Preferences of patients and clinicians for treatment of Graves' disease: a discrete choice experiment

Exploring Pet Owner Preferences in Order to Assess the Role of Cost and Quality of Life in Anti-Pruritic Treatment Plan Selection for Dog Owners

A web-based quantitative survey tested pet owners' preferences and willingness-to-pay for canine anti-pruritus therapies, and for improvements in pruritus-related quality of life. This survey was designed using findings from recent research into quality of life in pruritus, interviews with pet owners and veterinarians, and clinical and cost data. The survey was completed by 251 dog owners in the United Kingdom. A total of 46-47% were willing to pay to improve individual concepts of pruritus-related quality of life, including comfort, scratching behavior, and appearance. Instituting treatment to manage pruritus and the investigation of pruritus causes were considered important actions; safety and effectiveness were the most important attributes of therapy. Comparing the administration, effectiveness, safety, and costs of (unbranded) therapy profiles, on average, 63% preferred hypothetical tablet or injectable therapies (with higher cost and improved safety) over corticosteroid treatment for acute pruritus (p < 0.05). Over 50% of respondents preferred the hypothetical therapies in all tested subgroups, and results were similar for chronic pruritus. This research highlighted that many pet owners are willing to pay to improve their pet's quality of life, and to receive comparably effective, yet safer therapies for the management of acute canine pruritus, regardless of insurance status. Veterinarians should consider discussing and offering newly available therapies for acute and chronic pruritus with pet owners where medically appropriate.

A Predictive Model for Graves' Disease Recurrence After Antithyroid Drug Therapy: A Retrospective Multicenter Cohort Study

OBJECTIVES

Predicting recurrence after antithyroid drug (ATD) cessation is crucial for optimal treatment decision-making in patients with Graves' disease (GD). We aimed to identify factors associated with GD recurrence and to develop a model using routine pretherapeutic clinical parameters to predict GD recurrence risk during the first year following ATD discontinuation.

METHODS

This electronic health records-based observational cohort study analyzed patients with GD treated with ATDs at 3 U.S. academic centers. Demographic, clinical characteristics, and GD recurrence within 1 year following ATD discontinuation were assessed. Univariable and multivariable analyses were performed. A predictive model for GD recurrence was developed and visualized as a nomogram.

RESULTS

Among the 523 patients included in the study, 211 (40.34%) discontinued treatment. Of these, the 142 (67.29%) that had a follow-up period exceeding 12 months after stopping ATD were used for the development of the predictive model. Among the patients included in the model, the majority were women (n = 111, 78.16%), with a mean age of 49.29 years (standard deviation 16.31) and baseline free thyroxine (FT4) levels averaging 3.39 ng/dl (standard deviation 2.25). Additionally, 79 of 211 patients (37.44%) experienced recurrence within 1 year. Multivariable analysis indicated a 31% increased risk of GD recurrence per additional decade of age (odds ratio 1.31, 95% confidence interval 1.03-1.66, P = .0258), and a 65% increased risk of GD recurrence for every 2.0 ng/dL rise in baseline FT4 (odds ratio 1.65, 95% confidence interval 1.08-2.50, P = .0192). The recurrence predictive model's area under the curve was 0.69 in the derivation dataset and 0.65 in cross-validation.

CONCLUSIONS

This study introduced a practical model that can be used during the initial therapeutic decision-making process. It utilizes easily accessible baseline clinical data to predict the likelihood of GD recurrence after 1 year of ATD therapy. Further research is needed to identify other factors affecting risk of recurrence and develop more precise predictive models.

A 2023 International Survey of Clinical Practice Patterns in the Management of Graves Disease: A Decade of Change

CONTEXT

Over the past several decades, there have been indications of potential shifts in the diagnostic strategies, treatment, and monitoring of patients with Graves disease (GD).

OBJECTIVE

To evaluate current practices in managing GD and compare them to previous surveys.

METHODS

We used a global online survey of endocrinologists to assess shifts in the diagnosis, monitoring, and treatment in a typical patient with GD, as well as treatment variation in 5 different clinical scenarios.

