Clinician attitudes captured by this survey reflect recent changes in guidelines towards hemithyroidectomy for low-risk WDTC, particularly amongst MDT attendees. There is a need to further examine the impact of de-escalated care on fear of recurrence and quality of life in thyroid cancer survivors.

The Preferred Route for the Diagnosis and Management of Thyroid Carcinoma Among the General Population in Saudi Arabia

BACKGROUND

 Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer. Papillary thyroid microcarcinoma (PTMC) is a specific subgroup of PTC. Given their small size, PTMCs are often asymptomatic and behave benignly. This puts physicians in a challenging situation about how to prevent overdiagnosis and overtreatment of PTMC. This study aimed to assess the preferences regarding the route of PTMC diagnosis and treatment among Saudi Arabia's general population.

METHODS

 This is a cross-sectional questionnaire-based-study conducted among the general population in Saudi Arabia. The target subjects were the general population of Saudi Arabia both genders and different age groups from various regions of Saudi Arabia (Western, Central, Eastern, Southern, and North). Participants who did not complete the questionnaire or did not agree to participate were excluded. A self-administered questionnaire was distributed on different social media platforms to collect data from different regions. Data analysis was conducted by using Statistical Package for the Social Sciences (SPSS) 24.0 version (IBM Inc., Chicago, USA) statistical software. A Chi-square test was used to compare categorical variables.

RESULTS

 A total of 1,428 participants were included. The majority of them were females (64.4%), and most of them were aged between 19 and 25 years. Moreover, we found that 4.8% of the study population had a medical history of thyroid cancer. Our results revealed that more than half of respondents (54.6%) would select surgical operation immediately if they have a thyroid nodule less than 1 cm in maximal diameter, which turns out to be a PTC. The vast majority of participants (90.1%) would prefer to do cytologic confirmation immediately if they have a thyroid nodule less than 1 cm in maximal diameter, which has suspicious characteristics of PTC in neck ultrasound examination. Regarding PTMC operation, 59.8% of responders were more concerned about complications than recurrences. We found that neither age nor gender significantly affects decision-making for management or operative extent for PTC. There was a significant difference between age and decision-making for the diagnosis of suspicious thyroid nodules (p value = 0.041).

CONCLUSION

 Our results concluded that most of the participants preferred to select immediate surgery and cytologic confirmation regarding the management and diagnosis of PTC. More research is advised. The need to inform patients about their disease state and treatment options should be highlighted more.

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.

Patient Experiences With Thyroid Nodules: A Qualitative Interview Survey

Objective

To qualitatively explore the broad set of preferences and attitudes patients have about thyroid nodules, which influence the decision-making process.

Study Design

A descriptive survey design was administered as interviews.

Setting

Outpatient thyroid surgery clinic.

Methods

Semistructured interviews were conducted with 20 patients presenting for initial evaluation of thyroid nodules at a surgeon's office. Probative, open-ended questions were posed regarding diagnosis, treatment, risk attitudes, and the decision-making process. Thematic analysis was used to develop code-transcribed interviews, and an iterative refinement resulted in underlying themes.

Results

During the diagnostic process, patients integrated emotional responses (fear, anxiety, and shock) with rationale concerns (likelihood of cancer, risk assessment), and ultimately relied heavily on expert opinion and recommendation. Contextualization with other personal or familial health problems served as helpful touchstones for decision-making. Overtreatment and overdiagnosis were not commonly discussed. When thinking about potential therapies, there was a strong bias to action rather than surveillance among patients. Surgical risk and the possibility of lifelong medication, however, were strong motivators for a subset of patients to seek nonsurgical alternatives.

Conclusion

Patients describe a decision-making process that incorporates emotional response and rational consideration of risks, contextualized within the personal experience and physician expertise. The bias for action and intervention is strong, and most patients strongly weighted physicians' recommendations. Themes from this qualitative analysis may serve as the backbone for future stated preference research pertaining to thyroid disease.

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.

The Patient Experience of Thyroid Cancer

The 3 phases of thyroid cancer care are discussed: diagnosis, management, and survivorship. Drivers of quality of life (QOL) in each phase are described, and suggestions are made for mitigating the risk of poor QOL. Active surveillance is another emerging management strategy that has the potential to improve QOL by eliminating upfront surgical morbidity but will need to be studied prospectively.

Barriers to the Use of Active Surveillance for Thyroid Cancer Results of a Physician Survey

OBJECTIVE

The aim of this study was to determine physician-reported use of and barriers to active surveillance for thyroid cancer.

SUMMARY BACKGROUND DATA

It is not clear whether active surveillance for thyroid cancer is widely used.

METHODS

Surgeons and endocrinologists identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles County were surveyed between 2018 and 2019. Multivariable weighted logistic regression analyses were conducted to determine physician acceptance and use of active surveillance. Results: Of the 654 eligible physicians identified, 448 responded to the survey (69% response rate). The majority (76%) believed that active surveillance was an appropriate management option, but only 44% used it in their practice. Characteristics of physicians who stated that active surveillance was appropriate management, but did not report using it included more years in practice (reference group <10 years in practice): 10 to 19 years [odds ratio, OR 0.50 [95% confidence interval, CI 0.28-0.92]; 20 to 29 years [OR 0.31 (95% CI 0.15-0.62)]; >30 years [OR 0.30 (95% CI 0.15-0.61)] and higher patient volume 11 to 30 patients per year [OR 0.39 (95% CI 0.21 -0.70)] and >50 patients per year [OR 0.33 (95% CI 0.16-0.71)] compared to < 10, with no significant difference in those seeing 31 to 50 patients. Physicians reported multiple barriers to implementing active surveillance including patient does not want (80.3%), loss to follow-up concern (78.4%), more patient worry (57.6%), and malpractice lawsuit concern (50.9%).

