Patient Preferences Around Extent of Surgery in Low-Risk Thyroid Cancer: A Discrete Choice Experiment

Abstract

Background: Patient preferences pertaining to surgical options for thyroid cancer management are not well studied. Our aim was to conduct a discrete choice experiment (DCE) to characterize participants' views on the relative importance of various risks and benefits associated with lobectomy versus total thyroidectomy for lowrisk thyroid cancer. Methods: Adult participants with low-risk thyroid cancer or a thyroid nodule requiring surgery were asked to choose between experimentally designed surgical options with varying levels of risk of nerve damage (1%, 9%, 14%), hypocalcemia (0%, 3%, 8%), risk of needing a second surgery (0%, 40%), cancer recurrence (1%, 3%, 5%), and need for daily thyroid hormone supplementation (yes, no). Their choices were analyzed using randomparameters logit regression. Results: One hundred fifty participants completed an online DCE survey. Median age was 58 years; 82% were female. Twenty-four participants (16%) had a diagnosis of thyroid cancer at the time of completing the survey, and 126 (84%) had a thyroid nodule necessitating surgery. On average, 35% of participants' choices were explained by differences in the risk of cancer recurrence; 28% by the chance of needing a second surgery; 19% by the risk of nerve damage; and 9% by differences in risks of hypocalcemia and the need for thyroid hormone supplementation. When accounting for differences in postoperative risks, the average patient favored lobectomy over total thyroidectomy as long as the chance of needing a second (i.e., completion) surgery after initial lobectomy remained below 30%. Participants would accept a 4.1% risk of cancer recurrence if the risk of a second surgery could be reduced from 40% to 10%. Conclusions: While patients with thyroid cancer may have clear preferences for extent of surgery, common themes moderating preferences for surgical interventions were identified in the DCE. Adequate preoperative evaluation to decrease the chance of a second surgery and providing patients with a good understanding of risks and benefits associated with extent of surgery can lead to better treatment decision-making.

Efficacy and safety of ultrasound-guided radiofrequency ablation for low-risk papillary thyroid microcarcinoma in patients aged 55 years or older: a retrospective study

“…Surgery is still the firstline treatment for most low-risk PTMCs. However, postoperative complications, including permanent recurrent laryngeal nerve paralysis, hypoparathyroidism, osteoporosis, and cardiac events, decrease patients' quality of life [32][33][34]. According to some studies, surgery can be considered as an overtreatment clinical strategy for such a low-risk but high-incidence disease [35].…”

Favorable Early Outcomes With Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: The Mayo Clinic Experience

“…It is possible that some of these “recurrences” are in fact, persistent disease, particularly when “new” lymph nodes are seen in lateral neck shortly after initial thyroidectomy, and that many could have been avoided with detailed lymph node mapping preoperatively. Ahmadi et al 11 evaluated patient preferences regarding initial lobectomy vs. total thyroidectomy. The risk for recurrence was the most important factor in decision-making, followed by the potential need for CT.…”

Thyroid Lobectomy for Low to Intermediate Risk Differentiated Thyroid Cancer

“…HRQoL was 1.5-times worse in patients having undergone total thyroidectomy (95% CI, 1.04-2.12) and 2.3-times worse in those having undergone total thyroidectomy and neck dissection (95% CI, 1.10-4.80) compared with patients having undergone lobectomy [29]. Finally, a recent online survey asking 150 patients to state their choice between total thyroidectomy and thyroid lobectomy found that their choices were, on average, determined for 35% of patients by the risk of cancer recurrence, 28% by the need for a second operation, 19% by the risk of recurrent nerve damage, and 9% by the risk of hypocalcemia and need for thyroid hormone treatment [30]. Oncologic considerations thus seem to be more important to patients than complications, and we will focus on this aspect of thyroid lobectomy in the following paragraphs.…”

“…Even if preoperative patient selection is very careful and careful intraoperative evaluation excludes patients with suspected extrathyroidal extension or lymph node metastases, at least 30% of patients may still require completion thyroidectomy secondarily due to higher-risk features that can only be ascertained upon definitive histopathological and molecular analysis of the tumor [56,57]. Patient preference, recently studied via an online questionnaire, found that among other considerations, patients favored lobectomy over total thyroidectomy as long as the risk of needing a completion operation was below 30% [30]. Unfortunately, patient preferences do not fall within the estimated 34-59% rate of completion thyroidectomy, as cited above.…”