RESULTS

A total of 1252 respondents from 85 countries completed the survey. Methods used to diagnose an uncomplicated GD case have changed over the past decade, reflecting increased use of thyrotropin receptor antibody (TRAb) and reciprocal decreases in nuclear medicine studies. The preferred mode of therapy for uncomplicated GD was antithyroid drugs (ATDs) by 91.5% of respondents, radioactive iodine (RAI) therapy by 7%, and thyroidectomy by 1.5%. Compared with previous surveys, the use of RAI as a first-line choice decreased in all geographic regions. The United States had the sharpest decline in the selection of initial therapy with RAI, decreasing from 69% in 1990 to 11.1% in 2023. In patients with persistent TRAb positivity after 18 months, 68.7% of respondents would continue the use of ATDs. After a relapse of GD, resumption of ATDs was selected by 59.9% of respondents. In patients with active thyroid eye disease or planning pregnancy, ATDs were the first choice (67.5% and 72.8%, respectively), and thyroidectomy emerged as the second choice (22.9% and 15.6%, respectively).

CONCLUSION

Paradigm shifts have occurred in the management of uncomplicated GD and its variants, as well as the response to persistent and recurrent hyperthyroidism.

The need for the GREAT+ score to predict relapse in Graves' disease: a questionnaire among patients and internal medicine specialists

PURPOSE

Graves' disease (GD) is an auto-immune cause of hyperthyroidism. First-line treatment often consists of a 12-18 month course of antithyroid drugs (ATD). After discontinuation of ATD, GD relapses in approximately 50% of patients. The 'Graves recurrent event after therapy+ ' (GREAT+) score may predict individual relapse chances after ATD discontinuation more accurately based on clinical and laboratory parameters at diagnosis. We investigated the need for the GREAT+ score through an online questionnaire among GD patients and physicians treating GD.

METHODS

An anonymous online questionnaire was distributed to patients and physicians between June 2022 and August 2023.

RESULTS

The questionnaire was completed by 532 patients and 44 physicians. Results showed that 94% of patients were interested in knowing their GREAT+ score at the start of treatment. 55% would consider definite treatment (radioiodine/thyroidectomy) as first-line treatment in case of a high relapse chance. 98% of the physicians indicated the GREAT + score would support patient counseling. 84% may change their advice for first-line treatment if a patient has a high relapse chance based on the score.

CONCLUSION

Patients and physicians considered the GREAT+ score as a valuable addition to the current available information which could change treatment decisions. Therefore, external validation of the GREAT+ score is justified to implement this score in clinical practice.

Approach to the Patient Considering Long-term Antithyroid Drug Therapy for Graves' Disease

Antithyroid drugs (ATD) are the treatment of choice for the majority of patients with Graves' hyperthyroidism worldwide. However, relapse of hyperthyroidism after withdrawal of arbitrarily chosen conventional 12 to 18 months of therapy is very common. In the last 2 decades, many studies have shown that treatment with long-term ATD (LT-ATD) is effective and safe in the maintenance of euthyroidism. In addition, it has been reported that serum TSH receptor antibody may not decrease permanently before 5 to 6 years of ATD treatment, and clinical trials have shown that ≥5 years of ATD treatment is accompanied by remission in the majority of patients with Graves' hyperthyroidism. The objective of this article is to discuss the optimal time to withdraw of conventional ATD therapy, to illustrate the decision-making of the management of recurrent hyperthyroidism, to review the proper management of LT-ATD, and to generate suggestions for lifelong ATD treatment by discussing 4 scenarios of decision-making in patients with Graves' disease.

Preference Phenotypes in Thyroid Nodule Management: A Patient Segmentation Approach

OBJECTIVE

Patient preferences regarding thyroid nodules are poorly understood. Our objective is to (1) employ a discrete choice experiment (DCE) to explore risk tradeoffs in thyroid nodule management, and (2) segment respondents into preference phenotypes.

STUDY DESIGN

DCE.

SETTING

Thyroid surgery clinic, online survey.

