Patient and surgeon perspectives on the American Thyroid Association (ATA) 2015 & British Thyroid Association (BTA) 2014 guidelines in the management of “Low-Risk” Thyroid Cancers (LRDTCs): Two sides of the coin

Abstract

Objectives:
To investigate how surgeons interpret the ATA 2015 and BTA 2014 guidelines for low risk well differentiated thyroid cancers (LRDTCs) and how they impact patient experiences across the UK.
Design:
Three nationally disseminated anonymised questionnaires.
Setting:
A nationwide snapshot of LRDTC management.
Participants:
Thyroid surgeons and their respective thyroid cancer multidisciplinary teams (MDTs) and thyroid cancer patients.
Main outcome measures:
The outcomes of interest were how surgeons/MDTs are managing LRDTCs and patient perspectives on ‘shared-decision-making’ and their ideal surgical management for LRDTCs.
Results:
74 surgeons responded. 88% utilised BTA guidelines to assess recurrence risk. Tumour size, histology, stage T3b and central nodal involvement were important for >85%, but age (>45 years) only for 50%. In T1 (2cm), Thy5 solitary nodule, 58% supported hemi-thyroidectomy (HT), with 33% for total thyroidectomy (TT). In T2 (3cm) PTC, 54% opted for TT, with 24% favouring HT. Over 90% recommended TT for any incidentally excised microscopically positive lymph nodes. In T1a(m) multifocal micro-PTC, 63% suggested HT, but with contralateral benign nodules, 66% supported TT.
40% of patients felt ‘pros and cons’ of different managements were not fully explained. 47% felt they didn’t have significant input in their management, with 53% feeling final management was clinician’s choice. 60% preferred TT, with 80% wanting to ensure there was no cancer left and avoid recurrence. 20% preferred HT, with 46% wishing to avoid lifelong thyroxine.
Conclusions:
There is variation in risk assessment and management of LRDTCs nationally, with contrasting views of optimum treatment between patients and clinicians. These variations in practice are affecting patient experiences nationally.

Introduction

In the UK, the incidence of thyroid cancer has risen from 2 per 100,000 in 1993 to 6 per 100,000 in 2016, with a projected incidence of 11 per 100,000 in 20351. This increase is attributed largely to the use of high-resolution ultrasonography and the diagnosis of small ‘low-risk’ papillary thyroid cancers (PTCs)2,3. Although most patients with thyroid cancer have an excellent prognosis, up to 30% recur4. Many risk stratification systems have been designed to predict survival. However, only the American Thyroid Association (ATA) risk stratification (2009) was tailored for recurrence risk. The 2015 ATA guidelines5 refines its stratification for recurrence. This identifies ‘low-risk’ cancers that may be suitable for treatment de-escalation in the form of hemithyroidectomy only. Similarly, the British Thyroid Association (BTA) 2014 guidelines have provided similar risk criteria and management strategies of ‘low-risk’ patients6.
The British Association of Endocrine and Thyroid Surgeons’ (BAETS) 2012 national audit report demonstrated that, prior to the release of the two guidelines, total thyroidectomy (either as a staged or a single procedure) was used to treat the majority of thyroid cancer cases7. Two recent studies by Israeli and American groups have demonstrated that the updated guidelines have caused a significant change in surgical management of ‘low-risk’ small tumours that represent the majority of new thyroid cancer diagnoses8,9.
Much debate remains about the pros and cons of total thyroidectomy (TT) (standard treatment to date) versus hemithyroidectomy (HT) (treatment de-escalation) in these patients, largely due to lack of level one evidence and potentially biased and limited retrospective data. Further, interpretation of “low-risk thyroid cancer” is open to potential variability, depending on specific guidelines used. This can lead to heterogenous clinical practice as demonstrated by Haymart et al.10–13 who reported significant variation in thyroid cancer management that was not explained by case-mix, but more related to the physicians’ decision making. This in turn, will lead to varied (over- or under-treated) patient experiences.
This study aims to investigate how UK thyroid surgeons and multidisciplinary teams (MDTs) interpret the latest BTA and ATA guidelines to formulate their management strategy for patients with low risk differentiated thyroid cancers (LRDTCs) and how these clinical decisions impact patient perspectives and experiences surrounding difficult ‘shared-decision-making’ processes.

Study Methods

A questionnaire was sent to thyroid surgeons and their regional thyroid MDTs to ascertain the current national perspective on the management of LRDTCs (Appendix A). Surgeons and their respective MDTs were identified through the “De-anonymised data from BAETS National Database of Endocrine & Thyroid Procedures 2016” 14 website, although not all are MDT-designated thyroid cancer surgeons. The questionnaire was emailed via the BAETS, ENT-UK, National Cancer Research Institute and Thyroid Cancer Forum websites. This questionnaire enquired about which guidelines they followed and the risk factors they considered important for decision making. It also presented index case scenarios to investigate how different surgeons/MDTs managed LRDTC cases of varying complexity.
A questionnaire was sent to patients to understand their experiences and perspectives on the ‘shared-decision-making’ process during their management (Appendix B). This focused on which treatment options were offered and how patients felt about the information given to them regarding their management plans. This was posted online through the National Butterfly Thyroid Cancer Trust’s social media platforms (Facebook and Twitter).
Another questionnaire sent to a different cohort of thyroid cancer patients (Appendix C) specifically enquired, given the ‘pros and cons’ of each surgical choice, which surgical management (hemi- vs total thyroidectomy (or completion surgery)) they would ideally have preferred if diagnosed with LRDTC and their reasons for the choice. We explained that ATA and BTA guidelines proposed treatment de-escalation in LRDTC cases and patients should be offered the choice between a hemi-thyroidectomy or total thyroidectomy. We wished to investigate whether patients’ views and preferences were in line with the updated guidelines.

Results

Surgeons’ Responses

There were 74 responses from thyroid surgeons. Mapping out the area of practice, most of the UK was covered (Figure 1), giving a good national representation of current practice.
Seventy-two surgeons (97.3%) confirmed they were a core member of the regional thyroid cancer MDT and the majority (72%) reported performing over 30 thyroid operations (hemi- and total thyroidectomies) per annum.
Our survey observed that 87.9% utilised the BTA guidelines with or without other guidelines (ATA, AJCC, AMES) to assess recurrence risk in LRDTC (Table 1.1).
Risk factors that were most frequently considered by MDTs in assessing recurrence risk can be seen in Table 1.2.
To understand how risk assessment and the ATA and BTA guidelines for treatment de-escalation have influenced current UK practice in the management of LRDTC, a series of index cases of LRDTCs were presented. Respondents were asked how they would manage such cases. The responses are represented in Table 1.3.