CONCLUSION AND RELEVANCE

Despite most physicians considering active surveillance to be appropriate management, more than half are not using it. Addressing existing barriers is key to improving uptake.

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.

Papillary Thyroid Microcarcinoma: Active Surveillance Against Surgery. Considerations of an Italian Working Group From a Systematic Review

Introduction

Active surveillance is considered a viable option for papillary thyroid microcarcinoma. Since the last decade of the 20th century, this method has spread from Japan to other countries, but has not yet been fully accepted and validated by the major Western Scientific Societies. In 2016, a systematic review on the results of active surveillance was published, based on two articles that showed encouraging results. Other reviews published subsequently, were mainly based on articles from the Far East. The aim of this review is to assess the most recent results published from 2017 to 2020 on this subject.

Materials and Methods

A systematic literature search was performed on MEDLINE via PUBMED, Web of Science, and Scopus according to PRISMA criteria. The MESH terms “papillary thyroid microcarcinoma” and “active surveillance” were adopted. Tumor progression, secondary localizations, and quality of life were the main benchmarks.

Results

Nine studies met the inclusion criteria. The increase in volume ranged from 2.7% and 23.2%; the occurrence of lymph node metastases from 1.3% to 29%; QoL was improved in both articles that addressed this topic. The level of evidence is considered low due to the retrospective and uncontrolled nature of most of the studies included in the review.

Conclusion

The evidence from the literature currently available on AS falls into two strands: a robust data set from the Japanese experience, and an initial experience from Western countries, whose data are still limited but which show a lack of substantial alerts against this practice. Further data is useful to validate the spread of Active Surveillance.

The value of ultrasound guided laser ablation in papillary thyroid recurrence carcinoma: A retrospective, single center study from China

OBJECTIVE

The efficacy and safety of ultrasound-guided percutaneous laser ablation (PLA) for treating recurrent papillary thyroid cancer nodules (RPTCNs).

METHODS

A retrospective study was conducted in 43 patients with single recurrent thyroid cancer which was diagnosed by fine needle aspiration biopsy (FNAB). The extent of ablation was assessed by contrast-enhanced ultrasound (CEUS) 24h after PLA. At baseline (before ablation), 6, and 12 months, and every 6 months thereafter, the following were recorded: nodule maximum diameter, volume reduction rate (VRR), complications, and side effects.

RESULT

All 43 patients were successfully treated with PLA without serious complications. All patients underwent CEUS 24 hours after PLA treatment, and all achieved complete ablation. The success rate of single ablation was 100%. The average follow-up time was 23.47 ± 6.50 months, 12 ~ 36 months. At the last follow-up, 32 (74.4%) ablation lesions disappeared completely and 11 (25.6%) ablation lesions showed scar-like changes. No lymph node metastasis was found during follow-up. The maximum diameter and volume of nodules decreased from 5.1 ± 1.4 mm, 86.22 ± 20.46 mm³ before operation to 0.73 ± 1.1 mm, 1.02 ± 1.92 mm³ at the end of observation (P < 0.01). The average volume reduction rates (VRR) at 6, 12, 18, 24, 30 and 36 months after ablation were 11.92%, 60.64%, 82.26%, 90.96%, 93.7% and 97.79% respectively. No regrowth of treated nodule and distant metastases were detected. One patient (2.3%) had local recurrence and was treated with PLA again.

CONCLUSION

Ultrasound-guided PLA appears to be effective and safe for treating unifocal RPTCNs in selected patients who are ineligible for surgery, which is suitable for clinical application and promotion.

Rethinking Low-Risk Papillary Thyroid Cancers < 1cm (Papillary Microcarcinomas): An Evidence Review for Recalibrating Diagnostic Thresholds and/or Alternative Labels

