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Maniam P, Hey SY, Evans-Harding N, Li L, Conn B, Adamson RM, Hay AJ, Lyall M, Nixon IJ. Practice patterns in management of differentiated thyroid cancer since the 2014 British Thyroid Association (BTA) guidelines. Surgeon 2024; 22:e54-e60. [PMID: 37821296 DOI: 10.1016/j.surge.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The updated 2014 BTA guidelines emphasised a more conservative, risk adapted model for the management of low-risk differentiated thyroid cancer (DTC). In comparison to historical approach of total thyroidectomy combined with radioactive iodine, treatment de-escalation is increasingly supported. AIMS To evaluate the impact of the updated BTA guidelines on the management of DTC cases at regional UK centre. METHODS All DTC patients were retrospectively identified from regional thyroid MDT database between Jan2009-Dec2020. Oncological treatment and clinico-pathological characteristics were analysed. RESULTS 623 DTC cases were identified; 312 (247 female: 65 male) between 2009 and 2014 and 311 (225 female: 86 male) between 2015 and 2020. Median age is 48 years (range 16-85). By comparing pre- and post-2015 cohorts, there was a significant drop in total thyroidectomy (87.1% vs 76.8%, p = 0.001) and the use of radioactive iodine (RAI) (73.1% vs 62.1%, p = 0.003) in our post-2015 cohort. When histological adverse features were analysed, extra-thyroidal extension (4.2% vs 17.0%, p=< 0.001), lymphovascular invasion (31.4% vs 50.5%, p=<0.001) and multi-centricity (26.9% vs 43.4%, p = 0.001) were significantly increased in the post 2015 cohort. Nonetheless, total thyroidectomy (TT) remains the treatment choice for low risk T1/2 N0 M0 disease in 65.3% (124/190) in post-2015 cohort for several reasons. Reasons include adverse histological features (50.8%), benign indications (32.5%), contralateral nodules (11.7%), patient preference (2.5%), and diagnostic uncertainty (2.5%). CONCLUSION Our study confirms a move towards a more conservative approach to patients with low-risk DTC in the UK, which is in keeping with the BTA 2014 guideline and international trends, but total thyroidectomy remains prevalent for low risk T1/2 N0 M0 disease for other reasons.
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Affiliation(s)
- P Maniam
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK
| | - S Y Hey
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK
| | - N Evans-Harding
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK
| | - L Li
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK
| | - B Conn
- Department of Pathology, NHS Lothian, Edinburgh, UK
| | - R M Adamson
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK
| | - A J Hay
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK
| | - M Lyall
- Department of Medicine, NHS Lothian, Edinburgh, UK
| | - I J Nixon
- Department of Otolaryngology Head and Neck Surgery, St John's Hospital, Livingston, UK.
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Wallner LP, Banerjee M, Reyes-Gastelum D, Hamilton AS, Ward KC, Lubitz C, Hawley ST, Haymart MR. Multilevel Factors Associated With More Intensive Use of Radioactive Iodine for Low-Risk Thyroid Cancer. J Clin Endocrinol Metab 2021; 106:e2402-e2412. [PMID: 33687063 PMCID: PMC8118575 DOI: 10.1210/clinem/dgab139] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Indexed: 12/28/2022]
Abstract
CONTEXT The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs. OBJECTIVE To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer. METHODS This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer. RESULTS Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67). CONCLUSIONS Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.
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Affiliation(s)
- Lauren P Wallner
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
| | | | - Ann S Hamilton
- Keck School of Medicine, University of Southern California, Department of Preventive Medicine, Los Angeles, CA, USA
| | - Kevin C Ward
- Emory University, Department of Epidemiology, Atlanta, GA, USA
| | - Carrie Lubitz
- Massachusetts General Hospital, Department of Surgery, Boston, MA, USA
| | - Sarah T Hawley
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Departments of Health Management and Policy and Health Behavior and Education, Ann Arbor, MI, USA
| | - Megan R Haymart
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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3
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McDow AD, Roman BR, Saucke MC, Jensen CB, Zaborek N, Jennings JL, Davies L, Brito JP, Pitt SC. Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer. Am J Surg 2020; 222:111-118. [PMID: 33248684 DOI: 10.1016/j.amjsurg.2020.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC. METHODS We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS). RESULTS The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS. CONCLUSIONS Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.
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Affiliation(s)
- Alexandria D McDow
- Division of Surgery Oncology, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive EH 537, Indianapolis, IN, 46202, USA.
| | - Benjamin R Roman
- Division of Head and Neck, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Catherine B Jensen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Nick Zaborek
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Jamia Linn Jennings
- Wisconsin Department of Health Services, 1 West Wilson Street, Madison, WI, 53703, USA.
| | - Louise Davies
- The VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, USA and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
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Ronen O, Robbins KT, Olsen KD, Shaha AR, Randolph GW, Nixon IJ, Zafereo ME, Hartl DM, Kowalski LP, Rodrigo JP, Coca-Pelaz A, Mäkitie AA, Vander Poorten V, Sanabria A, Angelos P, Rinaldo A, Ferlito A. Case for staged thyroidectomy. Head Neck 2020; 42:3061-3071. [PMID: 32761849 DOI: 10.1002/hed.26393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/01/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022] Open
Abstract
Recent modifications in the management of well-differentiated thyroid cancer have resulted in significant alterations in clinical approach. Utilizing a series of preoperative and postoperative risk factors involving both the patient and the disease pathology, we offer the term "staged thyroidectomy" to help organize these risk factors for patients and the endocrine team to optimize management. This approach is intended to incorporate our latest nuanced understanding of certain endocrine pathology and may serve to optimize patient outcomes.