METHODS

A DCE including 5 attributes (cancer risk, voice concerns, incision/scar, medication requirement, follow-up frequency) was refined with qualitative patient and physician input. A final DCE including 8 choice tasks, demographics, history, and risk tolerance was administered to participants with and without thyroid disease. Analysis was performed with multinomial logit modeling and latent class analysis (LCA) for preference phenotyping.

RESULTS

A total of 1026 respondents were included; 480 had thyroid disease. Risk aversion was associated with increasing age (P < .001), female gender (P < .001), and limited education (P = .038), but not previous thyroid disease. Cancer risk most significantly impacted decision-making. Of the total possible utility change from thyroid nodule decision-making, 47.8% was attributable to variations in cancer risk; 20.0% from medication management; 14.9% from voice changes; 12.7% from incision/scar; and 4.6% from follow-up concerns. LCA demonstrated 3 classes with distinct preference phenotypes: the largest group (64.2%) made decisions primarily based on cancer risk; another group (18.2%) chose based on aversion to medication; the smallest group (17.7%) factored in medication and cancer risk evenly.

CONCLUSION

Cancer risk and the need to take medication after thyroid surgery factor into patient decision-making most heavily when treating thyroid nodules. Distinct preference phenotypes were demonstrated, reinforcing the need for individual preference assessment before the treatment of thyroid disorders.

Pet Owners' Preferences for Quality of Life Improvements and Costs Related to Innovative Therapies in Feline Pain Associated with Osteoarthritis-A Quantitative Survey

This research aimed to explore UK cat owners' preferences for treatments for feline osteoarthritis (OA) by exploring preferences around quality of life (QoL) improvements, safety considerations, and costs associated with hypothetical innovative pain therapies. Aspects identified in an existing conceptual framework were extracted for inclusion in exploratory interviews with cat owners (n = 3) to identify key domains that contribute to the QoL of cats. QoL descriptions for cats with OA and hypothetical product attributes were developed and validated through interviews with veterinarians (n = 3). An online survey was subsequently shared with 255 pet owners in the UK. Pet owners were presented with QoL descriptions and hypothetical product attributes to gather their preferences for QoL improvements and their willingness to pay (WTP) for (unbranded) pain therapies at various price points. Pet owners were motivated to improve their cats' QoL, which translated into WTP for therapies; specifically, pet owners valued QoL improvements in mobility, pain expression, and well-being. When presented with a product profile of the hypothetical novel monoclonal antibody (mAb) and cost, 50% of cat owners were willing to pay more for a mAb that is expected to have improved efficacy and safety when compared to a hypothetical standard of care (SoC). Significantly more pet owners preferred the mAb than the SoC when price was not presented (p < 0.01), with product efficacy and safety driving pet owners' decision-making. The majority of pet owners did not agree that taking their cats to the veterinarian once a month for their treatment would be burdensome. Cat owners in the UK are motivated to improve their cats' QoL, which translates into WTP for the efficacious treatment of pain associated with osteoarthritis. Veterinarians should offer cat owners the pain treatment they feel is best suited for improving the cat's QoL and to ensure subsequent owner-pet bond is preserved.

A Personalized Patient Preference Predictor for Substituted Judgments in Healthcare: Technically Feasible and Ethically Desirable

When making substituted judgments for incapacitated patients, surrogates often struggle to guess what the patient would want if they had capacity. Surrogates may also agonize over having the (sole) responsibility of making such a determination. To address such concerns, a Patient Preference Predictor (PPP) has been proposed that would use an algorithm to infer the treatment preferences of individual patients from population-level data about the known preferences of people with similar demographic characteristics. However, critics have suggested that even if such a PPP were more accurate, on average, than human surrogates in identifying patient preferences, the proposed algorithm would nevertheless fail to respect the patient's (former) autonomy since it draws on the 'wrong' kind of data: namely, data that are not specific to the individual patient and which therefore may not reflect their actual values, or their reasons for having the preferences they do. Taking such criticisms on board, we here propose a new approach: the Personalized Patient Preference Predictor (P4). The P4 is based on recent advances in machine learning, which allow technologies including large language models to be more cheaply and efficiently 'fine-tuned' on person-specific data. The P4, unlike the PPP, would be able to infer an individual patient's preferences from material (e.g., prior treatment decisions) that is in fact specific to them. Thus, we argue, in addition to being potentially more accurate at the individual level than the previously proposed PPP, the predictions of a P4 would also more directly reflect each patient's own reasons and values. In this article, we review recent discoveries in artificial intelligence research that suggest a P4 is technically feasible, and argue that, if it is developed and appropriately deployed, it should assuage some of the main autonomy-based concerns of critics of the original PPP. We then consider various objections to our proposal and offer some tentative replies.

