Practice patterns in the management of thyroid cancer

In this issue of the Journal of Surgical Oncology, Schumm et al. from the University of California, Los Angeles, discuss the perception of risk and treatment decisions in the management of differentiated thyroid cancer. The authors have undertaken an interesting study of various clinical vignettes on thyroid cancer and response from members of the American Thyroid Association (ATA). The authors have noted that there is a wide variation in risk estimates and treatment preferences among thyroid cancer specialists. Surprisingly, they found that only 10.3% of the observed variation in the initial treatment management recommendations was explained by the clinicians' perceived risk reduction associated with more aggressive treatment recommendations. As part of their study, the authors emailed a survey link to 1367 thyroid specialists from the ATA asking for treatment decisions for four common clinical case scenarios and analyzed the data critically in relation to the clinicians' perceived risk of structural disease recurrence, risk of surgical complications, the estimated 5‐year risk of metastatic disease, and other factors. Only 590 (43%) opened the email and of those only 183 (31%) completed the survey, accounting for an overall response rate of 13.4%. This poor response rate is likely due to the high volume of emails physicians receive, sometimes from unknown or disreputable senders; the email may have largely been inadvertently disregarded as a result. Of note, although the surgical membership of ATA is much smaller than endocrinologists, among the respondents 52% were endocrinologists and 44% were surgeons, suggestive of a higher participation rate from the surgical membership. While focusing on the importance of perceived assessment of the risk of structural recurrence and surgical complications, the survey would not address the wide variety of other factors that could influence treatment decisions that the authors consider in the discussion. In any case, the study is quite interesting as to the clinical vignettes and response from thyroid experts both in endocrinology and surgery. Respondents were also asked to classify their personal management approach to thyroid cancer: as conservative, moderate, or aggressive. Not surprisingly, the majority self‐identified as moderate (61%) and very few as aggressive (9%); however, we are not sure everybody thinks critically enough to accurately assess themselves as being conservative, moderate, or aggressive (or as minimalist or maximalist). It is very interesting that despite the clinicians' perceived risk of structural recurrence, surgical complications, or impact of more aggressive interventions on these risk factors, they were highly aligned with local practice patterns, which appeared to have a significant influence on their management recommendations. The four clinical vignettes are interesting and common problems in the management of thyroid cancer and the opinions can vary largely depending upon the clinical practice pattern of the institution, who is dealing with the patient primarily, a surgeon or endocrinologist, who can convince the patient that the treatment they have received is the best approach. The authors have presented four cases of low‐risk thyroid cancer, including one tall cell case and one BRAF‐positive case. As reported by the authors, there is considerable variation in the response. Our team at Memorial Sloan Kettering Cancer Center (MSK) feels very comfortable with lobectomy alone as long as the opposite lobe is within normal limits and there are no suspicious lymph nodes during preoperative imaging and intraoperative findings. We believe completion thyroidectomy should only be considered in cases involving multiple positive nodes, gross extrathyroidal extension, or very aggressive histology. This clearly requires a decision‐making approach between the surgeon and the endocrinologist who will monitor the patient and underscores the importance of local practice patterns on management recommendations. We feel the role of radioactive iodine (RAI) is very limited and completion thyroidectomy should not be considered unless there is a strong indication for RAI. Treatment should be individualized, with decisions about the extent of thyroidectomy and RAI based on the extent of the primary tumor, nodal status, histological studies, the likelihood that RAI will have a significant impact on outcomes, and patient preference. There has been a major paradigm shift in the management of thyroid cancer to avoid overly aggressive therapy and treatment‐ related medical and surgical complications. However, it is important to identify patients who may benefit from aggressive surgery and RAI. Preoperative evaluation includes a high‐quality ultrasonographic evaluation of the thyroid and cervical lymph nodes, as well as CT scan with contrast to better, define the extent of disease in all but the most low‐risk thyroid cancer patients. The authors have also included a case of microcarcinoma for active surveillance. Interestingly, 36% of the respondents recommended active surveillance which is a handsome number today in the United States as active surveillance has been practiced only in a few institutions in the United States and the largest experience comes from MSK with approximately 500 patients. Active surveillance has been practiced in Japan over the last 25 years with cautious monitoring and avoiding surgery. However, the risk estimated for cervical lymph node metastasis (interquartile range [IQR]: 45%–15%) or distant metastasis (IQR 1%–5%) are significantly higher than