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Affiliation(s)
- Ohad Ronen
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center, affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - K Thomas Robbins
- Department of Otolaryngology Head and Neck Surgery, Southern Illinois University Medical School, Springfield, Illinois, USA
| | - Kerry D Olsen
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Iain J Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Mark E Zafereo
- Head and Neck Endocrine Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dana M Hartl
- Department of Otolaryngology-Head and Neck Surgery, Institut Gustave Roussy, Villejuif Cedex, France.,Laboratoire de Phonétique et de Phonologie, Paris, France
| | - Luiz P Kowalski
- Department of Otorhinolaryngology-Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil.,Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias-ISPA, Oviedo, Spain.,Department of Otolaryngology, University of Oviedo-IUOPA, Oviedo, Spain.,Head and Neck Cancer Unit, CIBERONC, Madrid, Spain
| | - Andrés Coca-Pelaz
- Department of Otolaryngology, Hospital Universitario Central de Asturias-ISPA, Oviedo, Spain.,Department of Otolaryngology, University of Oviedo-IUOPA, Oviedo, Spain.,Head and Neck Cancer Unit, CIBERONC, Madrid, Spain
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vincent Vander Poorten
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia/Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Department of Surgery, CEXCA-Centro de Excelencia en Enfermedades de Cabeza y Cuello, Medellín, Colombia
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
| | - Alessandra Rinaldo
- Department of Otolaryngology, University of Udine School of Medicine, Udine, Italy
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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5
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Evron JM, Reyes-Gastelum D, Banerjee M, Scherer LD, Wallner LP, Hamilton AS, Ward KC, Hawley ST, Zikmund-Fisher BJ, Haymart MR. Role of Patient Maximizing-Minimizing Preferences in Thyroid Cancer Surveillance. J Clin Oncol 2019; 37:3042-3049. [PMID: 31573822 PMCID: PMC6839910 DOI: 10.1200/jco.19.01411] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To understand the effect of patient preferences on thyroid cancer surveillance intensity. PATIENTS AND METHODS Eligible patients diagnosed with thyroid cancer between January 1, 2014, and December 31, 2015, from the Georgia and Los Angeles County SEER registries were surveyed between February 2017 and October 2018 (N = 2,632; response rate, 63%). Patient reports on health care utilization in the past year and responses to the validated Medical Maximizer-Minimizer Scale were linked to SEER data in the 2,183 disease-free patients. Ordered logistic regression was performed using a cumulative logit with nonproportional odds. RESULTS Of disease-free patients, 31.6% were classified as minimizers, 42.5% as moderate maximizers, and 25.9% as strong maximizers. In the past year, 25.2%, 27.3%, and 38.5% of minimizers, moderate maximizers, and strong maximizers, respectively, had ≥ 4 doctor visits, and 18.3%, 24.9%, and 29.5%, respectively, had ≥ 2 neck ultrasounds. When controlling for age, sex, race and ethnicity, comorbidity, stage, and SEER site, strong maximizers (compared with minimizers) were significantly more likely to report ≥ 4 doctor visits (odds ratio [OR], 1.45; 95% CI, 1.10-1.92), ≥ 2 neck ultrasounds (OR, 1.58; 95% CI, 1.17-2.14), ≥ 1 radioactive iodine scan (OR, 1.73; 95% CI, 1.19-2.50), and ≥ 1 additional imaging study (OR, 2.06; 95% CI, 1.56-2.72). CONCLUSION Among patients with thyroid cancer who have been declared disease free, preference for a more maximal versus minimal approach to medical care is associated with increased number of physician visits and imaging tests. Because increased surveillance does not clearly correlate with improved outcomes, poses potential risks to patients, and contributes to increased healthcare costs, stronger consideration of the role of patient preferences is necessary when framing discussions on surveillance.
