Have 2006 ATA practice guidelines affected the treatment of differentiated thyroid cancer in the United States?

Improved Adherence to ATA Medullary Thyroid Cancer Treatment Guidelines

BACKGROUND

The 2009 American Thyroid Association (ATA) guidelines for medullary thyroid cancer (MTC) were created to unify national practice patterns. Our aims were to (1) evaluate national adherence to ATA guidelines before and after 2009, (2) identify factors that are associated with concordance with guidelines, and (3) evaluate whether there is an association between survival and concordant treatment.

PATIENTS AND METHODS

Patients with MTC were identified from the 2009 to 2015 National Cancer Database. Adherence to ATA recommendations regarding extent of surgery (R61-R66) was analyzed. Logistic regression was used to determine predictors of discordance and propensity score matching was used to compare concordant treatment rates between time periods. Kaplan-Meier survival analysis was used to determine association between survival and concordant treatment.

RESULTS

There were 3421 patients with MTC, and of these 3087 had M0 disease and 334 had M1 disease. We found that 72% of M0 cases adhered to R61-66, and 68% of M0 cases without advanced local disease were adherent to R61-63. Following propensity score matching, the adherence rate was 67% before 2009 and 74% after. Patient factors associated with discordant treatment were female gender, older age, treatment at a nonacademic facility, and living within 50 miles of the treatment facility. Adherence to guidelines was associated with improved overall survival (OS) (p < 0.01).

CONCLUSIONS

Treatment of MTC was discordant from guidelines in 26% of cases from 2009 to 2015 compared with 33% prior to 2009 in a propensity matched analysis, and was most often in cases with localized, noninvasive disease. Improved adherence to guidelines may improve overall survival.

Changes in Population-Level and Institutional-Level Prescribing Habits of Radioiodine Therapy for Papillary Thyroid Cancer

Background: In the past two decades, new evidence and guidelines have emerged to refine recommendations for the use of radioactive iodine (RAI) therapy after thyroidectomy for cancer. We aim to describe national trends in RAI utilization, assess the impact of individual hospitals on RAI utilization, and examine whether variation in prescribing habits has declined over time. Methods: The National Cancer Database (NCDB) was queried from 2004 to 2016 for patients with papillary thyroid cancer (PTC) who received total thyroidectomy. Trends were analyzed using Joinpoint analysis. Hospital-specific effects and variation in prescribing habits were assessed through a hierarchical, mixed regression model. Results: RAI utilization declined from 61.0% in 2004 to 43.9% in 2016. RAI use declined most profoundly in patients with T1a, N0/X, M0 PTC without extrathyroidal extension (34.8% in 2004 to 9.5% in 2015), but continues to be used commonly in patients with advanced disease for whom it is routinely recommended (73.4% in 2004 to 72.0% in 2015). Furthermore, ∼80% of hospitals in 2016 utilized at or below the median utilization rate in 2006. Variation in RAI utilization across hospitals decreased by ∼50% from 2004 to 2016 (Levene's test p < 0.001), with a significant decline (p = 0.002) in the variation after 2012 (confidence interval: 2010 to 2014). Conclusions: Recommendations for whom to prescribe RAI appear to have impacted both the number of patients receiving RAI and the variation in prescribing habits across hospitals. Hospital selection has contributed less to the probability of receiving RAI over time.

Thyroid Cancer Incidence Trends in the United States: Association with Changes in Professional Guideline Recommendations

