BACKGROUND
Thyroid ultrasound is an essential tool in the evaluation and management of thyroid nodules. Thyroid nodules are the most common endocrine problem, occurring in up to half of the US population. The main concern with a thyroid nodules is the possibility of thyroid cancer, which overall occurs in ~5% of thyroid nodules. In recent years there has been a marked increase in incidence of thyroid cancer. Much of this increase in diagnosis of thyroid cancer has been thought to be due to increased use of neck imaging studies, including ultrasound, leading to greater detection of nodules. Some authors have suggested wide-spread use of neck imaging has led to the overdiagnosis of thyroid nodules and cancer, resulting in finding very low risk thyroid cancers that may not need to be treated. This study sought to understand physician attitudes and practice patterns for ordering thyroid ultrasounds. They surveyed physicians taking care of patients with thyroid cancer as to how the cancer came to be diagnosed.

THE FULL ARTICLE TITLE
Chen DW et al 2020 Physician-reported misuse of thyroid ultrasonography. JAMA Surg 155:984–986. PMID: 32804996.

SUMMARY OF THE STUDY
Authors of this study surveyed physicians in Georgia and Los Angeles, California identified as caretakers of patients with thyroid cancer who were diagnosed between 2014 and 2015 and identified in the Surveillance, Epidemiology and End Results (SEER) Registry regarding their practice patterns and the use of neck/thyroid ultrasounds in a variety of clinical scenarios. The scenarios presented were grouped into three categories:

1) Clinically supported use: palpable thyroid nodule, large thyroid or goiter on exam, thyroid nodule seen on another imaging study and / or new onset horseness or compressive symptoms.
2) Clinically unclear use: history of head/neck radiation or family history of thyroid cancer.
3) Clinically unsupported use: patient request, abnormal thyroid function tests, or positive thyroid antibodies.

There were 610 physicians that participated in the survey including surgeons, endocrinologists, and primary care physicians. Approximately 60% worked in private practice, 66% were men and 70% reported having read published clinical guidelines related to the management of thyroid nodules and/or thyroid cancer. Although most of the physicians reported the use of neck/ thyroid ultrasound for clinically supported indications, a substantial proportion reported using the test in nonclinically supported scenarios such as patient request or abnormal thyroid laboratory results. For example, 98.2% of respondents reported thyroid ultrasound use if the patient had a palpable thyroid nodule (clinically supported reason) and 32.7% reported using thyroid ultrasound when the sole reason was patient request (non-clinically supported reason). Specialists were more likely order an ultrasound in response to a patient request than primary care providers. Private practice physicians were more likely to order thyroid ultrasounds in response to abnormal thyroid laboratory results than physicians working in academic centers. Most physicians acknowledged published clinical guidelines as impacting their decisions to order neck/thyroid ultrasounds.

In summary, most physicians order neck/thyroid ultrasounds for reasons supported by the published literature. A smaller yet significant percent of physicians report using neck/thyroid ultrasound for reasons not supported by clinical guidelines.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
Physicians order neck/thyroid ultrasound for a variety of reasons. Most clinicians reported more frequent use of the neck/thyroid ultrasounds in patient scenarios supported by clinical guidelines (palpable thyroid nodules, large goiter, nodule seen on other imaging, new voice changes or compressive symptoms). However, a relatively high percent of physicians reported ordering neck/thyroid ultrasounds for non-indicated reasons such as patient request or abnormal thyroid laboratory tests. This pattern may increase the risk of finding thyroid nodules that need further evaluation. These findings suggest the need for increased education about the clinically appropriate uses of thyroid ultrasound and that there should be increased discussion between patients and ordering physicians about the potential negative effects of ordering unnecessary neck/thyroid ultrasounds.

— Whitney W. Woodmansee MD

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