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Affiliation(s)
| | | | | | | | | | - Ann S. Hamilton
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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6
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The overuse of radioactive iodine in low-risk papillary thyroid cancer patients. Surg Oncol 2019; 29:184-189. [DOI: 10.1016/j.suronc.2019.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/23/2019] [Accepted: 05/18/2019] [Indexed: 11/20/2022]
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7
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Park KW, Wu JX, Du L, Leung AM, Yeh MW, Livhits MJ. Decreasing Use of Radioactive Iodine for Low-Risk Thyroid Cancer in California, 1999 to 2015. J Clin Endocrinol Metab 2018; 103:1095-1101. [PMID: 29267880 DOI: 10.1210/jc.2017-02269] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 12/12/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT Routine radioactive iodine (RAI) ablation for low-risk differentiated thyroid cancer (DTC) is not supported by current practice guidelines. OBJECTIVE To assess recent stage-specific trends in use of RAI ablation. DESIGN, SETTING, AND PATIENTS Retrospective study of patients with DTC (1999 to 2015) identified from the California Cancer Registry. Statistical analysis included standardized differences, P values, and multivariable analyses using RAI as the predictor variable. MAIN OUTCOME MEASURES Trends and drivers of RAI ablation for low-risk DTC. RESULTS Of 46,906 patients with DTC who underwent near-total or total thyroidectomy [mean age 48.2 ± 15.5 (standard deviation) years, 77% female), 25,457 (54%) received RAI. The proportion of patients with regional/distant disease who received RAI remained stable at 68%. Use of RAI for patients with localized disease (no extrathyroidal extension, lymph node, or distant metastases) decreased from 55% (1999) to 30% (2015), with the most substantial change occurring in tumors <1 cm (39% to 11%). The rate also decreased for localized tumors between 1 and 2 cm (62% to 34%) and 2 and 4 cm (67% to 49%) and remained stable at 59% for tumors >4 cm. In multivariable analyses, patients with localized disease were less likely to receive RAI if they were >65 years old [odds ratio (OR) 0.77, 95% confidence interval (CI): 0.71 to 0.83], had tumors <1 cm (OR 0.33, 95% CI: 0.31 to 0.35), or were treated in an academic hospital (OR 0.71, 95% CI: 0.67 to 0.75). CONCLUSIONS The rate of RAI ablation decreased over time, mainly attributable to decreased use for localized DTCs <2 cm. Many patients with low-risk DTC still receive RAI unnecessarily.
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Affiliation(s)
- Ki Wan Park
- Section of Endocrine Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - James X Wu
- Section of Endocrine Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Lin Du
- Department of Biostatistics, University of California Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael W Yeh
- Section of Endocrine Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Masha J Livhits
- Section of Endocrine Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
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8
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Lamartina L, Durante C, Lucisano G, Grani G, Bellantone R, Lombardi CP, Pontecorvi A, Arvat E, Felicetti F, Zatelli MC, Rossi R, Puxeddu E, Morelli S, Torlontano M, Crocetti U, Montesano T, Giubbini R, Orlandi F, Aimaretti G, Monzani F, Attard M, Francese C, Antonelli A, Limone P, Rossetto R, Fugazzola L, Meringolo D, Bruno R, Tumino S, Ceresini G, Centanni M, Monti S, Salvatore D, Spiazzi G, Mian C, Persani L, Barbaro D, Nicolucci A, Filetti S. Are Evidence-Based Guidelines Reflected in Clinical Practice? An Analysis of Prospectively Collected Data of the Italian Thyroid Cancer Observatory. Thyroid 2017; 27:1490-1497. [PMID: 29020892 DOI: 10.1089/thy.2017.0299] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Livia Lamartina
- 1 Department of Internal Medicine and Medical Specialties, University of Rome Sapienza , Rome, Italy
| | - Cosimo Durante
- 1 Department of Internal Medicine and Medical Specialties, University of Rome Sapienza , Rome, Italy
| | - Giuseppe Lucisano
- 2 Center for Outcomes Research and Clinical Epidemiology , Pescara, Italy
| | - Giorgio Grani
- 1 Department of Internal Medicine and Medical Specialties, University of Rome Sapienza , Rome, Italy
| | - Rocco Bellantone
- 3 Division of Endocrine Surgery, Fondazione Policlinico Gemelli, Catholic University , Rome, Italy
| | - Celestino Pio Lombardi
- 3 Division of Endocrine Surgery, Fondazione Policlinico Gemelli, Catholic University , Rome, Italy
| | - Alfredo Pontecorvi
- 4 Division of Endocrinology and Metabolic Diseases, Fondazione Policlinico Gemelli, Catholic University , Rome, Italy