Background: Overdiagnosis is the leading factor contributing to the rapid increase in thyroid cancer incidence of the last decades. During this period, however, thyroid cancer incidence has not been increasing at a constant pace. We hypothesized that changes in the slope of the incidence trends curve, called joinpoints, could be associated with changes in clinical practice guideline recommendations. Methods: Data were obtained from the initial nine registries of the Surveillance, Epidemiology, and End Results (SEER) Program. Thyroid cancer incidence was analyzed from 1975 to 2016. Joinpoints in thyroid cancer incidence trends and clinical variables were correlated with significant changes in clinical practice recommendations. Results: Incidence rate trends of medullary and anaplastic thyroid cancer were constant during the study period. Among papillary thyroid cancers (PTCs), three main joinpoints were identified, mainly driven by changes in incidence trends of smaller cancers. First, acceleration followed by two deceleration periods in thyroid cancer incidence coincident in time with the release of American Thyroid Association guidelines in 1996, 2009, and 2015. In 1996, the use of thyroid ultrasound and fine needle aspiration biopsy for the evaluation of thyroid nodules was described; and in 2009 and 2015, higher size thresholds for the biopsy of thyroid nodules were set. For the follicular variant of PTC, a joinpoint was observed around 1988, when the histological diagnosis of this entity was revised in the World Health Organization classification; and another one in 2015 coinciding with the proposal to remove the term carcinoma from noninvasive follicular-pattern tumors with papillary-like nuclear features which contributed to drive down the overall thyroid cancer incidence. Follicular thyroid cancer incidence was affected as well by changes in the guidelines, but to a lesser extent, and it was fairly stable during the study period. Conclusions: This study suggests that thyroid cancer incidence trends have been shaped, in large part, but not completely, by changes in professional guideline recommendations.

Thyroid cancer surgery guidelines in an era of de-escalation

Well-differentiated thyroid carcinoma has seen a tremendous rise in global incidence over the past three decades, largely owing to widespread screening and identification of small, incidentally detected tumors. With this increased incidence has emerged a movement questioning whether all cases of thyroid cancer merit a treatment approach focused on oncologic completeness. Such trends towards thoughtful, evidence-based treatment de-escalation paradigms reflect better risk stratification of thyroid cancers, and recognition that not all detected disease poses a threat to health or survival. Thus, national and professional guidelines are evolving to incorporate higher thresholds for surgery, acceptance of less than total thyroidectomy in specific circumstances, higher thresholds for adjuvant therapy, and introduction of the role of active surveillance for selected cases of low risk disease. Despite these common themes, there are significant differences among guidelines. This lack of consensus in guidelines persists due to variation in clinical practice patterns, differences in consideration and interpretation of existing evidence, cultural and geographical considerations, and resources available for both diagnosis and treatment.

Are Evidence-Based Guidelines Reflected in Clinical Practice? An Analysis of Prospectively Collected Data of the Italian Thyroid Cancer Observatory

OBJECTIVES

The goal of evidence-based practice guidelines is to optimize the management of emerging diseases, such as differentiated thyroid cancer (DTC). The aim of this study was to assess therapeutic approaches for DTC in Italy and to see how closely these practices conformed to those recommended in the 2009 American Thyroid Association (ATA) guidelines.

METHODS

The Italian Thyroid Cancer Observatory was established to collect data prospectively on thyroid cancers consecutively diagnosed in participating centers (uniformly distributed across the nation). Data on the initial treatment of all pathologically confirmed DTC cases present in the database from January 1, 2013 (database creation) to January 31, 2016, were analyzed.

RESULTS

A total of 1748 patients (77.2% females; median age 48.1 years [range 10-85 years]) were enrolled in the study. Most (n = 1640; 93.8%) were papillary carcinomas (including 84 poorly differentiated/aggressive variants); 6.2% (n = 108) were follicular and Hürthle cell carcinomas. The median tumor diameter was 11 mm (range 1-93 mm). Tumors were multifocal in 613 (35%) and presented extrathyroidal extension in 492 (28%) cases. Initial treatments included total thyroidectomy (involving one or two procedures; n = 726; 98.8%) and lobectomy (n = 22; 1.2%). A quarter of the patients who underwent total thyroidectomy had unifocal, intrathyroidal tumors ≤1 cm (n = 408; 23.6%). Neck dissection was performed in 40.4% of the patients (29.5% had central compartment dissection). Radioiodine remnant ablation (RRA) was performed in 1057 (61.2%) of the 1726 patients who underwent total thyroidectomy: 460 (41.2%) of the 983 classified by 2009 ATA guideline criteria as low-risk, 570 (87.1%) of the 655 as intermediate-risk, and 82 (93.1%) of the 88 as high-risk patients (p < 0.001). RRA was performed in 44% of the cases involving multifocal DTCs measuring ≤1 cm.

