Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey

Abstract

Context Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States. Objective To understand factors associated with adoption of AS. Design/Setting/Participants We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for two hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Main Outcome Measure Adoption of AS (non-adopters vs adopters, who respectively did not recommend or recommended AS at least once; partial vs full adopters, who respectively recommended AS for one or both cases) Results The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Non-adopters (45.7%) were significantly (p<0.001) less likely than adopters to: practice in academic settings, see >25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (p=0.04), know how to determine a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Non-adopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (p=0.03) and more likely to be anxious (p=0.04), have reservations (p=0.03), and have concerns about the psychological burden (p=0.009) of AS. Few respondents (3.2%) believed patients were aware of AS. Conclusions Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

Physician Perspectives of Overdiagnosis and Overtreatment of Low-Risk Papillary Thyroid Cancer in the US

“…Nonrespondents were demographically similar to respondents but more likely to be female. 3 Overdiagnosis was recommended by 280 respondents (64.0%). No significant demographic, specialty, or regional differences existed between respondents recommending overdiagnosis vs appropriate care (Table 1).…”

“…Respondents’ demographics were similar to those of Association of American Medical Colleges active physicians in each specialty. Nonrespondents were demographically similar to respondents but more likely to be female …”

“…Survey development and administration were previously described (eAppendix in the Supplement ). 3 Respondents who were actively practicing, had treated thyroid cancer since 2015 (ATA guidelines publication date), and had responded to questions about overdiagnosis (biopsy outside ATA guideline for nodules <1 cm with suspicious features or nodules <1.5 cm without suspicious features) and overtreatment (total or completion thyroidectomy, central neck dissection, and/or RAI for 1 low-risk PTC <1 cm) were included. Responses were calculated using the AAPOR guideline (response rate 2), in which all nonresponders are considered eligible.…”

Development of an Active Surveillance or Surgery Model to Predict Lymph Node Metastasis in cN0 Papillary Thyroid Microcarcinoma

“…In the context of overdiagnosis and overtreatment of PTMC, AS was introduced as an alternative treatment and attempted to reduce unnecessary surgery (17)(18)(19)(20)(21). However, the clinical acceptance of AS was relatively low (22). The reason was lack in knowledge and awareness of AS among physicians on the one hand, and concerning adverse outcomes of this non-operative approach on the other.…”

2022 ETA Consensus Statement: What are the indications for post-surgical radioiodine therapy in differentiated thyroid cancer?

“…Nowadays, the large majority of thyroid cancer patients have a low risk of recurrence after complete surgery and an even smaller risk of thyroid cancer related death, and careful examinations of patients’ outcome suggests that the use of post-surgical RAI ablation may be tailored according to a risk-based approach. This is even more relevant in view of changes in DTC management, preceding a decision on RAI therapy, taking a de-escalating approach with increasing use conservative DTC surgery (lobectomy rather than total thyroidectomy), changes in DTC nomenclature, for example, NIFTP and the concept of 'active surveillance' in (very) low-risk PTC ( 8 , 12 ).…”