Graves-PCD: protocol for a randomised, dose-finding, adaptive trial of the plasma cell-depleting agent daratumumab in severe Graves' disease

INTRODUCTION

Severe Graves' disease is a life-changing condition with poor outcomes from currently available treatments. It is caused by directly pathogenic thyroid-stimulating hormone receptor-stimulating antibodies (TRAb), which are secreted from plasma cells. The human anti-CD38 monoclonal antibody daratumumab was developed to target plasma cells which express high levels of CD38, and is currently licensed for treatment of the plasma cell malignancy, myeloma. However, it can also deplete benign plasma cells with the potential to reduce TRAb and alter the natural history of severe Graves' disease. This study aims to establish proof of concept that daratumumab has efficacy in patients with severe Graves' disease and will provide important data to inform a choice of dosing regimen for subsequent trials.

METHODS AND ANALYSIS

The Graves-PCD trial aims to determine if daratumumab modulates the humoral immune response in patients with severe Graves' disease, and if so, over what time period, and to find an optimal dose. It is a single-blinded, randomised, dose-finding, adaptive trial using four different doses of daratumumab or placebo in 30 adult patients. Part 1 of the trial is dose-finding and, following an interim analysis, in part 2, the remaining patients will be randomised between the chosen dose(s) from the interim analysis or placebo. The primary outcome is the percentage change in serum TRAb from baseline to 12 weeks.

ETHICS AND DISSEMINATION

The trial received a favourable ethical opinion from London-Hampstead Research Ethics Committee (reference 21/LO/0449). The results of this trial will be disseminated at international meetings, in the peer-reviewed literature and through partner patient group newsletters and presentations at patient education events.

TRIAL REGISTRATION NUMBER

ISRCTN81162400.

Risk of recurrence at the time of withdrawal of short- or long-term methimazole therapy in patients with Graves' hyperthyroidism: a randomized trial and a risk-scoring model

PURPOSE

In Graves' disease, administration of low-dose methimazole for more than 60 months induces higher remission rates compared with the conventional duration of 12-18 months. However, the risk of recurrence and its predictors beyond 48 months of drug withdrawal are not known. The aims of this study were to determine the risk of recurrence during 84 months after withdrawal of short- or long-term methimazole therapy and a risk stratification for recurrence of hyperthyroidism.

METHODS

A total of 258 patients were treated with methimazole for a median of 18 months and randomized to discontinuation of the drug(conventional short-term group; n = 128) or continuation of the treatment up to 60-120 months(long-term group; n = 130). Patients were followed for 84 months after methimazole withdrawal. Cox proportional hazards modeling was performed to identify factors associated with relapse and develop a risk-scoring model at the time of discontinuing the treatment.

RESULTS

Hyperthyroidism recurred in 67 of 120(56%) of conventionally-treated patients versus 20 of 118(17%) of those who received long-term methimazole treatment, p < 0.001. Age, sex, goiter grade, triiodothyronine, thyrotropin, and thyrotropin receptor antibodies were significant predictors of recurrence in both "conventional" and "long-term" groups but free thyroxine just in the "long-term" group. The risk-scoring model had a good discrimination power (optimism corrected c-index = 0.78,95%CI = 0.73-0.82) with a range of 0-14 and sensitivity of 86% and specificity of 62% at the risk-score of eight.

