BACKGROUND
Surgery to remove all, or part, the thyroid gland is a common way to treat some types of thyroid disease. Most common is surgery to treat thyroid cancer but there is often surgery recommended for non-cancer causes of thyroid disease. As long as this is true, thyroid surgeons will try to improve the way that this surgery is done. Because surgery for the thyroid gland, which is located in the front of the neck, requires making an incision (cut) in the neck (traditional approach), one area of interest for some thyroid surgeons is to try and eliminate the neck scar that develops where this cut is made. Although the traditional approach neck incision is usually small and, when healed, invisible, a noticeable (or even ugly) scar will rarely form for some people. Sometimes, treating such a scar can mean more surgery. Because of this, new ways of doing thyroid surgery have been developed that do not require making a cut in neck (‘scarless’ surgery) or hide this incision under the chin. The newest way of doing this is by making cuts inside the mouth and, using cameras and fine surgical instruments, removing the thyroid through these cuts (transoral surgery). Because the cuts are inside the mouth, no visible scar can form after surgery. Although this way of removing the thyroid has been successful for some types of thyroid disease, it is not yet clear if the results of this surgery are as good as when thyroid surgery is done by the traditional approach.

The research described here studied patients planning thyroid surgery to learn what factors were important to them when deciding whether to have their surgery using a ‘scarless’ approach. This is important information, since understanding how patients make decisions about their health care makes providing such care easier and more efficient.

THE FULL ARTICLE TITLE
Sukpanich R et al 2020 The influence of cosmetic concerns on patient preferences for approaches to thyroid lobectomy: A discrete choice experiment. Thyroid 30:1306–1313. PMID: 32204688.

SUMMARY OF THE STUDY
The authors of this study used a series of questions focusing on risk surgical complications, surgery cost, travel distance for surgery, and the presence/absence of a neck scar to understand how patients planning thyroid surgery decide whether or not to pursue a ‘scarless’ approach. The study involved 109 people scheduled to undergo removal of half of their thyroid gland (thyroid lobectomy) for benign/non-cancer thyroid disease or for thyroid nodules unlikely to be cancerous. All 109 patients were eligible for both traditional and transoral thyroid surgery. Although most patients in the group ultimately chose the traditional thyroid surgery approach (100 of 109), the authors found that patients 60 years old or younger said that they would prefer ‘scarless’ surgery. Compared to the traditional approach, these patients indicated they were willing to pay over $2000 more, accept a small (2.2%) increased risk of having a surgical complication and travel almost 700 miles more to have ‘scarless’ thyroid surgery. On the other hand, patients over the age of 60 years preferred the traditional approach over ‘scarless’ thyroid surgery. Compared to the ‘scarless’ approach, these patients said they were willing to pay almost $3500 more, accept a small (3.2%) increased risk of having a surgical complication and travel over 1000 miles further for traditional approach thyroid surgery.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
The study authors found that avoiding a neck scar is an important factor in deciding on how to proceed with thyroid surgery for some people (especially younger patients), so much so that these patients might pay more, travel farther and accept a higher risk of surgical complications to have ‘scarless’ surgery. It is important to understand that the 109 patients studied here were mostly white, mostly well off and mostly college educated. Compared to this population, it is unclear if people having a different racial, financial and/or educational backgrounds would have the same preferences for surgery approach. It is also important to understand the importance of a surgeon’s recommendation. Overall, this has been shown to play the most important role in selecting an approach to thyroid surgery.

— Jason D. Prescott, MD PhD

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