Background: Recalibrating diagnostic thresholds or using alternative labels may mitigate overdiagnosis and overtreatment of papillary microcarcinoma (mPTC). We aimed at identifying and collating relevant epidemiological evidence on mPTC, to assess the case for recalibration and/or new labels. Methods: We searched EMBASE and PubMed databases from inception to December 2020 for natural history, autopsy, diagnostic drift, and diagnostic reproducibility studies. Where a relevant systematic review was pre-identified, only new articles were additionally included. Non-English articles were excluded. One author screened titles and abstracts. Two authors screened full text articles, performed quality assessments, and extracted data. We undertook narrative synthesis of included evidence (pooled estimates from systematic reviews and single estimates from primary studies). Results: One systematic review of patients undergoing active surveillance found that after 5 years of follow-up, 5.3% (95% confidence interval [CI 4.4-6.4%]) of the mPTC lesions had increased in size by ≥3 mm, and 1.6% [CI 1.1-2.4%] of patients had lymph node metastases. Among 7 new primary studies (including 3 updates on 2 studies included in the systematic review), 1-5% of patients undergoing active surveillance had lymph node metastases after a median follow-up of 1-10 years. One systematic review found that subclinical thyroid cancer incidentally discovered at autopsy is relatively common, with a pooled prevalence of 11.2% [CI 6.7-16.1%] among studies that examined the whole thyroid. Four diagnostic drift studies evaluated the new classification of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Three studies of cases previously diagnosed as papillary thyroid cancer found 1.3-2.3% were reclassified as NIFTP (reclassifications were from follicular variation of papillary thyroid cancer [FVPTC]). One study of 48 cases previously diagnosed as mPTC found that 23.5% were reclassified as NIFTP. Thirteen reproducibility studies of papillary thyroid lesions found substantial variation in the histopathological diagnosis of thyroid lesions, including FVPTC and NIFTP classifications (no study evaluated mPTC). Conclusions: This review supports consideration of recalibrating diagnostic thresholds and/or alternative labels for low-risk mPTC.

Patient perception of receiving a thyroid cancer diagnosis

PURPOSE OF REVIEW

This review describes the current state of the literature on patients' perceptions of receiving a diagnosis of thyroid cancer. The evaluation progresses from people's understanding about thyroid cancer in general to the lived experiences of those receiving an initial diagnosis or one of recurrence. The implications on patients' quality of life and treatment decisions are also discussed.

RECENT FINDINGS

Receiving a diagnosis of thyroid cancer often elicits intense and immediate emotions of shock and fear evoked by the word 'cancer,' which may be related to lack of knowledge about thyroid cancer specifically. Describing thyroid cancer as the 'good cancer' in an attempt to reassure patients is not necessarily reassuring and can inadvertently minimize the impact of a patient's diagnosis. Fear and worry about cancer in general and the possibility for recurrence contribute to lasting psychological distress and decreased quality of life. Patients' perceptions of their diagnosis and resulting emotional reactions influence treatment decision-making and have the potential to contribute to decisions that may over-treat a low-risk thyroid cancer.

SUMMARY

Understanding patients' experience of receiving a thyroid cancer diagnosis is critical because their emotional reactions can have a profound impact on treatment decision-making and quality of life.

Needs, Preferences, and Values during Different Treatment Decisions of Patients with Differentiated Thyroid Cancer

Background: The purpose of this study was to identify the needs, preferences, and values of patients with differentiated thyroid cancer (DTC) and the physicians treating patients with DTC regarding two different treatment decisions, namely: the extent of primary surgery (low-risk patients) and the tyrosine kinase inhibitor (TKI) treatment (high-risk patients). Methods: A qualitative study was conducted. There were two physician focus groups discussing the extent of primary surgery. One included endocrinologists (n = 4) and surgeons (n = 5), and the other included nuclear medicine physicians (n = 3) treating patients with low-risk DTC. The physicians focus group discussing waiting or starting TKIs included endocrinologists (n = 2) and oncologists (n = 5) treating patients with advanced radioactive iodide (RAI) refractory DTC. Moreover, one patient focus group per treatment decision took place. In total 13 patients and 19 physicians participated. Interviews were audio-taped, fully transcribed verbatim, and analyzed. Results: Several themes were identified. Patients, but not physicians, mentioned the importance of a strong doctor–patient relationship. Patients in both treatment decision groups wanted to receive more detailed information, whereas physicians preferred providing more general information. Patients in the TKI decision group focused on palliative care, whereas physicians focused more on the effect and benefit of TKIs. Conclusions: Considering the identified themes in DTC, based on the patients’ needs, preferences, and values, enables us to improve doctor–patient communication and to develop decision support tools.

Terminology Change for Small Low-Risk Papillary Thyroid Cancer As a Response to Overtreatment: Results from Three Australian Community Juries

Background: The majority of small papillary thyroid cancers (sPTCs) are treated surgically, rather than by active surveillance. Patient and clinician preference for surgery may be partially driven by the use of cancer terminology. Some experts propose that changing terminology would better communicate the indolent nature of sPTCs and improve uptake of active surveillance. Others argue that terminology that includes "cancer" correctly reflects the biological nature of these tumors. The views of informed lay publics can provide value-based perspectives on complex issues and guide policy discussions. Methods: We recruited 40 people for three community juries, held in Sydney, Wodonga, and Cairns, Australia. Participants were of diverse backgrounds and ages, recruited through random digit dialing and a topic-blinded social media strategy. Juries were informed about thyroid cancer, overdiagnosis, and overtreatment, and heard arguments for and against terminology change before deliberation. The deliberative process in Jury 1 led to a refinement of jury charge, the updated version that was then used in Juries 2 and 3. Results: Jury 1 favored no terminology change, and Juries 2 and 3 were divided on the topic. Key reasons for opposing terminology change included a strong desire to retain terminology that aligns with the pathological definition of cancer, and to avoid even a minimal risk of harm that could arise if patients became complacent in follow-up. Key reasons to support terminology change included a desire to reduce psychological distress, stigma, and discrimination associated with a cancer diagnosis, and an argument that terminology change may be a more effective trigger for health system reform compared with other options. The juries unanimously recommended community education and health system reforms to reduce harms of overtreatment, and expressed an expectation that clinicians and researchers reach agreement on clinical guidelines to promote better uptake of active surveillance. Conclusions: The conceptual tension between a pathological and an outcome-based understanding of cancer was apparent in deliberation. This highlights an ongoing challenge for those advocating changing disease terminology. Regardless of action on terminology, jurors shared a strong expectation that practical changes would be made to respond to the harms of overtreatment.

