The Impact of Regional Variation in Clinical Practice on Thyroid Cancer Diagnosis: A National Population-Based Study

Abstract

Objective: Regional variation in thyroid cancer incidence in Belgium, most pronounced for low risk cancer, was previously shown to be related to variation in clinical practice, with higher thyroid surgery rates and lower proportions of preoperative fine-needle aspiration (FNA) in regions with high thyroid cancer incidence (period 2004–2006). The objective of this study was to investigate regional thyroid cancer incidence variation in relation with variation in thyroid surgery threshold in a more recent Belgian thyroid cancer cohort. Methods: A population-based cohort of thyroid cancer patients that underwent a (near) total thyroidectomy in the period 2009–2011 (n = 2,329 patients) was identified and studied by linking data from the Belgian cancer registry and the Belgian health insurance companies, and case-by-case study of the pathology protocols. The execution of preoperative FNA and the thyroid resection specimen weight were compared between high and low thyroid cancer incidence regions. Thyroid weight in the pT1a-restricted group was studied as a proxy for surgical threshold for benign nodular goiter. Furthermore, time trend analyses were performed for the execution of FNA for the period 2004–2012. Results: Although a lower proportion of FNA in the high thyroid cancer incidence region persisted in the period 2009–2011 (41.2% [31.9–50.9] vs. 72.9% [64.9–79.7] in the low-incidence region (LIR), p < 0.001), a positive time trend was observed for the period 2004–2012. The median thyroid surgical specimen weight was lower in the high incidence region compared to the LIR (27.0 g [IQR 18.0–45.3] vs. 36.0 g [IQR 22.0–73.0], p < 0.0001), and this finding was corroborated in the pT1a-restricted group. Conclusion: Interregional differences in use of FNA and surgical thyroid specimen weight are consistent with an inverse relation between thyroid cancer incidence and thyroid surgery threshold, carrying risk for overdiagnosis.

A multicenter, prospective study to observe the initial management of patients with differentiated thyroid cancer in China (DTCC study)

“…It is also worth noting that only 37% of DTC patients in this study had pre-surgical FNA use, which is higher than the estimate of 32% observed in the US [ 42 ], but lower than the estimate of 41-73% across different regions of Belgium [ 43 ]. Although ATA and other Associations recommend FNA as an important preoperative diagnostic tool for thyroid nodules, it is not widely accepted in China, and some hospitals use intraoperative frozen section for diagnosis.…”

Thyroid Lobectomy for Low‐Risk 1–4 CM Papillary Thyroid Cancer is not Associated with Increased Recurrence Rates in the Dutch Population with a Restricted Diagnostic Work‐Up

“…In the Netherlands a restrictive diagnostic work-up strategy is standard care for thyroid nodules, recommending diagnostic work-up only for palpable nodules, preventing fine needle aspiration (FNA) biopsies of incidentalomas detected by imaging [ 8 ]. Since 2013, the number of PET/CT scans performed grew by 6% annually, and together with the exponential increase in use of US imaging, more incidentalomas are found [ 10 , 11 , 14 ]. However, the Dutch guideline only recommend diagnostic FNA for patients with palpable or symptomatic thyroid nodules, which possibly prevents a significant amount of indolent PTC from being diagnosed, resulting in more intensely selected and possibly more aggressive recorded PTCs in The Netherlands when compared to the U.S. population [ 8 , 9 ].…”

“…However, in contrast to the ATA guidelines, the Dutch guidelines recommend more restricted work-up for thyroid incidentalomas recommending only fine needle aspiration (FNA) in case of a ‘palpable thyroid nodule’. [ 8 , 9 ] Multiple studies showed that increased use of imaging modalities leads to increased number of PTC diagnoses, mostly without clinical relevance [ 10 , 11 ]. Subsequently, using a restrictive diagnostic work-up algorithm may result in the identification of less PTCs with an indolent nature and may lead to a patient population with relatively more aggressive PTCs.…”

Characteristics of Patients Sponsored by the Internet Platforms of Medical Mutual Aid

“…Although relevant medical experts have formulated relevant rules for the diagnosis and treatment of thyroid cancer [9], the relevant regulations for the implementation of medical insurance do not specifically consider the actual clinical situation. It is still difficult to avoid the occurrence of over-diagnosis and over-treatment in clinical practice [10]. Under this situation, the medical cost of thyroid cancer treatment is not covered by the medical insurance reasonably according to the clinical diagnosis and treatment [11].…”