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.