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.

Patients' Reaction to Diagnosis with Thyroid Cancer or an Indeterminate Thyroid Nodule

Introduction: Little is known about the experiences and concerns of patients recently diagnosed with thyroid cancer or an indeterminate thyroid nodule. This study sought to explore patients' reactions to diagnosis with papillary thyroid cancer (PTC) or indeterminate cytology on fine needle aspiration. Methods: We conducted semistructured interviews with 85 patients with recently diagnosed PTC or an indeterminate thyroid nodule before undergoing thyroidectomy. We included adults with nodules ≥1 cm and Bethesda III, IV, V, and VI cytology. The analysis utilized grounded theory methodology to create a conceptual model of patient reactions. Results: After diagnosis, participants experienced shock, anxiety, fear, and a strong need to "get it out" because "it's cancer!" This response was frequently followed by a sense of urgency to "get it done," which made waiting for surgery difficult. These reactions occurred regardless of whether participants had confirmed PTC or indeterminate cytology. Participants described the wait between diagnosis and surgery as difficult, because the cancer or nodule was "still sitting there" and "could be spreading." Participants often viewed surgery and getting the cancer out as a "fix" that would resolve their fears and worries, returning them to normalcy. The need to "get it out" also led some participants to minimize the risk of complications or adverse outcomes. Education about the slow-growing nature of PTC reassured some, but not all patients. Conclusions: After diagnosis with PTC or an indeterminate thyroid nodule, many patients have strong emotional reactions and an impulse to "get it out" elicited by the word "cancer." This reaction can persist even after receiving education about the excellent prognosis. Understanding patients' response to diagnosis is critical, because their emotional reactions likely pose a barrier to implementing guidelines recommending less extensive management for PTC.

Treatment decision-making among patients with oropharyngeal squamous cell cancer: A qualitative study

Oropharyngeal squamous cell cancer (OPSCC) is now the most common site of head and neck squamous cell cancer. Despite the focus on treatment deintensification in clinical trials, little is known about the preferences, experiences and needs of patients with OPSCC when deciding between surgery and radiation therapy as primary treatment with curative intent. In this qualitative study, pre-treatment and post-treatment oropharyngeal cancer patients were recruited to take part in one-on-one interviews (n = 11 pre-treatment) and focus group discussions (n = 15 post-treatment) about treatment decision-making. Recordings were transcribed and assessed for emergent themes using framework analysis. From the one-on-one interviews and focus group discussions with OPSCC patients, fourteen themes were identified. Participants expressed alarm at diagnosis, decisional conflict, and a variety of roles in decision-making (physician-controlled, shared, and autonomous). Decisions were driven by the perceived recommendation of the treatment team, a desire for physical (surgical) tumor removal, fear of adverse effects of treatment, and patient-specific values. Although participants felt well-informed by their treating physicians, they identified a need for additional patient-centered information. Participants were critical of the poor quality of information available on the internet, and acknowledged the advantage of hearing the experiences of post-treatment patients. The experiences identified herein may be used to guide patient-centered communication during patient counseling and to inform interventions designed to support patients' needs at diagnosis, ultimately helping to implement high-quality, patient-centered care.

An 8 miRNA-Based Risk Score System for Predicting the Prognosis of Patients With Papillary Thyroid Cancer

Background:

Dysregulation of microRNAs (miRNAs) in papillary thyroid cancer (PTC) might influence prognosis of PTC. This study is aimed to develop a risk score system for predicting prognosis of PTC.

Methods:

The miRNA and gene expression profiles of PTC were obtained from The Cancer Genome Atlas database. PTC samples were randomly separated into training set (n = 248) and validation set (n = 248). The differentially expressed miRNAs (DE-miRNAs) in the training set were screened using limma package. The independent prognosis-associated DE-miRNAs were identified for building a risk score system. Risk score of PTC samples in the training set was calculated and samples were divided into high risk group and low risk group. Kaplan-Meier curves and receiver operating characteristic (ROC) curve were used to assess the accuracy of the risk score system in the training set, validation set and entire set. Finally, a miRNA-gene regulatory network was visualized by Cytoscape software, followed by enrichment analysis.

Results:

Totally, 162 DE-miRNAs between tumor and control groups in the training set were identified. An 8 independent prognosis-associated DE-miRNAs, (including miR-1179, miR-133b, miR-3194, miR-3912, miR-548j, miR-6720, miR-6734, and miR-6843) based risk score system was developed. The area under ROC curve in the training set, validation set and entire set was all above 0.93. A miRNA-gene regulatory network involving the 8 DE-miRNAs were built and functional enrichment analysis suggested the genes in the network were significantly enriched into 13 pathways, including calcium signaling pathway and hedgehog signaling pathway.

