The Relationship Between Imaging and Thyroid Cancer Diagnosis and Survival

Timely assessment of 5-year relative survival for patients with thyroid cancer from Taizhou, eastern China: a period analysis

BACKGROUND

While timely assessment of long-term survival in thyroid cancer patients is critical for assessing early detection and screening programs for thyroid cancer, those data are sorely lacking in China. We aimed to timely and accurately assess the long-term survival of thyroid cancer patients in eastern China.

METHODS

Patients diagnosed with thyroid cancer during 2004-2018 from four cancer registries in Taizhou, eastern China were included. The 5-year relative survival was estimated by period analysis and stratified by sex, age at diagnosis, and region. The 5-year RS of thyroid cancer patients during 2019-2023 was also predicted using the model-based period analysis.

RESULTS

During 2014-2018, the overall 5-year relative survival of thyroid cancer patients was 87.7%, 91.2% for women and 79.4% for men. The 5-year RS decreased along with increasing age at diagnosis, decreasing from 94.9% for age <45 years to 81.3% for age >74 years, while 5-year RS was higher in urban areas than in rural areas (93.2% vs. 86.1%). The 5-year RS for thyroid cancer patients improved greatly between 2004-2008 to 2014-2018. The predicted overall 5-year RS could reach 91.4% over the upcoming 2019-2023 period.

CONCLUSION

We provided, for the first time in China using period analysis, the most up-to-date 5-year RS for thyroid cancer patients from Taizhou, eastern China, which has important implications for timely evaluation on early detection and screening programs for patients with thyroid cancer in eastern China.

Thyroid cancer

The past 5-10 years have brought in a new era in the care of patients with thyroid cancer, with the introduction of transformative diagnostic and management options. Several international ultrasound-based thyroid nodule risk stratification systems have been developed with the goal of reducing unnecessary biopsies. Less invasive alternatives to surgery for low-risk thyroid cancer, such as active surveillance and minimally invasive interventions, are being explored. New systemic therapies are now available for patients with advanced thyroid cancer. However, in the setting of these advances, disparities exist in the diagnosis and management of thyroid cancer. As new management options are becoming available for thyroid cancer, it is essential to support population-based studies and randomised clinical trials that will inform evidence-based clinical practice guidelines on the management of thyroid cancer, and to include diverse patient populations in research to better understand and subsequently address existing barriers to equitable thyroid cancer care.

Current Controversies in Low-Risk Differentiated Thyroid Cancer: Reducing Overtreatment in an Era of Overdiagnosis

CONTEXT

Low-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy.

EVIDENCE ACQUISITION

This mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed.

EVIDENCE SYNTHESIS

Recommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad.

CONCLUSION

Clinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.

Towards De-Implementation of low-value thyroid care in older adults

PURPOSE OF REVIEW

This review discusses the current literature regarding low-value thyroid care in older adults, summarizing recent findings pertaining to screening for thyroid dysfunction and management of hypothyroidism, thyroid nodules and low-risk differentiated thyroid cancer.

RECENT FINDINGS

Despite a shift to a "less is more" paradigm for clinical thyroid care in older adults in recent years, current studies demonstrate that low-value care practices are still prevalent. Ineffective and potentially harmful services, such as routine treatment of subclinical hypothyroidism which can lead to overtreatment with thyroid hormone, inappropriate use of thyroid ultrasound, blanket fine needle aspiration biopsies of thyroid nodules, and more aggressive approaches to low-risk differentiated thyroid cancers, have been shown to contribute to adverse effects, particularly in comorbid older adults.

SUMMARY

Low-value thyroid care is common in older adults and can trigger a cascade of overdiagnosis and overtreatment leading to patient harm and increased healthcare costs, highlighting the urgent need for de-implementation efforts.

Large, Slowly Growing, Benign Thyroid Nodules Frequently Coexist With Synchronous Thyroid Cancers

CONTEXT

Thyroid nodules' size should not be the sole criterion for thyroidectomy; however, many patients undergo surgery for large or slowly growing nodules.

OBJECTIVE

We evaluated risk for clinically significant thyroid cancer in patients with large or slowly growing nodules.

METHODS

We reviewed data from 2 prospectively collected databases of patients undergoing thyroidectomies in tertiary referral centers in the USA and Greece over 14 consecutive years. We collected data on the preoperative surgical indication, FNA cytology, and surgical pathology. We included subjects operated solely for large or growing thyroid nodules, without any known or presumed thyroid cancer or high risk for malignancy, family history of thyroid cancer, or prior radiation exposure.

