Clinical Tool Introduces Active Surveillance for Papillary Thyroid Cancer

A discussion protocol that prompts shared decision making based on objective treatment considerations of asymptomatic, small papillary thyroid tumors makes room for active surveillance over total thyroidectomy.

With Juan P. Brito, MD, and Elizabeth J. Murphy, MD, DPhil

The most current American Thyroid Association Guidelines identify active surveillance as an important and appropriate approach albeit an insufficiently considered option to the standard of care, which involves immediate surgery for papillary thyroid cancers (PTC).1

While thyroid cancer has become growing more rapidly than any other form of cancer, tripling in incidence over the past 30 years, the mortality rates have remained low (~3.5% of all thyroid cases).2 The rise in the incidence of papillary thyroid tumors has been attributed to more frequent diagnostic testing, specifically ultrasonography, which resulted in detection of subclinical, papillary macroadenomas; and women have been diagnosed with 75% of the cases of thyroid cancer.

The prospect of deintensifying care may be best accomplished with an objective discussion of the facts, so a team of researchers set out to develop a methodology to enhance patient-physician dialogue about the facts surrounding papillary cancer.

Patients should be given full facts on treatment options for papillary thyroid cancer.

Why Active Surveillance Has Failed to Gain Traction

For patients who are determined to have a small PTC, the persistence of sticking to convention by advising surgical treatment—a total thyroidectomy—may expose too many patients to too high a cost when active surveillance has been deemed a reasonable option.1,3 Adverse effects to endocrine function, bone loss, and possibly unnecessary voice changes are significant factors to be considered.

Carefully selected patients deemed at low risk for papillary thyroid cancer who have been treated using active surveillance, also referred to as ‘delayed or deferred surgery’, demonstrated no greater risk for mortality or disease progression when compared to patients who underwent immediate surgery.1

Furthermore, the validity of active surveillance was confirmed in an observational study of 291 patients who had been referred to a major tertiary care center.3 The findings, published in the journal Thyroid, were reported by a team of investigators at Memorial Sloan Kettering Cancer Center in support the recommendation of active surveillance in cases of small PTC tumors (< 1.5 cm), particularly when found incidentally.

Even as the American Thyroid Association has endorsed efforts to reduce the overdiagnosis of papillary thyroid tumors,1 particularly those detected inadvertently and to refrain from conducting biopsies of small thyroid nodules, there is still a long way to go to gain clinical acceptance. A case in point— despite the substantial benefits gained by opting for active surveillance, few patients are choosing to forego immediate surgery.

This has been attributed to a lack of physician knowledge and comfort with the safety of this option, as well as lack of patient knowledge that active surveillance is a reasonable treatment option for them. Notably, clinicians are not effectively and consistently discussing active surveillance with appropriate patients – owing to lack of knowledge regarding who might be most appropriate for active surveillance as well as lack of comfort and communication skill in raising this option. Prior research has helped to delineate patient characteristics that are most amenable to active surveillance.4

To address this clinical deficit and to accelerate acceptance of active surveillance as an appropriate course of treatment in low risk patients, an international team of clinicians from the US, South Korea, and Mexico developed and pilot tested a decision-aid tool – the Thyroid Cancer Treatment Choice (TCTC), based on user-centered design principles, for papillary thyroid cancer.5

Introduction of Papillary Thyroid Cancer Treatment Decision Tool

The investigators developed a total of 12 prototypes before consensus was reached on the optimal version for field-testing. The initial models were trialed with real patients in the United States to evaluate physician-patient interactions and to assess what information and questions did or did not facilitate constructive conversations, looking at factors such as content, format, ease of use, and usefulness. Feedback was gathered from both patients and clinicians that was then considered in order to arrive at a final decision-making tool.5  

The TCTC tool employed a number of pre-printed cards to explain:

  • An overview of papillary microadenoma (vs other forms of thyroid cancer).
  • Objectively presentation of the two treatment options—surgery or active surveillance.
  • Review the consequences of each treatment choice (ie, physical effects of treatments and risk of growth and metastasis.
  • Facilitate discussion between the clinician and patient to help determine the best treatment approach for the individual.

After substantial field-testing in the United States to determine what best enabled clinicians and patients to discuss the treatment alternatives, and, as they noted, for patients to “try on” different treatment options, the final prototype version of the thyroid treatment decision tool was adapted for use (eg, translated) and pilot tested with 278 patients who were attending one of two endocrinology clinics in South Korea.5

At one clinic, the TCTC conversation aid was employed exclusively with 53% of the total patients, while the remaining patients (attending the second clinic) was treated with the usual clinician discussion about the two treatment options.5

Among those using the TCTC tool, 89% of these patients selected active surveillance in comparison to 77% in the usual care clinic.5

“The tool was not intended to convince patients to select active surveillance, but rather to objectively present the best available evidence regarding the treatment options,” said Juan P. Brito, MD, MSc, assistant professor of medicine in the Division of Endocrinology and medical director of the Shared Decision Making National Resource Center at the Mayo Clinic in Rochester, Minnesota.

 “This tool was developed to support treatment conversations: given this goal, the implementation of the tool in practice aims to support the clinician by facilitating often difficult conversations with the patient… the tool should be there, available, in case it is needed,” Dr. Brito told EndocrineWeb.

A Clinician Champions the Premise that Informed Patients Make Better Decisions

“Both physicians and patients alike struggle with uncertainty regarding whether it is safe to leave a known papillary thyroid tumor in and not immediately remove it,” said Elizabeth J. Murphy, MD, DPhil, professor of medicine and chief of the Division of Endocrinology and Metabolism at the University of California at San Francisco Medical School in California.  

“However, there are different levels of uncertainty–among patients, within providers, and between patients and their providers,” she told EndocrineWeb. She believes this tool will provide a useful framework to enable providers who might be struggling with their own uncertainties about which treatment approach to recommend a means to present objective information about both of the acceptable treatment options in an unbiased, directed manner.

Noting that the tool was “developed to support shared decision-making in the encounters,” Dr. Brito said he would “encourage clinicians to try the tool in conversation,” so they can see how helpful the tool might be in facilitating a positive conversation about the considerations for both the patient and the physician. Further, he suggested that “the tool can help clinicians get to know their patients better– by addressing what is important to them and how they value the different attributes of each of the treatment options.”

“During the process of seeing a patient in ‘high definition’, it is likely that the tool will help find the best treatment strategy that fits the patient’s context, values, and preferences,” he said.

Regardless of the approach used to arrive at which treatment may be right for which patient, it is necessary for clinicians to consider factors such as health care costs, risks associated with surgery, and the emotional toll of thyroid cancer as it may impact each patient.

While lifetime surveillance may be a daunting consideration for some patients, it may be a pragmatic initial treatment recommendation until better prognostic and predictive markers are found that may offer tailored information, regarding a more refined individualized thyroid cancer management plan.

Neither of the clinicians had any financial conflicts to report.

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