BACKGROUND
The most common types of thyroid cancer are papillary and follicular cancer, which are also known as differentiated thyroid cancer (DTC). Overall, DTC usually carries an excellent prognosis. Indeed, when talking about low, intermediate and high risk thyroid cancer, the risk is the risk of cancer recurrence, not necessarily death due to cancer. Over the last decade, the treatment options for DTC have changed to less aggressive treatment strategies, especially for low to intermediate risk DTC. The American Thyroid Association guidelines recommend determining risk before deciding on the management of DTC. Management options include active surveillance (no surgery, watching a small cancer with regular ultrasound imaging), partial removal of the thyroid (lobectomy), complete removal of the thyroid (total thyroidectomy), and radioactive iodine therapy after total thyroidectomy.

In general, active surveillance and lobectomy are options for very low risk cancers, lobectomy and total thyroidectomy are options for low risk and intermediate risk cancers while radioactive iodine therapy after total thyroidectomy are options for intermediate and high risk cancers.

However, the initial treatment approach chosen remains very variable due to several factors, such as the physician’s evaluation of risk of recurrence, benefits versus complications of treatment options as well as patient characteristics and patient preference. This study was done determine the physicians’ perceived risk with respect to the DTC progressing or recurring and their degree of aggressiveness exercised in choosing treatment options. The aim was to find any association between the physicians’ perception and management.

THE FULL ARTICLE TITLE
Schumm MA et al 2022 Perception of risk and treatment decisions in the management of differentiated thyroid cancer. J Surg Oncol 126:247–256. PMID: 35316538.

SUMMARY OF THE STUDY
The study was conducted in 2020 using an online survey which was distributed amongst members of the ATA that comprised endocrinologists, endocrine surgeons, medical oncologists, and nuclear medicine physicians. The participants were presented with four clinical scenarios that included commonly encountered cases of low to intermediate-risk DTC. On a sliding scale score of 1 to 100, the respondent physicians estimated the perceived risk of complications after surgery, cancer recurrence, and cancer progression based on their judgment. The physicians were also asked to pick their choice of treatment for each scenario. Their treatment responses were either categorized into ‘more aggressive’ or ‘less aggressive.’ The investigators then assessed the perceived risk reduction in the recurrence of cancer between the more and less aggressive treatment options. Analysis was done to predict a physician’s decision between the more and less aggressive approach while accounting for benefits/risk assessment.

The overall response rate to the survey was 13%. The respondents were predominantly male and 52% of participating physicians were endocrinologists. Most described their approach to DTC as ‘moderate’ with close with local clinical practice patterns. Interestingly, no single treatment option was recommended by >70% of respondents on any case example. The clinical scenario with very small papillary thyroid cancer was noted to have the most varied responses for treatment. The estimated risk for disease progression/recurrence when choosing ‘less aggressive’ versus ‘more aggressive’ approach showed a wide range across the clinical cases. No association was found between estimated operative risk and the planned treatment option. Most of the variation noted with respect to the degree of aggressiveness when managing DTC could not be correlated to the perceived risk of recurrence, with the likelihood of cancer recurrence accounting for only 10.3% of the observed variation in treatment aggressiveness. Physicians that self-identified to have less risk tolerance, that worked in a local practice environment and had a longer number of years in practice were more likely to recommend a more aggressive treatment approach.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study helps understand that nonclinical factors influence the extent of aggressiveness employed when treating low to intermediate risk DTC. Self-identification by physicians as ‘aggressive,’ ‘moderate,’ and ‘conservative’ with respect to the local clinical practice influences the ultimate treatment approach to thyroid cancer. Physicians in academic settings were likely to be less aggressive while those with more years in practice were likely more aggressive in their approach. With frequent disagreement observed amongst thyroid specialists on the best course of treatment for thyroid cancer, this study serves as an insightful tool for the patients to understand where the differences in a physician’s approach to their disease comes from. Also, this shows that, in a real-world scenario, consultations with different providers may give them a varied and broad range with respect to the risk of their cancer recurrence and progression. This would empower patients and help them understand that their input in shared decision-making is important and contributes to drafting a more effective management strategy.

— Sargun Singh, MD and Maria Brito, MD

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