CONCLUSIONS

The treatment approaches for DTCs used in Italy display areas of inconsistency with those recommended by the 2009 ATA guidelines. Italian practices were characterized by underuse of thyroid lobectomy in intrathyroidal, unifocal DTCs ≤1 cm. The use of RRA was generally consistent with risk-stratified recommendations. However, its frequent use in small DTCs (≤1 cm) that are multifocal persists, despite the lack of evidence of benefit. These data provide a baseline for future assessments of the impact of international guidelines on DTC management in Italy. These findings also illustrate that the dissemination and implementation of guideline recommendations, and the change in practice patterns, require ongoing education and time.

National Trends in the Surgical Treatment of Non-advanced Medullary Thyroid Cancer (MTC): An Evaluation of Adherence with the 2009 American Thyroid Association Guidelines

BACKGROUND

Medullary thyroid cancer (MTC) represents the third most common type of thyroid cancer, and the prognosis depends on the stage of the disease at diagnosis and completeness of tumor resection. In 2009, the American Thyroid Association (ATA) published guidelines with evidence-based recommendations for the treatment of MTC. This study aimed to determine national adherence rates of the treatment according to the ATA guidelines specific for MTC.

METHODS

Patients diagnosed with MTC from 2004 to 2013 were identified from the National Cancer Database. Guideline adherence rates for the treatment of MTC before and after the publication of ATA guidelines were analyzed and compared to determine patient and clinical variables that affected treatment.

RESULTS

A total of 3693 patients diagnosed with MTC were identified. We found 60.3 % of the patients had localized MTC and 39.7 % had regional metastases. Older age, female sex and having Medicaid or being uninsured were directly correlated with more advanced disease upon diagnosis (p < 0.001). Overall, a greater proportion of patients received care in accordance with the recommendations following the ATA guidelines' publication in 2009: 61.4 % of patients treated between 2004 and 2008 versus 66.8 % of patients treated between 2009 and 2013 received care in accordance with the recommendations (p < 0.01). Factors such as older age, African American race, localized disease at diagnosis, lower estimated median zip code household income and being treated in a community versus an academic hospital were associated with a lower likelihood of receiving care in accordance with the guidelines.

CONCLUSION

Adherence rates to the ATA recommendations for the treatment of MTC increased modestly following the publication of guidelines in 2009 with the largest increase seen in community hospitals. Being older, African American, diagnosed with localized disease and treated in a community hospital rather than in an academic institution was correlated with a lower likelihood of receiving treatment in accordance with the guidelines. Efforts should be made to continuously increase the adherence rates to the MTC ATA guidelines and to decrease socioeconomic disparities that continue to exist in the treatment of MTC.

Nationwide cohort study on the epidemiology and survival outcomes of thyroid cancer

In the past three decades, the thyroid cancer incidence has surged globally. Herein, the Taiwan National Health Insurance database was used to identify thyroid cancer patients and to estimate the prevalence and incidence of thyroid cancer during 1997-2012. The Taiwan Cancer Registry and the National Death Registry databases were crosslinked to obtain information on the histological subtypes and survival rates. Joinpoint regression analysis was used for estimating the average annual percentage changes (APCs) in prevalence, incidence, and survival. The age-standardized incidence of thyroid cancer increased from 5.66 per 100,000 person-years in 1997 to 12.30 per 100,000 person-years in 2012, with an average APC of 5.1 (6.9 in males, 4.6 in females). Thyroid cancer was more prevalent in patients with high socioeconomic status and in urban areas. Papillary carcinoma was the most abundant subtype, with a 2.9-fold increase of incident cases noted during 1998-2012 (from 80.6% to 89.8% of all cases). Among the different treatments, partial thyroidectomy increased the most (average APC, 17.3). The overall survival rates by sex and subtype remained stable over time, with 5-year survival rates of 90.2% in 1997 and 92.4% in 2010. In conclusion, 2.2- and 4.2-fold increases in the incidence and prevalence of thyroid cancer, respectively, were observed during 1997-2012 in Taiwan. The surging incidence of thyroid cancer but stable survival rates, and mainly increased in the papillary subtype, altogether imply enhanced detection of subclinical lesions. A true increase due to environmental carcinogens might also be responsible, but warrant further investigations.