Conclusion:

The risk score system developed this study might be used for predicting the prognosis of PTC. Besides, the 8 miRNAs might affect the prognosis of PTC via hedgehog signaling pathway and calcium signaling pathway.

Active surveillance for low-risk small papillary thyroid cancer in North American countries: past, present and future (bridging the gap between North American and Asian practices)

Papillary thyroid cancer (PTC) is increasingly being diagnosed worldwide; yet the mortality remains very low, suggesting widespread overdiagnosis. While traditional management of PTC includes thyroid surgery, sometimes followed by radioactive iodine treatment, there is a global trend towards more conservative approaches for patients who are considered as the lowest risk of recurrence or death from their disease. Active surveillance (AS), once called watchful waiting, involves close follow-up, with the intention to intervene if the cancer progresses, or on patient request. The Kuma Hospital in Japan was the first to introduce AS as an alternative to immediate thyroid surgery for low-risk papillary thyroid microcarcinomas (PTMC, <1 cm) in 1993. Accumulated evidence over the years has shown that AS is a safe and effective approach in select patients, with a low rate of cancer progression during AS. Consequently, the Japanese Clinical Guidelines for treatment of thyroid tumor approved AS as a first-line management for patients with asymptomatic PTMC in 2010. Subsequently, the latest 2015 American Thyroid Association guidelines endorsed AS as an alternative approach to immediate surgery for cytologically confirmed very low-risk PTC. However, the acceptance, feasibility and results of AS in patients with low-risk PTC outside of Japan are still largely unknown. Most guidelines recommend that thyroid nodules <1 cm should not be aspirated but instead monitored regardless of the ultrasonographic characteristics. In essence, these patients are also being subjected to AS. Specific recommendations and the role of molecular testing for the optimal selection of PTMC patients for an AS management approach are not well established. Furthermore, research is needed to assess the long-term clinical and psychosocial outcomes in patients with larger tumor sizes (>1 cm) who undergo screening and diagnosis according to the North American guidelines and practices. The first Canadian prospective observational study launched in 2016 is intended to complement the existing data for AS of small low-risk PTC (≤2 cm) and may provide insight into the different approaches in North American and Asian practices. This review intends to summarize the development and the rationale of AS for PTMC and highlights significant differences between North American and Japanese practices.

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.

Media coverage of calls to rename low-risk cancers: a content analysis

OBJECTIVES

The use of more medicalised labels can increase both concern about illness and the desire for more invasive treatment. This study analyses the media's coverage of an Analysis article in The BMJ which generated a large amount of high-profile international media coverage. It aims to understand how to better communicate messages about low-risk cancers and overdiagnosis to the public.

DESIGN

Content analysis of media coverage.

SETTING

Media was identified by Isentia Media Portal, searched in Google News and cross-checked in Factiva and Proquest databases from August 2018.

METHODS

Media headlines, full text and open access public comments responding to the coverage on the article proposing to 'rename low-risk conditions currently labelled as cancer' were analysed to determine the main themes.

RESULTS

45 original media articles and their associated public comments (n=167) were identified and included in the analysis. Overall, headlines focused on cancer generally and there was little mention of 'low-risk', 'overdiagnosis' or 'overtreatment'. The full text generally presented a more balanced view of the evidence and were supportive of the proposal, however, public responses tended to be more negative towards the idea of renaming low-risk cancers and indicated confusion. Comments seemed to focus on the headlines rather than the full article.

CONCLUSIONS

This study offers a novel insight into media coverage of the complex and counterintuitive problem of overdiagnosis. Continued deliberation on how to communicate similar topics to the public through the mainstream media is needed. Future work in the area of low-risk cancer communication should consider the powerful impact of people's previous experience with a cancer diagnosis and the criticism about being paternalistic and concealing the truth from patients.

Experience with Active Surveillance of Thyroid Low-Risk Carcinoma in a Developing Country

Background: The incidence of thyroid carcinoma is growing worldwide. More than 50% of new malignant tumors are classified as classical papillary carcinomas in low-risk category with a low rate of recurrence and high long-term survival. Active surveillance is a strategy to control low-risk tumor evolution with the intention to avoid unnecessary treatments and maintain thyroid function. The aim of this study was to report a cohort of patients with thyroid nodules classified as Bethesda V-VI and who are under active surveillance in Colombia. Methods: A prospective cohort was assembled since January 2015. All patients had been evaluated clinically, biochemically with ultrasonography and fine needle aspiration biopsy previous to the first evaluation. Active surveillance was proposed to patients with asymptomatic low-risk carcinoma (<1.5 cm, encapsulated, without evidence of lymph node metastasis), independent of sex or age. The strategy included a specific discussion about the surgical option and expected risk of complications, risk of long-term thyroxine support, and the active surveillance strategy. The data on age, sex, reason for an ultrasound examination, ultrasound risk by American Thyroid Association (ATA) classification, size and volume of the nodule, reason to consider active surveillance and follow-up ultrasounds, and surgical decision were recorded prospectively. A Kaplan-Meier curve was constructed for the rate of growth and increase in volume of the nodule, growth >3 mm and increase in volume >50%, and need of operation. Results: One hundred two patients were analyzed. Seventy-five percent of patients had a nodule smaller than 1 cm. Only 24/102 (23%) nodules were classified as ATA low risk. Thirty-four of 102 (33.3%) nodules were classified as Bethesda VI and the others were Bethesda V. The median follow-up was 13.9 months, and 32.3% of patients had more than 24 months of follow-up. Only 11/102 (10.8%) nodules grew more than 3 mm and 26/102 (25.5%) nodules grew more than 50% in volume. 12.7% patients were submitted to surgery. The overall stability rate without growth >3 mm, without volume increase >50%, and without surgery at 24 months were 89.8%, 77.0%, and 85.5%, respectively Conclusions: Active surveillance is possible in developing Western countries with similar results to those provided by Asian and American authors.