CONCLUSION

A relapse-free state was achieved in 83% of patients with Graves' hyperthyroidism 84 months after cessation of long-term methimazole treatment which could be predicted by some significant predictors in a simple risk-scoring system.

Enhanced predictive validity of integrative models for refractory hyperthyroidism considering baseline and early therapy characteristics: a prospective cohort study

BACKGROUND

A subset of Graves' disease (GD) patients develops refractory hyperthyroidism, posing challenges in treatment decisions. The predictive value of baseline characteristics and early therapy indicators in identifying high risk individuals is an area worth exploration.

METHODS

A prospective cohort study (2018-2022) involved 597 newly diagnosed adult GD patients undergoing methimazole (MMI) treatment. Baseline characteristics and 3-month therapy parameters were utilized to develop predictive models for refractory GD, considering antithyroid drug (ATD) dosage regimens.

RESULTS

Among 346 patients analyzed, 49.7% developed ATD-refractory GD, marked by recurrence and sustained Thyrotropin Receptor Antibody (TRAb) positivity. Key baseline factors, including younger age, Graves' ophthalmopathy (GO), larger goiter size, and higher initial free triiodothyronine (fT3), free thyroxine (fT4), and TRAb levels, were all significantly associated with an increased risk of refractory GD, forming the baseline predictive model (Model A). Subsequent analysis based on MMI cumulative dosage at 3 months resulted in two subgroups: a high cumulative dosage group (average ≥ 20 mg/day) and a medium-low cumulative dosage group (average < 20 mg/day). Absolute values, percentage changes, and cumulative values of thyroid function and autoantibodies at 3 months were analyzed. Two combined predictive models, Model B (high cumulative dosage) and Model C (medium-low cumulative dosage), were developed based on stepwise regression and multivariate analysis, incorporating additional 3-month parameters beyond the baseline. In both groups, these combined models outperformed the baseline model in terms of discriminative ability (measured by AUC), concordance with actual outcomes (66.2% comprehensive improvement), and risk classification accuracy (especially for Class I and II patients with baseline predictive risk < 71%). The reliability of the above models was confirmed through additional analysis using random forests. This study also explored ATD dosage regimens, revealing differences in refractory outcomes between predicted risk groups. However, adjusting MMI dosage after early risk assessment did not conclusively improve the prognosis of refractory GD.

CONCLUSION

Integrating baseline and early therapy characteristics enhances the predictive capability for refractory GD outcomes. The study provides valuable insights into refining risk assessment and guiding personalized treatment decisions for GD patients.

Management after non-curative endoscopic resection of T1 rectal cancer

Since the introduction of population-based screening, increasing numbers of T1 rectal cancers are detected and removed by local endoscopic resection. Patients can be cured with endoscopic resection alone, but there is a possibility of residual tumor cells remaining after the initial resection. These can be located intraluminally at the resection site or extraluminally in the form of (lymph node) metastases. To decrease the risk of residual cells progressing towards more advanced disease, additional treatment is usually needed. However, with the currently available risk stratification models, it remains challenging to determine who should and should not be further treated after non-curative endoscopic resection. In this review, the different management strategies for patients with non-curatively treated T1 rectal cancers are discussed, along with the available evidence for each strategy and relevant considerations for clinical decision making. Furthermore, we provide practical guidance on the management and surveillance following non-curative endoscopic resection of T1 rectal cancer.

Preferences and Willingness to Pay for Medication in Patients with Renal Cell Carcinoma in China: A Discrete-Choice Experiment

OBJECTIVE

We aimed to assess the relative importance of attributes and the willingness to pay for pharmacological therapies among patients with renal cell carcinoma in China.

METHODS

Patients with renal cell carcinoma completed a D-efficient-designed, discrete-choice experiment online survey that presented a series of ten trade-off questions and one examining scenario. Based on the literature review and consultations with patients with renal cell carcinoma and clinicians, each question included a pair of hypothetical renal cell carcinoma medication profiles characterized by seven attributes including progression-free survival, objective response rate, medication regimen, fatigue, gastrointestinal reaction, hand-foot syndrome, and monthly out-of-pocket costs. Relative importance and willingness to pay were calculated using coefficients estimated by mixed logit regression in the main analysis. Subgroup analyses were conducted considering the heterogeneity of the participants, based on sex, education level, and income level, using conditional logit regression.