Racial Disparities in Differentiated Thyroid Cancer: Have We Bridged the Gap?

BACKGROUND

Racial disparities in the management of differentiated thyroid cancer (DTC) exist in the United States. There is a paucity of data examining their temporal trends. It was hypothesized that racial disparities in care provided to patients with DTC have improved over the past 15 years.

METHODS

Adult patients undergoing surgery for DTC were included from the National Cancer Data Base (1998-2012). Temporal trends in appropriate extent of thyroidectomy and radioactive iodine therapy (RAI) were described for different racial groups. Multivariable logistic regression models were employed to estimate the adjusted association of receipt of appropriate extent of surgery and RAI, specifically under- and over-treatment, among different racial groups.

RESULTS

Among 282,043 DTC patients, 80.3% were non-Hispanic white (white), 8.1% Hispanic, 7.2% non-Hispanic black (black), and 4.4% Asian. Black versus white race/ethnicity was associated with lower odds of receiving appropriate surgery (odds ratio [OR] = 0.78 [confidence interval (CI) 0.71-0.87]; p < 0.001). Appropriate RAI treatment was higher in blacks (OR = 1.07 [CI 1.02-1.12]; p = 0.01) and lower for Hispanics (OR = 0.90 [CI 0.86-0.95]; p < 0.001) compared with whites. There was a higher likelihood of RAI under-treatment in minority groups (Hispanic OR = 1.27, black OR = 1.26, Asian OR = 1.25; p < 0.001), and a lower likelihood of RAI over-treatment (Hispanic OR = 0.89, black OR = 0.83, Asian OR = 0.79; p < 0.001) compared with whites. Over time, an increasing proportion of black and white patients underwent appropriate extent of thyroidectomy (1998 vs. 2012: 78% vs. 88% and 81% vs. 91%, respectively). Compared with 1998, fewer patients in 2012 were under-treated with RAI: whites (48% vs. 29%, respectively), blacks (51% vs. 33%), Hispanics (51% vs. 37%), and Asians (55% vs. 39%). The extent of RAI over-treatment increased (1998 vs. 2012): whites (1% vs. 4%), blacks (2% vs. 4%), Hispanics (2% vs. 4%), and Asians (2% vs. 3%), respectively.

CONCLUSIONS

Appropriate utilization of surgery and RAI for DTC has improved over time. However, the proportion of patients receiving appropriate thyroid surgery is consistently lower for blacks compared with whites. RAI over-treatment increased for all races over the study period. Efforts are needed to standardize DTC care among minority patients.

Improving the adoption of thyroid cancer clinical practice guidelines

OBJECTIVES/HYPOTHESIS

To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer-based clinical support system.

DATA SOURCES

PubMed.

REVIEW METHODS

A review of studies on adherence to CPGs was conducted.

RESULTS

Awareness and adoption of CPGs is low in thyroid cancer management. Barriers to implementation include unfamiliarity with the CPGs and financial concerns. Effective interventions to improve adherence are possible, especially when they are readily accessible at the point of care delivery. Computerized clinical support systems show particular promise. The authors introduce the clinical decision making modules (CDMMs) of the Thyroid Cancer Care Collaborative, a thyroid cancer-specific electronic health record. These computer-based modules can assist clinicians with implementation of these recommendations in clinical practice.

CONCLUSION

Computer-based support systems can help clinicians understand and adopt the thyroid cancer CPGs. By integrating patient characteristics and guidelines at the point of care delivery, the CDMMs can improve adherence to the guidelines and help clinicians provide high-quality, evidence-based, and individualized patient care in the management of differentiated thyroid cancer. Laryngoscope, 126:2640-2645, 2016.