| | - Emanuela Arvat
- 5 Oncological Endocrinology Unit, Department of Medical Sciences, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, University of Turin , Turin, Italy
| | - Francesco Felicetti
- 5 Oncological Endocrinology Unit, Department of Medical Sciences, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, University of Turin , Turin, Italy
| | - Maria C Zatelli
- 6 Endocrine Unit, Azienda Ospedaliero Universitaria S. Anna , Ferrara, Italy
| | - Roberta Rossi
- 6 Endocrine Unit, Azienda Ospedaliero Universitaria S. Anna , Ferrara, Italy
| | - Efisio Puxeddu
- 7 Department of Medicine, University of Perugia , Perugia, Italy
| | - Silvia Morelli
- 7 Department of Medicine, University of Perugia , Perugia, Italy
| | - Massimo Torlontano
- 8 Department of Medical Science, Ospedale Casa Sollievo della Sofferenza-IRCCS , San Giovanni Rotondo, Italy
| | - Umberto Crocetti
- 8 Department of Medical Science, Ospedale Casa Sollievo della Sofferenza-IRCCS , San Giovanni Rotondo, Italy
| | - Teresa Montesano
- 9 Department of Nuclear Medicine, University of Rome Sapienza , Rome, Italy
| | - Raffaele Giubbini
- 10 Nuclear Medicine Unit, Spedali Civili Università degli Studi di Brescia , Brescia, Italy
| | - Fabio Orlandi
- 11 Department of Oncology, Division of Endocrinology and Metabolism, Humanitas-Gradenigo Hospital, University of Turin, Turin, Italy
| | - Gianluca Aimaretti
- 12 Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale , Novara, Italy
| | - Fabio Monzani
- 13 Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa , Pisa, Italy
| | - Marco Attard
- 14 Division of Endocrinology, Cervello Hospital , Palermo, Italy
| | - Cecilia Francese
- 15 Division of Endocrinology , Clinica Salus di Battipaglia, Salerno, Italy
| | - Alessandro Antonelli
- 16 Department of Clinical and Experimental Medicine, University of Pisa , Pisa, Italy
| | - Paolo Limone
- 17 Division of Endocrinology, Diabetology, and Metabolism, Mauriziano Umberto I Hospital , Turin, Italy
| | - Ruth Rossetto
- 18 Division of Endocrinology, Diabetology, and Metabolism, Department of Medical Sciences, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, University of Turin , Turin, Italy
| | - Laura Fugazzola
- 19 Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano , Milan, Italy
- 20 Department of Pathophysiology and Transplantation, University of Milan , Milan, Italy
| | - Domenico Meringolo
- 21 Simple Operating Unit, Department of Endocrinology, Bentivoglio Hospital , Bologna, Italy
| | - Rocco Bruno
- 22 Unit of Endocrinology, Tinchi-Pisticci Hospital , Matera, Italy
| | - Salvatore Tumino
- 23 Department of Clinical and Experimental Medicine, University of Catania , Catania, Italy
| | - Graziano Ceresini
- 24 Department of Medicine and Surgery, University of Parma , Parma, Italy
| | - Marco Centanni
- 25 Department of Medical and Surgical Sciences and Biotechnology, University of Rome Sapienza , Latina, Italy
| | - Salvatore Monti
- 26 Department of Endocrinology, Ospedale S. Andrea, Sapienza Università di Roma, Rome, Italy
| | - Domenico Salvatore
- 27 Department of Clinical Medicine and Surgery, University of Naples "Federico II ," Naples, Italy
| | - Giovanna Spiazzi
- 28 Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Verona , Verona, Italy
| | - Caterina Mian
- 29 Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padua , Padua, Italy
| | - Luca Persani
- 19 Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano , Milan, Italy
- 30 Department of Clinical Sciences and Community Health, University of Milan , Milan, Italy
| | - Daniele Barbaro
- 31 U.O. Endocrinologia, Livorno, ASL Nord Ovest Toscana , Livorno, Italy
| | - Antonio Nicolucci
- 2 Center for Outcomes Research and Clinical Epidemiology , Pescara, Italy
| | - Sebastiano Filetti
- 1 Department of Internal Medicine and Medical Specialties, University of Rome Sapienza , Rome, Italy
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Haymart MR, Esfandiari NH, Stang MT, Sosa JA. Controversies in the Management of Low-Risk Differentiated Thyroid Cancer. Endocr Rev 2017; 38. [PMID: 28633444 PMCID: PMC5546880 DOI: 10.1210/er.2017-00067] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Controversy exists over optimal management of low-risk differentiated thyroid cancer. This controversy occurs in all aspects of management, including surgery, use of radioactive iodine for remnant ablation, thyroid hormone supplementation, and long-term surveillance. Limited and conflicting data, treatment paradigm shifts, and differences in physician perceptions contribute to the controversy. This lack of physician consensus results in wide variation in patient care, with some patients at risk for over- or undertreatment. To reduce patient harm and unnecessary worry, there is a need to design and implement studies to address current knowledge gaps.