From Overdiagnosis to Overtreatment of Low-Risk Thyroid Cancer: A Thematic Analysis of Attitudes and Beliefs of Endocrinologists, Surgeons, and Patients

Introduction: The optimal management for patients with small, low-risk thyroid cancer is often debated. We aimed to characterize the attitudes and beliefs of providers and patients about management of small, low-risk thyroid cancer and how they relate to overtreatment. Methods: We conducted 34 semi-structured interviews with surgeons (n = 12), endocrinologists (n = 12), and patients with <1.5 cm papillary thyroid cancer (n = 10). Interviews probed about diagnosis and treatment decision-making, including nonoperative options. We used thematic analysis to identify themes related to overtreatment and created concept diagrams to map observed relationships between themes. Results: When providers discussed management of small, low-risk thyroid cancer, most felt that overtreatment was a problem, and some brought it up without prompting. Providers often believed that overtreatment results from overdiagnosis and relayed how the process commonly starts with incidental discovery of a thyroid nodule on imaging. Providers viewed biopsy of the nodule as a reflexive or habitual action. They ascribed inappropriate biopsy to lack of adherence to or knowledge of guidelines, radiologist recommendations, and the desire of patients and physicians to minimize diagnostic uncertainty. Providers described subsequent cancer diagnosis as an event that "opens Pandora's box" and often provokes a strong instinctive, culturally rooted need to proceed with surgery-specifically total thyroidectomy. Consequently, most providers felt that it is easier to prevent overdiagnosis than overtreatment and recommended strategies such as improving guideline adherence, resetting patients' expectations, and engaging the media. In contrast, patients did not bring up or openly discuss overtreatment or overdiagnosis. Some patients described the seemingly automatic process from an incidental finding to surgery. Their statements confirmed that the "need to know" was a major motivation for biopsying their nodule. Patients felt that once they had a cancer diagnosis, surgery was a foregone conclusion. Patients admitted their knowledge about thyroid nodules and cancer was low, leaving room for education about the need for biopsy and less extensive treatment options. Conclusions: Surgeons' and endocrinologists' attitudes and beliefs about overtreatment focus on the automaticity of overdiagnosis. Both patients and providers are cognizant of the cascade of clinical events that propel patients from incidental discovery of a thyroid nodule to surgery.

Systematic Review of Recurrence Rate after Hemithyroidectomy for Low-Risk Well-Differentiated Thyroid Cancer

BACKGROUND

Surgical extent in the management of well-differentiated thyroid cancer (DTC) remains a recurrent subject of debate. This is especially relevant in low-risk DTC of 1-4 cm, which represent the majority of new thyroid cancer diagnoses. With trends towards treatment de-escalation and recent guidelines from the American Thyroid Association and British Thyroid Association endorsing hemithyroidectomy (HT) alone for low-risk DTC of 1-4 cm, we sought to systematically appraise the literature to examine recurrence rate outcomes after HT in this low-risk group.

SUMMARY

Searching PubMed, Cochrane Library, and Ovid MEDLINE, we conducted a systematic review to assess the survival and recurrence rate data presented in all published studies that had a cohort of patients treated with HT for the treatment of DTC. Pooled 10-year survival and recurrence rates, odds ratios, and 95% confidence intervals were calculated for meta-analysis. We identified 31 studies (with a total of 228,746 patients (HT: 36,129, total thyroidectomy, TT: 192,617), which had published recurrence and/or survival data for patients having had HT for DTC. We discovered a pooled recurrence rate of 9.0% for HT, which is significantly higher than in previously published reports. Further, this rate is maintained when examining patients within low-risk cohorts established with recognised risk classifications. We also discovered that of those patients who develop recurrent disease, 48% recur outside the central neck.

KEY MESSAGES

Our study provides a comprehensive systematic review of evidence aimed primarily at defining the recurrence rate in DTC after HT, and more specifically within the low-risk subgroup. We describe pooled recurrence and 10-year survival rates from a larger, broader, and more contemporary patient population than has been previously reported. Our findings indicate that there is a small but significantly higher recurrence rate after HT than TT, but the evidence base is heterogenous and subject to confounding factors and would ultimately benefit from prospective randomised trials to overcome these deficiencies.