RESULTS

We reviewed 5523 consecutive cases (USA: 2711; Greece: 2812). After excluding 3059 subjects, we included 2464 subjects in the present analysis. Overall, 533 thyroid cancers were identified (21.3%): 372 (69.8%) microcarcinomas (<1 cm) and 161 (30.2%) macrocarcinomas (≥1 cm). The histology was consistent with papillary cancer (n = 503), follicular cancer (n = 12), Hürthle cell cancer (n = 9), medullary cancer (n = 5), and mixed histology cancers n = 4. Only 47 (1.9%) of our subjects had any form of thyroid cancer in the nodule that originally led to surgery. The cancers were multifocal in 165 subjects; had extrathyroidal extension in 61, capsular invasion in 80, lymph node involvement in 35, and bone metastasis in 2 subjects.

CONCLUSION

The risk of synchronous, clinically important thyroid cancers is small, but not null in patients with large or slow growing thyroid nodules. Therefore, more precise preoperative evaluation is needed to separate the patients who would clearly benefit from thyroid surgery from the vast majority of those who do not need to be operated.

Incidence and prognosis of thyroid cancer in children: based on the SEER database

OBJECTIVE

To update the recognition of the trends in the incidence of childhood thyroid cancer (TC) and its prognosis.

METHODS

A large-scale sample based on long time-line public database was recruited. Join-point regression model was used to analyze the incidence trend of childhood TC. Univariable and multivariable Cox regression model analyses were applied to explore the survival situation and prognostic factors.

RESULTS

The incidence rate of childhood TC increased between 1975 and 2016 from 3.8/million (95% CI 2.6-5.5) to 11.5/million (95% CI 9.2-14.1), AAPC = 2.38% (95% CI 1.98-9.65) and could be divided into two stages of increasing trends. The incidence rate of Trend1 (1975-2005) increased slowly (APC = 1.08%, 95% CI 0.38-1.82) while Trend2 (2005-2016) increased dramatically (APC = 6.77%, 95% CI 4.30-9.28). Annual incidence rate of small size tumor (< 4 cm) and local stage childhood TC increased significantly. The overall cumulative survival rate for childhood TC was high up to 97-99%. Males, black race, MTC type, distant metastasis, tumor size ≥ 4 cm, non-primary cancer were the independent risk factors of childhood TC prognosis.

CONCLUSION

A contribution of overdetection to rising pediatric TC rates might not be able to rule out. For clinical implications, screening TC in children with potential specific risk factors is feasible. Over-treatment to small size and local stage TC in children should be avoided.

Progress and Challenges in Thyroid Cancer Management

The state of thyroid cancer in 2021 is reviewed including the prevalence of thyroid cancer, vulnerable patient groups such as women and young adults, and known and hypothesized risk factors for thyroid cancer. Understanding the overdiagnosis and overtreatment of thyroid cancer and recent efforts to reduce harms secondary to overdiagnosis and overtreatment are addressed with optimism that future work will continue to evaluate and improve the care of patients with thyroid cancer.

The Ongoing Debate Regarding Completion Thyroidectomy Versus Primary Thyroid Surgery for Low and Intermediate Differentiated Thyroid Carcinoma: A Meta-Analysis

Lobectomy is increasingly performed for low-risk differentiated thyroid cancer (DTC) and papillary thyroid microcarcinoma (PTMC). However, there is a continuous controversy about completion thyroidectomy (CT) following lobectomy. The current meta-analysis aimed to assess the outcomes of the initial surgical procedure versus CT performed for low/intermediate-risk thyroid carcinoma. Six hundred and sixty-one articles were retrieved, and only 15 full texts fulfilled the inclusion and exclusion criteria. There were 15 studies, including 17,143 patients; twelve were retrospective, two prospective studies, and a controlled trial. Seven articles were from Asia, four from the USA, two from Europe, while two were published in Canada. The studies showed no difference between lobectomy and primary thyroid surgery regarding post-surgery complications. CT was not different from the initial surgical procedure in terms of complications for DTC. The study was limited by the retrospective studies included, the outcomes assessed were not uniform, and significant heterogeneity was observed. Further, well-controlled, more specific trials are needed.