BACKGROUND
Thyroid cancer is common and the prognosis is excellent. This is because we have excellent treatments, with surgery being the mainstay. This is especially true with small papillary thyroid cancers. The treatment of these low-risk papillary thyroid cancers has recently shifted toward less extensive surgery, specifically lobectomy as opposed ot total thyroidectomy. Although the standard of care for papillary thyroid cancers is surgery, some patients have opted for following these small cancers with ultrasound. This is called active surveillance. Surgery is deferred, usually until the cancer grows or the patients decides to move forward with surgery. Since the patient is living with a known cancer, there is the possibility that their quality of life may be affected with regret for the decision for active surveillance.

This study assessed the presence and extent of decision regret, fear of cancer progression, anxiety, depression, and quality of life 1 year after choosing between active surveillance and immediate surgery for low-risk papillary thyroid cancer.

THE FULL ARTICLE TITLE
Sawka AM, et al. Decision regret following the choice of surgery or active surveillance for small, low-risk papillary thyroid cancer: a prospective cohort study. Thyroid 2024;34(5):626-634. doi: 10.1089/thy.2023.0634. PMID: 38481111.

SUMMARY OF THE STUDY
This was a study from a major Canadian hospital system. Adults with low-risk papillary thyroid cancers <2 cm were offered active surveillance or surgery. The treatment options were explained to patients, and surgery was reported as the standard of care. Patients choosing active surveillance were asked to follow up in clinic. Patients who chose surgery or switched from active surveillance to surgery, which was recommended if cancer growth was observed, received standard postoperative follow-up. All patients consented to short-term follow-up regarding treatment choice and again at 1 year.

The study used multiple questionnaires to assess patient perspectives. The primary outcome was the Decision Regret Scale (DRS) score, which measures distress or remorse after a health care decision. Scores range from 0 to 100, with 100 representing maximal regret. A score of 25 was used to distinguish between lower versus higher decision regret. Patients who changed from active surveillance to surgery were compared to those who continued active surveillance.

Of the 191 patients studied, most were women (147, 77%) and the average age was 53 years; 151 (79.1%) opted for active surveillance. Patients who chose surgery were younger (average age 47 years vs. 55 years), more likely to be married (90% vs. 72%), have a college or advanced degree (97% vs. 67%), and have larger cancers (average size, 13 mm vs. 11 mm) than active surveillance patients. There were 11 (7.2%) active surveillance patients who crossed over to surgery: 2 due cancer progression and 9 due to personal preference. These patients were younger (45.2 years vs. 55.8 years) than other active surveillance patients. Of the 51 patients who underwent surgery, most (40) underwent lobectomy. No patient had cancer recurrence at the 1-year follow-up appointment.

At 1 year, there was no difference in decision regret in the active surveillance and surgery groups (average score, 22.4 vs. 20.9). Patients who crossed over from active surveillance to surgery had a significantly greater decision regret score. Patients choosing surgery had greater initial fear of cancer progression as compared to the active surveillance group (29.9 vs. 24.2), but there were no differences at 1-year follow-up (24.4 vs. 23.1) due to a significant reduction in fear of progression in the surgery group.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study shows that many patients with small low risk papillary thyroid cancers will choose to follow with active surveillance and defer surgery if they are given that option. Patients choosing surgery appeared to do so because of a greater fear of cancer progression. Patients that do move from active surveillance to surgery do have a greater decision regret. Of the rest, there is no significant difference in the level of decision regret between patients who chose active surveillance rather than surgery for small, low-risk papillary thyroid cancers.

—Alan P. Farwell, MD

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