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Affiliation(s)
- Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Michael T Stang
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
| | - Julia Ann Sosa
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
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Li JJ, Zheng PCJR, Wang YZ. The correlations between DNA methylation and polymorphisms in the promoter region of the human telomerase reverse transcriptase (hTERT) gene with postoperative recurrence in patients with thyroid carcinoma (TC). World J Surg Oncol 2017; 15:114. [PMID: 28587656 PMCID: PMC5461729 DOI: 10.1186/s12957-017-1170-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/16/2017] [Indexed: 12/28/2022] Open
Abstract
Background This study aims at exploring the correlations between DNA methylation and polymorphisms in the promoter region of the human telomerase reverse transcriptase (hTERT) gene and postoperative recurrence in patients with thyroid carcinoma (TC). Methods A total of 312 patients diagnosed with TC were chosen for the study and categorized into recurrence (n = 75) and non-recurrence (n = 237) groups. The hTERT rs2736100 and rs2736098 polymorphisms were detected by performing polymerase chain reaction-restriction fragment length polymorphism. DNA methylation in the promoter region of hTERT gene was evaluated by pyrosequencing. A telephonic and/or outpatient follow-up was conducted for all patients. The correlations of DNA methylation and polymorphisms in the promoter region of hTERT with postoperative recurrence of TC patients underwent analysis. Results The patient in the recurrence group showed evidently different pathological types and tumor stages in comparison to the non-recurrence group. The GG genotype of hTERT rs2736100 might increase the recurrence risk of TC patients. No correlations between hTERT rs2736098 polymorphisms and recurrence risk were observed. Compared to the TT + TG genotype frequency, the rs2736100 GG genotype frequency increased in patients without multicentricity, patients with extrathyroidal invasion, patients with lymph node metastasis, patients with undifferentiated carcinoma, and patients in the III + IV stage. The recurrence group showed significantly higher DNA methylation level compared to the non-recurrence group. The DNA methylation level was closely associated to tumor stage and lymph node metastasis of TC patients in the recurrence group. Conclusions The DNA methylation and rs2736100 polymorphisms in the promoter region of hTERT gene might be in correlation to postoperative recurrence of TC patients.
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Affiliation(s)
- Jian-Jun Li
- Thyroid Surgery, Ningbo No.2 Hospital, No. 41, Xibei Street, Haishu District, Ningbo, 315010, Zhejiang, People's Republic of China.
| | - Ping Chen Jue-Ru Zheng
- Thyroid Surgery, Ningbo No.2 Hospital, No. 41, Xibei Street, Haishu District, Ningbo, 315010, Zhejiang, People's Republic of China
| | - Yao-Zong Wang
- Thyroid Surgery, Ningbo No.2 Hospital, No. 41, Xibei Street, Haishu District, Ningbo, 315010, Zhejiang, People's Republic of China
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Marti JL, Morris LGT, Ho AS. Selective use of radioactive iodine (RAI) in thyroid cancer: No longer "one size fits all". Eur J Surg Oncol 2017; 44:348-356. [PMID: 28545679 DOI: 10.1016/j.ejso.2017.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/03/2017] [Accepted: 04/11/2017] [Indexed: 12/12/2022] Open
Abstract
A remarkable, evidence-based trend toward de-escalation has reformed the practice of radioactive iodine (RAI) administration for thyroid cancer patients. Updated guidelines have supported both decreased RAI doses for select populations, as well as expanded definitions of low-risk and intermediate-risk patients that may not require RAI. Correspondingly, there is now increased flexibility for hemithyroidectomy without need for RAI, and relaxed TSH suppression targets for low-risk thyroidectomy patients. Clinical judgment remains indispensable where multiple risk factors co-exist that individually are not indications for RAI. This is especially salient in intermediate-risk patients with a less than excellent response to therapy, determined through thyroglobulin and ultrasound surveillance. Such judgment, however, may lead to patterns of inappropriate RAI practices or overuse with little benefit to the patient and unnecessary harm. A multidisciplinary, risk-adapted approach is ever more important and obliges the surgeon to understand the likelihood that their patients will receive RAI. The risks and benefits of RAI, its evolved role in contemporary guidelines, and current patterns of use among endocrinologists are reviewed, as well as the practical implications for thyroid surgeons.
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Affiliation(s)
- J L Marti
- Department of Surgery, New York Presbyterian/Lower Manhattan Hospital, Weill Cornell Medicine, 156 William Street, 12th Floor New York, NY 10038, USA
| | - L G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue New York, NY 10065, USA
| | - A S Ho
- Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 590W, Los Angeles, CA 90048, USA.
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12
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Goldfarb M, Sener SF. Comparison of radioiodine utilization in adolescent and young adult and older thyroid cancer patients. Endocr Pract 2016; 20:405-11. [PMID: 24326000 DOI: 10.4158/ep13343.or] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Differentiated thyroid cancer (DTC) is 1 of the most common cancers in adolescents and young adults (AYA, ages 15-39). Although most AYAs with DTC are considered low risk compared to older patients, there are no specific postoperative radioiodine (RAI) treatment recommendations despite the potential adverse effects specific to this age group, namely secondary malignancies and fertility difficulties. This study compares factors influencing RAI utilization in AYA and older patients. METHODS A total of 5,687 primary DTC patients were identified from the SEER (Surveillance, Epidemiology, and End RESULTS) database between January 1, 2004 and January 31, 2009. The 2009 American Thyroid Association (ATA) guidelines were used to classify patients as low (LR) or intermediate/high risk (IHR) based on tumor characteristics. Multivariate logistic regression analysis was performed. RESULTS Overall, 56.9% of AYA (n = 1,963) patients received postoperative RAI compared to 52.2% of older (n = 3,724) patients (odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.09-1.35, P = .001). For AYA patients, having a total thyroidectomy (TTx) (OR: 3.53, 95% CI: 2.7-4.61, P<.001) predicted RAI in a multivariate model whereas LR status (OR: 0.52, 95% CI: 0.43-0.63, P<.001) and northeast residence (OR: 0.39, 95% CI: 0.29-0.52, P<.001) decreased the probability. All 3 factors similarly affected older patients in addition to an increased likelihood after lymph node (LN) dissection. Additionally, after selecting for TTx (n = 1,077), no factor influenced the use of RAI for AYA patients, whereas LR (OR: 0.30, 95% CI: 0.21-0.43, P<.001) and northeast residence (OR: 0.39, 95% CI: 0.19-0.79, P = .008) were associated with decreased RAI use in older patients. CONCLUSION Despite their excellent prognosis, AYA thyroid cancer patients are more likely to receive postoperative RAI compared to older patients. Increased awareness of the unique survivorship implications for AYA patients will be an important aspect to address going forward.