RESULTS

The analysis incorporated responses from 182 Chinese respondents. Except for the medication regimen, all attributes were statistically significant. Progression-free survival was the most important attribute, followed by objective response rate, monthly out-of-pocket costs, fatigue, gastrointestinal reaction, and hand-foot syndrome. Patients were willing to pay ￥2010.51 ($298.30), ￥494.93 ($73.43) for 1 unit improvement of progression-free survival, and objective response rate, and￥7558.93 ($1121.50), ￥6927.24 ($1027.78) to avoid experiencing fatigue and gastrointestinal reaction, respectively. Differences in preferences and willingness to pay were found according to patients' gender, income, and education level.

CONCLUSIONS

In China, patients with renal cell carcinoma preferred medications with better efficacy (objective response rate and progression-free survival) and lower out-of-pocket costs. Heterogeneity can be found in preferences and willingness to pay based on patients' gender, income, and education levels.

Radioactive Iodine: A Living History

Background: Before the development of antithyroid drugs in the 1940s, treatment of Graves' hyperthyroidism was primarily surgical. Surgical mortality was quite variable, but a significant minority of patients died during or after surgery. Summary: In 1936, Karl Compton, President of the Massachusetts Institute of Technology, in a lecture attended by Massachusetts General Hospital physicians, suggested that artificially radioactive isotopes might be useful for studying metabolism. By 1942, Hertz and Roberts reported on the successful use of radioactive iodine (RAI) to treat Graves' hyperthyroidism. RAI uptake was subsequently demonstrated in well-differentiated thyroid cancer metastases. In 1948, Seidlin demonstrated stimulation of uptake in thyroid cancer metastases by thyrotropin (TSH). By 1990, 69% of endocrinologists in North America recommended RAI for Graves' hyperthyroidism. Currently RAI is less frequently used for Graves' hyperthyroidism, related to concerns about exacerbation of thyroid eye disease, about radiation exposure, and about potential adverse consequences of permanent hypothyroidism. Similarly, RAI was administered to the majority of patients with thyroid cancer for decades, but its use is now more selective. Conclusions: RAI is a remarkable example of interinstitutional cooperation between physicians and scientists to transition from bench to bedside in only three years. It is the model for a theranostic approach to disease (the simultaneous use of a radioactive drug for diagnosis and therapy). The future of RAI is less certain; inhibition of TSH receptor stimulating antibodies in Graves' disease and more precise targeting of genes that drive thyroid oncogenesis may diminish the use of RAI. Alternatively, redifferentiation techniques may improve the efficacy of RAI in RAI-refractory thyroid cancer.

Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis

Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.

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.

Revisiting the role of surgery in the treatment of Graves' disease

Graves' disease (GD) can be managed by antithyroid drugs (ATD), radioactive iodine (RAI) and surgery. Thyroidectomy offers the highest success rates for both primary and persistent disease, yet it is the least recommended or utilized option reaching <1% for primary disease and <25% for persistent disease. Several surveys have found surgery to be the least recommended by endocrinologists worldwide. With the development of remote access thyroidectomies and intraoperative nerve monitoring of the recurrent laryngeal nerve, combined with current knowledge of possible risks associated with RAI or failure of ATDs, revaluation of the benefit to harm ratio of surgery in the treatment of GD is warranted. The aim of this review is to discuss possible reasons for the low proportion of surgery in the treatment of GD, emphasizing an evidence-based approach to the clinicians' preferences for surgical referrals, surgical indications and confronting traditional reasons and concerns relating to the low referral rate with up-to-date data.

Management of Graves' hyperthyroidism: present and future

INTRODUCTION

Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism.

AREAS COVERED

Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease.

EXPERT OPINION

ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.