Active surveillance as a management strategy for papillary thyroid microcarcinoma

Active surveillance (AS) can be considered as a treatment strategy for low risk papillary thyroid microcarcinoma (PTMC), with the absence of clinically apparent lymph nodes, extrathyroidal extensions, and distant metastasis. After reviewing the reports on AS of low risk PTMCs worldwide, we introduced AS, and discussed the selection criteria for active surveillance candidates based on different guidelines and the follow-up schedules. Moreover, the requirement of cytological diagnosis, progression evaluation methods, necessity of thyrotropin suppression, and medical costs were issues that both clinicians and patients considered. The usefulness of AS for low risk PTMC patients depended on accurate and confidential evaluation of patient risk. Clinicians may adopt measures like dynamic monitoring, risk stratification, and making personal follow-up schedules to minimize these potential risks. By appropriately selecting PTMC patients, AS can be an effective alternative treatment to immediate surgery.

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.

Factors Associated With Diagnosis and Treatment of Thyroid Microcarcinomas

CONTEXT

Nearly one-third of all thyroid cancers are ≤1 cm.

OBJECTIVE

To determine diagnostic pathways for microcarcinomas vs larger cancers.

DESIGN/SETTING/PARTICIPANTS

Patients from Georgia and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries with differentiated thyroid cancer diagnosed in 2014 or 2015 were surveyed. Survey data were linked to SEER data on tumor and treatment characteristics. Multivariable logistic regression analysis was performed.

MAIN OUTCOME MEASURES

Method of nodule discovery; reason for thyroid surgery.

RESULTS

Of patients who underwent surgery, 975 (38.2%) had cancers ≤1 cm, and 1588 cancers (61.8%) were >1 cm. The reported method of nodule discovery differed significantly between patients with cancers ≤1 cm and those with cancers >1 cm (P < 0.001). Cancer ≤1 cm was associated with nodule discovery on thyroid ultrasound (compared with other imaging, OR, 1.59; 95% CI, 1.21 to 2.10), older patient age (45 to 54 years vs ≤44, OR, 1.45; 95% CI, 1.16 to 1.82), and female sex (OR, 1.51; 95% CI, 1.22 to 1.87). Hispanic ethnicity (OR, 0.71; 95% CI, 0.57 to 0.89) and Asian race (OR, 0.67; 95% CI, 0.49 to 0.92) were negative correlates. Cancers ≤1 cm were associated with lower likelihood of surgery for a nodule suspicious or consistent with cancer (OR, 0.48; 95% CI, 0.40 to 0.57).

CONCLUSION

Thyroid microcarcinomas are more likely to be detected by ultrasound and less likely to be associated with surgery scheduled for known thyroid cancer. Understanding diagnostic pathways allows for targeted interventions to decrease overdiagnosis and overtreatment.

[The influence of the pathologist on the mental well-being of the patient]

The label cancer in itself leads to complex psychological reactions in patients that are closely related to previous experiences and self-image. A cancer diagnosis can lead to increased distress and subsequent mental comorbidity such as depression or anxiety disorders. The responsibility of the pathologist, as the person who first uses the label cancer, is high. The pathologist must be conscious and focus not only on the accuracy of the anatomical pathology, but also on the potential influences the wording may have on the mental health of the patient. The word "carcinoma" should only be used in the case of tumors with the respective biological behavior. The example of non-invasive follicular thyroid neoplasm with papillary-like nuclear features shows that changing a label can lead to an improvement in distress and quality of life.

Association of Preferences for Papillary Thyroid Cancer Treatment With Disease Terminology: A Discrete Choice Experiment

Importance

Given recent evidence of overdiagnosis and overtreatment of small papillary thyroid cancers (PTCs) and other low-risk cancers, strategies are needed to help patients consider less invasive treatment options.

Objectives

To determine which factors influence treatment preferences for patients with PTC, and the trade-offs in treatment factors people are willing to accept, and to understand how terminology influences preferences and benefit-harm trade-offs.

Design, Setting, and Participants

Preferences in PTC treatment were evaluated using a discrete choice experiment (DCE) conducted as a web-based survey using an existing public online research panel. Participants were randomized to receive 1 of 2 frames of information based on the terminology used to describe the condition: "cancer" or "lesion." Participants chose between 3 treatment options for PTC (thyroidectomy, hemithyroidectomy, and active surveillance). Analyses were conducted using a mixed logit model.

Main Outcomes and Measures

The main outcome variable was treatment preference; attributes of treatment options and sociodemographic characteristics were explanatory variables.

Results

The DCE was completed by 2054 participants (993 [48.3%] men and 1061 [51.7%] women; mean [SD] age, 46.0 [16.5] years) with no history of thyroid cancer. Participants preferred options with less frequent follow-up, lower out-of-pocket costs, lower chances of having voice and calcium level problems, and a lower risk of developing invasive thyroid cancer and of dying of thyroid cancer. When trading benefits against harms, participants were willing to accept a higher number of extra patients experiencing adverse effects to avoid a thyroid cancer death when the condition was described as a cancer compared with a lesion. Specifically, participants for whom the condition was described as a cancer were willing to accept more patients requiring lifelong medication (mean, 273; 95% CI, 207-339 vs mean, 98; 95% CI, 66-131), experiencing calcium problems (mean, 110; 95% CI, 77-144 vs mean, 56; 95% CI, 55-58), and fatigue (mean, 958; 95% CI, 691-1224 vs mean, 469; 95% CI, 375-564). For both the cancer and lesion terminology, health literacy consistently was associated with preferences for treatment options. Those with lower health literacy had a significantly lower preference for less invasive treatment options.

