BACKGROUND
The number of Americans aged 65 years and older is expected to increase by 50% from 2016 to 2030. The risk of developing thyroid nodules increases with age. The concern with a thyroid nodule is whether it is a thyroid cancer. Fortunately, only ~5% of thyroid nodules are cancerous. Despite an increased risk for having a thyroid nodule, older adults actually have an overall lower risk of thyroid cancer compared to younger adults. However, if thyroid cancer is detected in older adults, it has a higher likelihood of being high-risk. Even though surgery to remove the thyroid (thyroidectomy) is considered the standard of care for the initial management of patients with thyroid cancer, prior studies have shown that differences exist in their surgical care. This study aimed to identify factors that influence decisions regarding surgery in older adults with thyroid cancer.

THE FULL ARTICLE TITLE
Sutton W et al 2021 Understanding surgical decisionmaking in older adults with differentiated thyroid cancer: A discrete choice experiment. Surgery 169:14–21. PMID: 32475718.

SUMMARY OF THE STUDY
In this study, a survey was designed to determine surgeons’ preferences for recommending thyroid surgery for thyroid cancer in older patients. The survey included three main clinical storylines: (i) cancer size <4 cm without spread to the lymph nodes, (ii) cancer size <4 cm with spread to the lymph nodes, and (iii) cancer size ³4 cm without spread to the lymph nodes. For each storylines, 8 different patients were presented who differed in age, other medical conditions and functional status (ability for patients to perform normal daily activities) for a total of 24 clinical storylines presented in the survey. The survey also included questions on surgeon characteristics and methods they use to assess whether patients are able to tolerate surgery.

The survey was administered online to all active members of the American Association of Endocrine Surgeons who practice in the United States. Overall, 31.7% of surgeons responded to the survey with 25.7% completing all survey portions. When analyzing responses, the authors found that patient age and presence of other medical conditions were the main factors influencing decision to pursue surgery in patients with thyroid cancer, regardless of cancer size or extent of disease. Older age and presence of other medical conditions increased likelihood of deferring surgery and monitoring the cancer with ultrasound in all storylines. There was significant variation in treatment choices for each storyline depending on clinical and surgeon characteristics. The number of additional medical conditions, their ability to perform normal daily activities and the “eyeball test”, were the most commonly reported factors to evaluating the patient’s ability to tolerate surgery.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study found that patient age and additional medical conditions were the most significant predictors for deciding whether patients should undergo surgery, as well as the extent of surgery, for thyroid cancer. Additionally, the study showed that there is significant variation in treatment choices for adults with thyroid cancer. It is important to always weigh the potential risks of surgery against the likelihood of thyroid cancer progressing, especially in older adults and those with multiple additional medical conditions. It is also important to better understand reasons behind variation in care and to determine if there is a scientific evidence to support this variation.

— Maria Papaleontiou, MD

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