BACKGROUND
Thyroid nodules are fairly common, occurring in 30-50% of the adult population and the rate increases with age. It is important to identify which ones carry a risk for cancer, which occurs in 5-6% of nodules. Thus, the vast majority of nodules are benign (non-cancerous). Nodules are usually evaluated by ultrasound and concerning nodules are then biopsied. The biopsy results are reported using the Bethesda System which helps to determine the likelihood of cancer in the biopsied thyroid nodule. Bethesda I results means that there are not enough cells to make a diagnosis while Bethesda II results mean the nodule is benign. Bethesda V results are suspicious for cancer and Bethesda VI are positive for cancer. Bethesda III and IV results are called indeterminate, meaning that the cells are not entirely normal but not entirely abnormal. The likelihood of cancer increases going from Bethesda III to Bethesda IV. These nodules are either evaluated further with additional testing, monitored by ultrasound or referred to surgery.

Bethesda category III results are more common and include 2 categories: AUS – atypia of undetermined significance and FLUS — follicular lesion of undetermined significance. In these cases, it is important to evaluate and consider monitoring versus surgery. This study was done by a survey of patients, clinicians, and healthy patients with the goal to evaluate their preferences when addressing with Bethesda III thyroid nodules.

THE FULL ARTICLE TITLE
van Kinschot CMJ et al 2023 Preferences of patients, clinicians, and healthy controls for the management of a Bethesda III thyroid nodule. Head Neck 45:1772–1781. PMID: 37158317.

SUMMARY OF THE STUDY
Patients, clinicians, and healthy patients were added from hospitals in the Netherlands from August 2019 to July 2020. Those with a thyroid nodule were added to the study.

The goal was to evaluate the effect of having a thyroid nodule and if ready to accept risks related to it. Those without a thyroid disease were added as healthy patients and clinicians who have treated patients with thyroid disorders were also added. All of participants were asked to imagine they have a thyroid nodule diagnosed with a Bethesda III category and to decide between surgery or monitoring.

The study evaluated 129 patients, 46 clinicians and 66 controls (healthy patients). Patients diagnosed with a thyroid nodule as well as the healthy patients were agreeable to accept a risk for thyroid cancer of <10.0% to monitor the nodule while a higher risk would rather have surgery while clinicians would accept a risk of < 15% to monitor the nodules. Patients also were ready to accept a risk of >15.5% for surgery in the future, which was similar to clinicians at 15.0% and 15.5% by healthy patients. When the patients with the thyroid nodule were offered surgery instead of monitoring, they were willing to accept a risk of >10.0%.

For the potential consequences, all groups agreed thyroid cancer risk as being the most important, followed by risk of permanent voice changes for clinicians and risk of more extensive surgery for patients with thyroid nodules and healthy patients. Interestingly, all groups rated the risk for hypothyroidism post-surgery as the least important risk.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study explores the views of patients, clinicians, and healthy individuals on the management of Bethesda III thyroid nodules. These groups had similar viewpoints with regard to the risks of finding a thyroid cancer, of more extensive surgery, and of postoperative hypothyroidism. However, clinicians were less willing than patients to accept the risks of possible permanent voice changes.

— Joanna Miragaya, MD

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