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Affiliation(s)
- Melanie Goldfarb
- Division of Breast/Soft Tissue and Endocrine Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Stephen F Sener
- Division of Breast/Soft Tissue and Endocrine Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
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Liang T, Liu S, Mok K, Shi H. Associations of Volume and Thyroidectomy Outcomes. Otolaryngol Head Neck Surg 2016; 155:65-75. [DOI: 10.1177/0194599816634627] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/03/2016] [Indexed: 08/30/2023]
Abstract
ObjectiveThis study explored how different hospital volumes and surgeon volumes affect thyroidectomy outcomes in terms of length of stay (LOS), costs, and in‐hospital mortality.Data SourcesMEDLINE and EMBASE databases.Review MethodsThis study retrospectively analyzed a cohort of 125,037 thyroidectomy patients treated at Taiwan hospitals from 1996 to 2010. Relationships between hospital/surgeon volume and patient outcomes were retrospectively analyzed by propensity score matching. In conjunction with the retrospective study, a systematic review and meta‐analysis of the relevant literature also were performed.ResultsThe mean LOS for all thyroidectomies performed during the study period was 3.3 days, and the mean cost was $1193.5. Both high‐volume hospitals and high‐volume surgeons were associated with significantly shorter LOS and lower costs compared with their low‐volume counterparts (P <. 001). Different volume groups had similar in‐hospital mortality rates. The meta‐analysis results consistently showed that the benefits of high‐volume hospitals/surgeons are reduced LOS and costs. However, low in‐hospital mortality rates were associated with high‐volume surgeons but not with high‐volume hospitals.ConclusionsThis meta‐analysis showed that patients who received thyroidectomies performed by high‐volume hospitals and surgeons had shorter LOS and lower costs compared with those treated by low‐volume hospitals and surgeons. In addition, in‐hospital survival rates were better in patients treated by high‐volume surgeons. Further research is needed to define the learning curve for thyroidectomy and to clarify how hospital volume and surgeon volume affect its success rate.
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Affiliation(s)
- Tsung‐Jung Liang
- Division of General Surgery Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung Taiwan
- Department of Healthcare Administration and Medical Informatics Kaohsiung Medical University Kaohsiung Taiwan
| | - Shiuh‐Inn Liu
- Division of General Surgery Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung Taiwan
| | - King‐Tong Mok
- Division of General Surgery Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung Taiwan
| | - Hon‐Yi Shi
- Department of Healthcare Administration and Medical Informatics Kaohsiung Medical University Kaohsiung Taiwan
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Ying AK, Feeley TW, Porter ME. Value-based healthcare: implications for thyroid cancer. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2016. [DOI: 10.2217/ije-2015-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Today's delivery of care to thyroid cancer patients is complex, and costly, with uneven outcomes that can be improved. The incidence of thyroid cancer is rising and requires coordinated, multidisciplinary care with high volume centers that is not always available in our current fragmented healthcare system. To address the needs of patients, providers and payers, we believe that thyroid cancer care needs to be reexamined from the perspective of value for the patient, which is defined as the outcomes that matter to patients relative to the cost of delivering them. This paper provides recommendations based on the key principles of the value-based approach to transform the delivery of thyroid cancer care.
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Affiliation(s)
- Anita K Ying
- University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Thomas W Feeley
- University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Harvard Business School, Boston, MA 02163, USA
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Sacks W, Wong RM, Bresee C, Braunstein GD. Use of evidence-based guidelines reduces radioactive iodine treatment in patients with low-risk differentiated thyroid cancer. Thyroid 2015; 25:377-85. [PMID: 25578116 DOI: 10.1089/thy.2014.0298] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Wendy Sacks
- 1 Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
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16
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Noninvasive surface detection of papillary thyroid carcinoma by Fourier transform infrared spectroscopy. Chem Res Chin Univ 2015. [DOI: 10.1007/s40242-015-4354-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Beck M. Radiation safety in the management of patients undergoing radioactive iodine ablation therapy. Clin J Oncol Nurs 2015; 19:44-6. [PMID: 25689648 DOI: 10.1188/15.cjon.44-46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
High-dose radioiodine therapy for thyroid cancer poses risks to healthcare workers, family members, and the public. Oncology nurses can effectively manage these risks by employing the three key principles of time, distance, and shielding.
