American Thyroid Association 86th Annual Meeting:
Managing Thyroid Nodules: Are Guidelines Being Met?
The American Thyroid Association (ATA) updated recommendations for the management of thyroid nodules;1 yet, how well have clinicians made the necessary adjustments in their practice to follow these recommendations?
“Not quite [enough],” said Henry B. Burch, MD, professor of medicine at the Walter Reed Army Medical Center, in Bethesda, Maryland in presenting his findings on the Thyroid Nodule Management Survey,2 at the American Thyroid Association annual meeting in Denver, Colorado.
The results offered some surprising discrepancies.
"[Such as] things like testing, thresholds for biopsy, and management during pregnancy," Dr. Burch said. “In some cases, physicians did more testing than the guidelines called for, while in other cases, too little was done.’’
Practice to Guidelines Comparison
Dr. Burch took a case-based approach to the questions, using survey responses from 897 physicians who were asked how they would manage two specific cases. Dr. Burch's team initiated this study by approaching physicians after the guidelines came out online--getting 897 physician responses.
The guidelines1 were published in January 2016, but have been available online to ATA members since 2014. How closely does your practice align with the guidelines?
Index Case One: 52-year-old Female
The first case was a 52-year-old woman with an incident 1.5 centimeter right thyroid nodule. She had no known prior diagnosis of thyroid disease, was takings no medication, was not a smoker, had no history of radiation exposure, and there was no family history of thyroid disease.
On exam, she had no cervical lymphadenopathy, and the nodule was not palpable.
What Would Your Next Step Be?
Under the guidelines,1 a thyroid stimulating hormone (TSH) test would be recommended, but tests for neither serum thyroglobulin (Tg) or calcitonin, for which there is insufficient evidence, would not be warranted.
The survey uncovered an overwhelming majority (97%) of participating physicians would have opted to order a TSH test, while 8% of doctors also indicated that they would request a serum calcitonin be done, and 5% would request the test for Tg.2
The guidelines recommend ultrasound imaging with LN assessment would be recommended for all patients with known, or suspected nodules.1 Only if TSH was suppressed would a radionuclide scan be recommended.
However, in practice, nearly all (97%) participants ordered an ultrasound, and a large majority (68%) of practitioners included lymph node assessment.2
Case One Overview
Patient 1 had a TSH of 1.6 mU/L; the nodule was solid, and hypoechoic with regular margins, and no calcifications; and, not taller than wide.
Dr. Burch then compared the recommendations for fine needle aspiration (FNA), based on the risk category, and what the physicians said they would do. Nodules that were solid and hypoechoic were classified as intermediate risk, so an FNA was recommended.1Dr. Burch found that nearly 94% of clinicians would have done as the guidelines suggest and order a FNA.2
This patient had a benign FNA. Under the guidelines, an intermediate risk patient, as she was deemed--with a benign FNA--should have had a ultrasound repeated at 12 to 24 months, and a repeat FNA only if the nodule enlarged, or new suspicious features appeared.1
In practice, 65% of those surveyed indicated their intention to repeat the ultrasound serially, with 20% indicating their intent to repeat the ultrasound at least once.2
Case Two: 22-year-old Pregnant Patient
This patient was found to have a 1.5 cm nodule at 8 weeks. Her TSH was 1.0 mU/L and ultrasound showed no suspicious features.
Under the new guidelines,1 FNA would be treated the same as in a non pregnant patient, unless TSH is continuously suppressed after 16 weeks; then, FNA may be postponed until after delivery.
Yet, 36% of participating clinicians responded that they would perform the FNA immediately, while 34% would postpone.
According to Dr. Burch, there was one startling finding—among pregnant women, showing the least consistency with ATA recommendations.3 Current practice has not caught up with the guidelines in four key areas, including:
- Initial testing
- Selection of nodules for FNA
- Follow up strategies
- Timing of testing during pregnancy
"I was a bit surprised," Hussein Raef, MD, a session attendee, told EndocrineWeb. Dr. Raef, a clinical instructor at the Baylor College of Medicine in Houston, Texas, speculated that two factors may explain the discrepancies between the guidelines and practice.
"In practice, doctors tend to be protective," more often opting for more testing to offer reassurance to their patients, and the newness of the guidelines may also help explain the differences,” he said.
"It takes time to see change in practice," Dr. Burch agreed, saying one would expect that in time more clinicians will more readily adopt the guidelines.
The Thyroid Nodule Management Survey1 reflected representation from 5-23% of membership from ATA, the American Association of Clinical Endocrinologists, and the Endocrine Society, which was conducted between January and April 2015. International representation was 30%. Dr. Burch reported no relevant disclosures.