Conclusions and Relevance

This study makes an important contribution to understanding how attributes of treatment options, terminology, and patient characteristics, in particular health literacy, influence treatment decision making for PTC. As a result of increasing evidence of the indolent nature of PTC and other low-risk cancers, strategies to deal with potential overtreatment are critically needed.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12617000066381.

Which papillary thyroid microcarcinoma should be treated as "true cancer" and which as "precancer"?

BACKGROUND

Papillary thyroid microcarcinoma (PTMC) generally is a cancer with excellent prognosis, but the term "cancer" sounds severe and harsh, which can elicit emotional and physical responses from patients. To eliminate the word "cancer," the term noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was introduced. However, not all PTMCs can be classified as NIFTP. Sometimes, very aggressive PTMC cases might be observed. Some authors suggest that one of the risk factors for poor prognosis is lymph node metastasis. The aim of the study was to evaluate some clinicopathological features of PTMC as the risk factors for lymph node metastasis.

MATERIAL AND METHODS

We performed a retrospective chart review and selected 177 patients with PTMC. To analyze the cases with potentially aggressive behavior, we enrolled PTMC patients with lymph node metastases (pN1, central, and/or lateral) and evaluated some of their clinicopathological features.

RESULTS

The logistic regression analysis results demonstrated significantly higher rates of multifocal or bilateral tumor occurrence in the PTMC patients with pN1 than in the patients with pN0 (P < 0.0001 for both). In addition, the occurrence of thyroid tumors with sizes above 0.5 cm was a significant risk factor for lymph node metastasis (P < 0.0001). The results of the ROC analyses showed that the presence of multifocal or bilateral tumors and tumor sizes above 0.5 cm were significant predictors of lymph node metastasis (P < 0.0001 for all).

CONCLUSIONS

Multifocal and bilateral PTMC tumors with diameters above 0.5 cm should be treated aggressively as "true cancer" and might benefit from lymph node dissection. Unifocal PTMC tumors with diameters equal to or below 0.5 cm may be treated less aggressively.

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.

Can Active Surveillance be an Alternative to Surgery in Papillary Thyroid Microcarcinoma?: The Current Situation Worldwide

Papillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumors with a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosis of PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension to the tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However, PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increase in thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despite the sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatment strategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate, and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option for PTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillance of low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression, and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting toward more conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to active surveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidence extended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediate surgery for appropriately selected patients with PTMC.

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

BACKGROUND

The 2015 American Thyroid Association guidelines recognize active surveillance as an alternative to immediate surgery in patients with papillary microcarcinomas (PMCs). As a way to incorporate active surveillance as one of the management options for patients with PMCs, we developed and tested a tool to support conversations between clinicians and patients with PMCs considering treatment options.

METHODS

Thyroid Cancer Treatment Choice was developed using an iterative process based on the principles of interaction, design, and participatory action research. To evaluate the impact of the tool on treatment choice, a prospective study was conducted in two thyroid cancer clinics in Seongnam-si and Seoul, South Korea. Both clinics had the expertise to offer active surveillance as well as immediate surgery. One clinic was trained in the use of the conversation aid, while the other clinic continued to care for patients without access to the conversation aid.

RESULTS

Between May 2016 and April 2017, 278 patients, mostly women (n = 220, 79%), were included in the study; 152 (53%) received care at the clinic using the conversation aid. Age, sex, and mean (±SD) tumor size (6.6 ± 1.6 mm and 6.5 ± 1.9 mm) distributions were similar across clinics. Overall, 233 (84%) patients opted for active surveillance and 53 (16%) for thyroid surgery. Patients in the conversation aid group were more likely to choose active surveillance than the patients seen in the usual care clinic (relative risk = 1.16 [confidence interval 1.04-1.29]). Of all patients opting for active surveillance, more patients in the conversation aid group had thyroid cancer nodules >5 mm than in the usual care group (81% vs. 67%; p = 0.013).

CONCLUSIONS

Thyroid Cancer Treatment Choice is an evidence-based tool that supports the presentation of treatment options for PMCs. Pilot testing suggests that this conversation tool increases acceptance of active surveillance, suggesting that this option is an acceptable and preferable alternative for informed patients. Further studies are warranted to confirm this finding.

Active Surveillance as First-Line Management of Papillary Microcarcinoma

Papillary thyroid microcarcinoma (PMC) is defined as papillary thyroid carcinoma ≤10 mm. Active surveillance of PMC without high-risk features, such as clinical node metastasis, distant metastasis, and clinical evidence of significant extrathyroid extension, was initiated in two Japanese hospitals in the mid-1990s. This strategy was incorporated into guidelines in Japan in 2010 and in the United States in 2015. In studies conducted by the two hospitals, most PMCs grew very slowly or did not grow, and none of the patients during active surveillance showed distant metastasis or died of thyroid carcinoma. Furthermore, none of the patients who underwent surgery after progression signs were detected showed significant recurrence. Therefore, we conclude that active surveillance should be the first line in management of low-risk PMC, because it is safer and less costly than immediate surgery. Active surveillance helps in avoiding adverse events of surgery and is an economical strategy.