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Haymart MR, Banerjee M, Yang D, Stewart AK, Griggs JJ, Sisson JC, Koenig RJ. Referral patterns for patients with high-risk thyroid cancer. Endocr Pract 2014; 19:638-43. [PMID: 23512381 DOI: 10.4158/ep12288.or] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Knowledge of referral patterns for specialty cancer care is sparse. Information on both the need and reasons for referral of high-risk, well-differentiated thyroid cancer patients should provide a foundation for eliminating obstacles to appropriate patient referrals and improving patient care. METHODS We surveyed 370 endocrinologists involved in thyroid cancer management. From information in a clinical vignette, respondents were asked to identify the reasons they would need to refer a high-risk patient to a more specialized facility for care. We performed multivariable analysis controlling for hospital and physician characteristics. RESULTS Thirty-two percent of respondents reported never referring thyroid cancer patients to another facility. Of those that would refer a high-risk patient to another facility, the opportunity for a patient to enter a clinical trial was the most common reason reported (44%), followed by high-dose radioactive iodine (RAI) with or without dosimetry (33%), lateral neck dissection (24%), and external beam radiation (15%). In multivariable analysis, endocrinologists with a higher percentage of their practice devoted to thyroid cancer care were significantly less likely to refer patients to another facility (P = .003). CONCLUSION The majority of endocrinologists treating thyroid cancer patients report referring a high-risk patient to another facility for some or all of their care. Knowledge of the patterns of physician referrals and the likelihood of need for referral are key to understanding discrepancies in referral rates and obstacles in the referral process.
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Affiliation(s)
- Megan R Haymart
- Department of Medicine, University of Michigan, Ann Arbor, MI 48109-2800, USA.
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Haymart MR, Banerjee M, Yang D, Stewart AK, Sisson JC, Koenig RJ, Doherty GM, Griggs JJ. Variation in the management of thyroid cancer. J Clin Endocrinol Metab 2013; 98:2001-8. [PMID: 23539722 PMCID: PMC3644603 DOI: 10.1210/jc.2012-3355] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
CONTEXT Little is known about practice patterns in thyroid cancer, a cancer that is increasing in incidence. OBJECTIVE We sought to identify aspects of thyroid cancer management that have the greatest variation. DESIGN/SETTING/PARTICIPANTS We surveyed 944 physicians involved in thyroid cancer care from 251 hospitals affiliated with the US National Cancer Database. Physicians were asked questions in the following four domains: thyroid surgery, radioactive iodine use, thyroid hormone replacement postsurgery, and long-term thyroid cancer management. We calculated the ratio of observed variation to hypothetical maximum variation under the assumed distribution of the response. Ratios closer to 1 indicate greater variation. RESULTS We had a 66% response rate. We found variation in multiple aspects of thyroid cancer management, including the role of central lymph node dissections (variation, 0.99; 95% confidence interval [CI], 0.98-1.00), the role of pretreatment scans before radioactive iodine treatment (variation, 1.00; 95% CI, 0.98-1.00), and all aspects of long-term thyroid cancer management, including applications of ultrasound (variation, 0.97; 95% CI, 0.93-0.99) and radioactive iodine scans (variation, 0.99; 95% CI, 0.97-1.00). For the management of small thyroid cancers, variation exists in all domains, including optimal extent of surgery (variation, 0.91; 95% CI, 0.88-0.94) and the role of both radioactive iodine treatment (variation, 0.91; 95% CI, 0.89-0.93) and suppressive doses of thyroid hormone replacement (variation, 1.00; 95% CI, 0.99-1.00). CONCLUSION We identified areas of variation in thyroid cancer management. To reduce the variation and improve the management of thyroid cancer, there is a need for more research and more research dissemination.
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Affiliation(s)
- Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Papaleontiou M, Banerjee M, Yang D, Sisson JC, Koenig RJ, Haymart MR. Factors that influence radioactive iodine use for thyroid cancer. Thyroid 2013; 23:219-24. [PMID: 23134514 PMCID: PMC3569922 DOI: 10.1089/thy.2012.0380] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There is variation in the use of radioactive iodine (RAI) as treatment for well-differentiated thyroid cancer. The factors involved in physician decision-making for RAI remain unknown. METHODS We surveyed physicians involved in postsurgical management of patients with thyroid cancer from 251 hospitals. Respondents were asked to rate the factors important in influencing whether a thyroid cancer patient receives RAI. Multivariable analyses controlling for physician age, gender, specialty, case volume, and whether they personally administer RAI, were performed to determine correlates of importance placed on patients' and physicians' worry about death from cancer and differences between low- versus higher-case-volume physicians. RESULTS The survey response rate was 63% (534/853). Extent of disease, adequacy of surgical resection, patients' willingness to receive RAI, and patients' age were the factors physicians were most likely to report as quite or very important in influencing recommendations for RAI to patients with thyroid cancer. Interestingly, both physicians' and patients' worry about death from thyroid cancer were also important in determining RAI use. Physicians with less thyroid cancer cases per year were more likely than higher-volume physicians to report patients' (p<0.001) and physicians' worry about death (p=0.016) as quite or very important in decision-making. Other factors more likely to be of greater importance in determining RAI use for physicians with lower thyroid cancer patient volume versus higher include the accepted standard at the affiliated hospital (p=0.020), beliefs about RAI expressed by colleagues comanaging patients (p=0.003), and patient distance from the nearest facility administering RAI (p=0.012). CONCLUSION In addition to the extent of disease and adequacy of surgical resection, physicians place importance on physician and patient worry about death from thyroid cancer when deciding whether to treat a patient with RAI. The factors important to physician decision-making differ based on physician thyroid-cancer case-volume, with worry about death being more influential for low-case-volume physicians. As the mortality from thyroid cancer is low, the importance placed on death in decision making may be unwarranted.