Is there a role for an ultrasensitive thyroglobulin assay in patients with serum antithyroglobulin antibodies? A large (Australian) cohort study in differentiated thyroid cancer

OBJECTIVE

Serum thyroglobulin (Tg) is a marker of residual differentiated thyroid cancer (DTC) after total thyroidectomy; however, circulating antithyroglobulin antibodies (TgAb) may interfere with the immunoassay for Tg. Ultrasensitive assays may have a more significant role in detecting circulating Tg in the context of samples containing TgAb. The aim of this study was to evaluate the utility of ultrasensitive thyroglobulin (US-Tg) measurement compared to standard Tg measurement and to assess the influence of serum TgAb positivity on Tg detection in a large tertiary referral centre cohort in Australia.

DESIGN

All patients with DTC who had undergone total thyroidectomy were included in this retrospective, observational cohort study.

PATIENTS

Patients providing samples for the period of June 2006 until January 2014 were analysed. Three thousand two hundred and eight samples were measured at the same points in time, enabling serum Tg assays to be compared for the same TSH status (stimulated or suppressed).

MEASUREMENTS

The standard assay, the Siemens Immulite 2000 Tg assay, was compared to the serum ultrasensitive ELISA RSR^™ Tg. TgAb were simultaneously measured using Abbott Architect or Immulite 2000.

RESULTS

There were 3019 samples included in the final analysis for comparison of the standard and ultrasensitive assays along with TgAb status. The majority of samples were TgAb negative (87%), with 48% of TgAb-negative samples associated with an undetectable serum Tg, suggestive of disease-free status at the time of sampling. Of note, 26% (n = 104) of the TgAb-positive samples were positive for Tg on the ultrasensitive Tg assay, but negative on the immulite Tg assay, and 62·5% (n = 65) of these samples corresponded to DTC recurrence.

CONCLUSION

The US-Tg assay has greater clinical utility than the standard immulite Tg assay specifically in the scenario of antibody positivity, with a significant number of samples corresponding to clinically relevant recurrent or metastatic disease.

Same thyroid cancer, different national practice guidelines: When discordant American Thyroid Association and National Comprehensive Cancer Network surgery recommendations are associated with compromised patient outcome

BACKGROUND

The American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) guidelines have discordant recommendations for managing patients with differentiated thyroid cancer (DTC). We hypothesized that physician adherence to either of the 2009 extent of surgery guidelines of the ATA or NCCN was associated with improved survival, and that practice is most standardized nationally when guidelines are concordant.

METHODS

Adult patients undergoing surgery for DTC were included from the National Cancer Database. Multivariable modeling was used to identify factors associated with nonadherence to the 2009 ATA or NCCN guidelines (2010-2011) and hypothetically examine the association of retrospective adherence to guidelines with survival (1998-2006).

RESULTS

A total of 39,687 patients with DTC were included; 2,249 were not treated in accordance with ATA or NCCN guidelines. Factors independently associated with nonadherence were discordance between ATA and NCCN recommendations, black race, and treatment at nonacademic centers (P < .01). After adjustment, care not in accordance with either set of guidelines was associated with compromised survival (hazard ratio 1.16, P = .02).

CONCLUSION

A minority of patients received surgery for DTC not aligned with guidelines; nonadherent care was associated with compromised survival. Discordance in recommendations between guidelines is associated with reduction in adherent care, suggesting that standardizing guidelines could decrease confusion, increase adherence, and thereby may improve outcomes.

Use of evidence-based guidelines reduces radioactive iodine treatment in patients with low-risk differentiated thyroid cancer

OBJECTIVE

The goal was to determine if there was a relation between the introduction of evidence-based radioactive iodine (RAI) treatment guidelines for differentiated thyroid cancer (DTC) at Cedars-Sinai Medical Center (CSMC) and subsequent RAI use. In addition, we compared RAI treatment rates for DTC at CSMC to data from the National Cancer Database (NCDB) to see if the trends in RAI use at CSMC differed from the national trends.

