American Thyroid Association Guidelines and National Trends in Management of Papillary Thyroid Carcinoma

Abstract

ImportanceOver time, the American Thyroid Association (ATA) guidelines have increasingly promoted more limited treatments for well-differentiated thyroid cancers.ObjectiveTo determine whether the 2009 and 2015 ATA guidelines were associated with changes in the management of low-risk papillary thyroid carcinomas on a national scale.Design, Setting, and ParticipantsThis historical cohort study used the National Cancer Database. All papillary thyroid carcinomas diagnosed from 2004 to 2019 in the National Cancer Database were selected. Patients with tumors of greater than 4 cm, metastases, or clinical evidence of nodal disease were excluded. Data were analyzed from August 1, 2021, to September 1, 2022.Main Outcomes and MeasuresThe primary aim was to tabulate changes in the rates of thyroid lobectomy (TL), total thyroidectomy (TT), and TT plus radioactive iodine (RAI) therapy after the 2009 and 2015 ATA guidelines. The secondary aim was to determine in which settings (eg, academic vs community) the practice patterns changed the most.ResultsA total of 194 254 patients (155 796 [80.2%] female patients; median [range] age at diagnosis, 51 [18-90] years) who underwent treatment during the study period were identified. Among patients who underwent surgery, rates of TL decreased from 15.1% to 13.7% after the 2009 guidelines but subsequently increased to 22.9% after the 2015 changes. Among patients undergoing TT, rates of adjuvant RAI decreased from 48.7% to 37.1% after 2009 and to 19.3% after the 2015 guidelines. Trends were similar for subgroups based on sex and race and ethnicity. However, academic institutions saw larger increases in TL rates (14.9% to 25.7%) than community hospitals (16.3% to 19.5%). Additionally, greater increases in TL rates were observed for tumors 1 to 2 cm (6.8% to 18.9%) and 2 to 4 cm (6.6% to 16.0%) than tumors less than 1 cm (22.8% to 29.2%).Conclusions and RelevanceIn this cohort study among patients with papillary thyroid carcinomas up to 4 cm, ATA guideline changes corresponded with increased TL and reduced adjuvant RAI. These changes were primarily seen in academic institutions, suggesting an opportunity to expand guideline-based care in the community setting.

Prognostic Value of Preoperative Molecular Testing and Implications for Initial Surgical Management in Thyroid Nodules Harboring Suspected (Bethesda V) or Known (Bethesda VI) Papillary Thyroid Cancer

“…However, approximately 80% of MRG-intermediate and MRG-low patients underwent total thyroidectomy in our study, of whom two-thirds received RAI ablation. This finding is consistent with a recent national study showing that 77% of low-risk thyroid cancers are treated with total thyroidectomy, as well as with other studies . Thus, an opportunity to deescalate surgery and decrease the burden of permanent surgical complications may be indicated for many patients with thyroid cancer when interpreted within the limitations of the lower power of our findings.…”

Regional Collaboration and Trends in Clinical Management of Thyroid Cancer

“…As observed in our study, the rate of thyroid lobectomy in patients with low‐risk differentiated thyroid cancer has increased over time and a growing number of patients did not receive radioactive iodine therapy after total or completion thyroidectomy. This indicates that changes in the 2015 ATA guidelines not only have implications for patients in America but also for patients in countries that have not formally adopted these guidelines such as The Netherlands 20 . While we cannot definitely determine the sole influence of the updated ATA guidelines, it is plausible that the network played a supportive role in enabling the implementation of these de‐escalated treatment approaches and ensuring consistent care throughout the region 21 .…”

“…This indicates that changes in the 2015 ATA guidelines not only have implications for patients in America but also for patients in countries that have not formally adopted these guidelines such as The Netherlands. 20 While we cannot definitely determine the sole influence of the updated ATA guidelines, it is plausible that the network played a supportive role in enabling the implementation of these de-escalated treatment approaches and ensuring consistent care throughout the region. 21 Notably, de-escalating treatment strategies in the Southwestern of The Netherlands are often backed by the regional multidisciplinary tumor board, which benefits from the input of several experts in the field of thyroid cancer.…”

Clinical inertia in thyrotropin suppressive therapy for low-risk differentiated thyroid cancer: A real-world experience at an endocrine center in Bangkok

“…[23] Studies from the Surveillance, Epidemiology, and End Results Program in the United States revealed increases in rates of treatment de-escalations in all aspects following the release of the 2015 ATA guidelines. [24] The risks of severe thyrotropin suppressive therapy would be more relevant in our present cohort because their age poses a greater risk for many age-related diseases. Moreover, recent data also showed that long-term TSH suppression in elderly patients with DTC was associated with sarcopenia and frailty.…”