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Affiliation(s)
- Maria Papaleontiou
- Division of Metabolism, Endocrinology, and Diabetes, Department of Medicine, University of Michigan Health System, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Di Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - James C. Sisson
- Department of Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan
| | - Ronald J. Koenig
- Division of Metabolism, Endocrinology, and Diabetes, Department of Medicine, University of Michigan Health System, University of Michigan, Ann Arbor, Michigan
| | - Megan R. Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Medicine, University of Michigan Health System, University of Michigan, Ann Arbor, Michigan
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Haymart MR, Muenz DG, Stewart AK, Griggs JJ, Banerjee M. Disease severity and radioactive iodine use for thyroid cancer. J Clin Endocrinol Metab 2013; 98:678-86. [PMID: 23322816 PMCID: PMC3565122 DOI: 10.1210/jc.2012-3160] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Although variation in radioactive iodine (RAI) use for thyroid cancer has been demonstrated, the role of region and nonclinical correlates of use within risk groups has not been investigated. OBJECTIVE The objective of the study was to determine the correlates of RAI use within risk groups. DESIGN/SETTING/PATIENTS Use of RAI was evaluated across 9 US regions in 85 948 patients with well-differentiated thyroid cancer diagnosed between 2004 and 2008 at 986 hospitals associated with the US National Cancer Database. Cancers were then categorized as low risk (tumor size ≤ 1 cm and American Joint Committee on Cancer stage I disease), medium risk (neither low nor high-risk), and high risk (American Joint Committee on Cancer stage III or IV). Within each risk stratum, the role of region and nonclinical correlates of RAI use were evaluated using hierarchical logistic regression. MAIN OUTCOME MEASURE Use of RAI was measured. RESULTS Rates of RAI use varied across geographic regions from 49% to 66%. Regional differences persisted after controlling for patient and hospital characteristics and evaluating less vs more intensive regions within low-risk [odds ratio (OR) 0.36 (95% confidence interval [CI] 0.25-0.53)], medium-risk [OR 0.23 (95% CI 0.16-0.34)], and high-risk cancers [OR 0.30 (95% CI 0.19-0.49)]. Patterns of RAI use were similar in medium- and high-risk patients. The most nonclinical correlates of use were in low-risk patients. CONCLUSION Similar treatment patterns for the heterogeneous medium-risk thyroid cancer patients compared with the high-risk patients suggest more intensive management in patients with medium-risk disease. The large number of nonclinical correlates of RAI use, including region, imply controversy over indications for RAI.
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Affiliation(s)
- M R Haymart
- Department of Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road Building 16, Room 408E, Ann Arbor, Michigan 48109-2800, USA.
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Schuessler KM, Banerjee M, Yang D, Stewart AK, Doherty GM, Haymart MR. Surgeon training and use of radioactive iodine in stage I thyroid cancer patients. Ann Surg Oncol 2012; 20:733-8. [PMID: 23224826 DOI: 10.1245/s10434-012-2745-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The majority of thyroid cancer diagnoses in the United States are stage I well-differentiated cancer. The use of radioactive iodine (RAI) in these low-risk patients has increased over time. The role of surgeon training in decision making regarding treatment with RAI is unknown. METHODS Thyroid surgeons affiliated with 368 hospitals associated with the US National Cancer Database (NCDB) were surveyed. Survey data were linked to the NCDB data. A multivariable weighted analysis controlling for surgeon and hospital characteristics was conducted to examine the relationship between surgeon training, continuing education and hospital-level RAI use for stage I well-differentiated thyroid cancer. RESULTS The response rate was 70% (560 of 804). In both univariate and multivariable analysis controlling for hospital case volume, practice setting and surgeon specialty, training with a thyroid surgeon was associated with less RAI use for stage I thyroid cancer (P = 0.022 and 0.028, respectively). Attending one or more professional society meetings a year was associated with a lower rate of hospital-level RAI use in univariate analysis (P = 0.044) but not multivariable analysis. CONCLUSIONS Training with a surgeon or group of surgeons who focus on thyroid surgery was associated with a lower proportion of stage I thyroid cancer patients receiving RAI after total thyroidectomy. This study emphasizes the importance of surgeon training in hospital practice patterns.
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Affiliation(s)
- Kathryn M Schuessler
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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