METHODS

RAI data from the CSMC Thyroid Cancer Center were reviewed to determine if RAI treatment was given appropriately. Kaplan-Meier curves were used to estimate disease-free survival for patients who received or did not receive treatment. RAI data from the NCDB were also used to compare how CSMC treatment rates compare nationally.

RESULTS

There were 444 CSMC patients identified with DTC between 2009 and 2012. Approximately 95% of the patients had papillary thyroid cancer (n=423) with 65% in the stage I risk group (n=290). Kaplan-Meier curves for stages I-III show that those who did not receive RAI treatment had 100% disease-free survival, which was better than those who had received RAI. However, given that the total population in both stages II and III is quite small, having received RAI ablation was not found to be statistically significant. Stage I patients who received RAI had a significantly increased incidence of recurrent disease. The NCDB RAI rates for all DTC stages in each year have consistently been over 50% with an overall treatment rate of 57%. There were significant differences in the treatment rates between CSMC and NCDB, with a decrease in the use of RAI in low-risk patients with stage I tumors at CSMC following institution of the guidelines.

CONCLUSION

Prudent use of RAI treatment should be considered for low-risk patients. Ablation rates have been decreasing steadily at CSMC, particularly among low-risk patients, with the adoption of more stringent RAI treatment guidelines. It is apparent from our data that physician practices can change with the implementation and dissemination of evidence-based guidelines for the treatment of DTC with RAI.

Trends in imaging after diagnosis of thyroid cancer

BACKGROUND

The largest growth noted among differentiated thyroid cancer (DTC) diagnosis is in low-risk cancers. Trends in imaging after the diagnosis of DTC are understudied. Hypothesizing a reduction in imaging use due to rising low-risk disease, the authors evaluated postdiagnosis imaging patterns over time and patient characteristics that are associated with the likelihood of imaging.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare database, the authors identified patients diagnosed with localized, regional, or distant DTC between 1991 and 2009. Medicare claims were reviewed for use of neck ultrasound, iodine-131 (I-131) scan, or positron emission tomography (PET) scan within 3 years after diagnosis. Trends in imaging use were evaluated using regression analyses. Multivariable logistic regression was used to estimate the likelihood of imaging based on patient characteristics.

RESULTS

A total of 23,669 patients were included. Compared with patients diagnosed between 1991 and 2000, those diagnosed between 2001 and 2009 were more likely to have localized disease (P<.001) and tumors measuring <1 cm (P<.001). Use of neck ultrasound and I-131 scans increased in patients with localized disease (P ≤.001 and P = .003, respectively), regional disease (P<.001 and P<.001, respectively), and distant metastasis (P = .001 and P = .015, respectively). Patients diagnosed after 2000 were more likely to undergo neck ultrasound (odds ratio, 2.15; 95% confidence interval, 2.02-2.28) and I-131 scan (odds ratio, 1.44; 95% confidence interval, 1.35-1.54). Compared with 1996 through 2004, PET scan use from 2005 to 2009 increased 32.4-fold (P≤.001) in patients with localized disease, 13.1-fold (P<.001) in patients with regional disease, and 33.4-fold (P<.001) in patients with distant DTC.

CONCLUSIONS

Despite an increase in the diagnosis of low-risk disease, the use of postdiagnosis imaging increased among patients with all stages of disease. The largest growth observed was in the use of PET after 2004.

Comparative effectiveness in thyroid cancer: key questions and how to answer them

Controversies in treatment of thyroid cancer remain despite numerous published studies. Robust comparative effectiveness studies examining: (1) the role of prophylactic central compartment neck dissection (pCCND) in patients with papillary thyroid cancer (PTC); (2) the use of post-operative radioactive iodine (RAI) ablation therapy following total thyroidectomy; (3) use of low versus high doses of I-131 in RAI therapy; (4) thyroid hormone withdrawal (THW) versus recombinant thyroid stimulating hormone (rhTSH) prior to RAI; and (5) the role of routine measurement of serum calcitonin levels are needed to help strengthen existing treatment recommendations. Reasons for the controversies and suggestions for quality comparative effectiveness studies are discussed.