BACKGROUND
Thyroid cancer is common. Fortunately, the prognosis for patients with thyroid cancer is excellent as we have very effective treatment options, and the most common type of thyroid cancer is very slow growing. Many thyroid cancers that are discovered are small and we know that small thyroid cancer is known to have excellent outcomes in most cases. For the last decade or so, the option to monitor small, low-risk cancers as an alternative to surgery has become more common. This practice is called active surveillance and requires following patients with thyroid ultrasounds. While undergoing active surveillance, most patients will have stability of the small thyroid cancer and no additional treatment is needed. A few patients (<10%) may then proceed with surgery if they have growth of the cancer, a change in the appearance of the cancer, a new finding on the ultrasound related to the cancer or patient preference to move on with surgery. Studies to date have shown that there has been no difference in survival between surgery initially and active surveillance. However, there is limited data regarding those patients that have surgery after a period of active surveillance.

This study aims to investigate the indication for surgery, the cancer doubling time, the findings during surgery, surgical complications, and surgical pathology findings in patients that proceed to surgery after a period of active surveillance.

THE FULL ARTICLE TITLE
Levyn H, et al Outcomes of conversion surgery for patients with low-risk papillary thyroid carcinoma JAMA Otolaryngol Head Neck Surg. Epub 2024 May 15; doi: 10.1001/jamaoto.2024.1699. PMID: 38749064.

SUMMARY OF THE STUDY
This study was performed with patients at Memorial Sloan Kettering Cancer Center to look at the results and outcomes of patients who underwent surgery after active surveillance compared to those who had surgery upfront. A review of the records of 550 patients with low-risk thyroid cancer that were being monitored with active surveillance were studied and 55 of these patients underwent surgery during their follow up (on average, follow up was 3.6 years). The main reason for surgery was cancer growth/ progression, followed by patient preference. Compared to patients who had surgery upfront, there was no difference in the rates of total thyroid removal versus partial thyroid surgery, no difference in the microscopic findings of cancer aggressiveness or overall cancer staging. There seemed to be a bit more presence of cancer in local lymph nodes in patients who had surgery after active surveillance as compared to those had initial surgery, but overall clinical outcomes were unchanged, including survival.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study further emphasizes that active surveillance is a reasonable option as an alternative to surgery for small, low risk thyroid cancer. This is important for patients to know, such that they understand the safety of monitoring low risk cancers. It is important to note that the decision to proceed with active surveillance is a joint decision between the doctor and patient, which considers patient preference, anxiety about living with cancer, age, surgical risk, access to high quality ultrasound and ability to keep up with follow ups.

— Maria Brito, MD, ECNU

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