Miriam E. Tucker

April 19, 2013

CHICAGO — Rates of thyroid nodule fine-needle aspirations (FNAs) have increased rapidly in the United States over the past few years, especially those performed using ultrasound guidance, with a downstream rise in the number of total thyroidectomies, a new analysis of several large claims databases has shown.

And 60% of all thyroid-nodule–related surgery is now performed in the outpatient setting, said Julie A. Sosa, MD, chief of the section of endocrine surgery and director of health services research at Duke University, Durham, North Carolina. She reported the study, which was supported by Veracyte, here at the American Association of Endocrine Surgeons 2013 Annual Meeting.

Taken together, she told Medscape Medical News, the results highlight the need for assessment of resource utilization, which can help inform future policy decisions.

"We need to establish criteria for determining what incidentally identified nodules merit interrogation and how to manage the results of diagnostic testing in order to afford patients the most cost-effective management alternatives," said Dr. Sosa.

Session moderator Elizabeth G. Grubbs, MD, from the University of Texas MD Anderson Cancer Center, Houston, told Medscape Medical News, "It's a good analysis, using large databases that are well-maintained… It's our job to go back and try to understand why these trends are happening."

What to Do With Thyroid Nodules Is a Daily Problem

Dr. Sosa told Medscape Medical News that increases in the use of diagnostic imaging in the United States have dramatically expanded the detection of thyroid nodules, and it is not clear what to do with these thyroid nodules when they are found; most do not represent thyroid cancer, and they often do not cause any problems.

"The phenomenon of the incidentally identified thyroid nodule is a daily one. Unfortunately, there are still no guidelines to help us manage these," she commented.

In their study, Dr. Sosa and her colleagues analyzed several national claims databases for the years 2006 to 2011. Inpatient data came from the US Agency for Healthcare Research and Quality's Healthcare Cost Utilization Project Nationwide Inpatient Sample. Outpatient figures were obtained from the Thomson Reuters Outpatient View database, which included 10 million commercially insured claims as well as Medicare and Medicaid claims data and other public and private sources.

During the 5-year study period, there was a 107% increase in the number of thyroid FNAs performed, with an approximate 16% increase per year. The proportion of FNAs performed using ultrasound guidance grew at a rate of 21% per year, nearly double that of FNA without ultrasound guidance (11%).

In another dramatic shift, thyroid FNAs grew from 49% to 65% of all FNAs performed for any indication.

Thyroid-nodule–related surgery rose 31% from 2006 to 2011. And of all thyroid surgeries performed during this period, 71% were nodule-related.

Despite the dramatic rise in procedures, no increase was seen in the proportion of thyroid cancers diagnosed with either inpatient or outpatient surgery, Dr. Sosa said.

Yet this is set against a background of rapidly increasing incidence of thyroid cancer, she noted; from 2001 to 2013, the incidence of thyroid cancer in the United States rose by 209%, and it is now the most common cancer among women younger than 35 years.

While it is possible that the increased detection of thyroid nodules is partially responsible for the rise in thyroid-cancer diagnoses, similar rises in thyroid cancer have been seen in other countries that have not embraced imaging the way the United States has, Dr. Sosa commented.

Using the Data to Inform Future Practice

"More and more resources are being spent on the evaluation, treatment, and surveillance of thyroid nodules in the US. It is important that consensus be reached and guidelines be followed to standardize [this]," Dr. Sosa told Medscape Medical News.

For example, she noted, because more patients are undergoing surgery for the purposes of both diagnosis and treatment, "we need to find ways to ensure that surgery is performed by high-volume surgeons in order to afford patients the best opportunity to have good outcomes. With the increase in demand, it is unclear whether supply of these surgeons will be adequate going forward."

The data sets also show that, over time, more and more thyroid operations were being performed in the outpatient setting, she noted. While inpatient thyroid operations rose by just 11% over the 5 years, outpatient procedures grew by 47%. By 2011, 62% of thyroid surgeries were performed in this way.

Dr. Grubbs praised the study's use of large databases but also noted the weaknesses. "She's looked at large-scale data, which has the power to allow you to look at trends a lot more than at a single institution… But there are weaknesses; you can't capture the reason in these databases."

Thus, she said, more information is needed. "Are we doing a better job with our ultrasound-guided biopsies, so that we're biopsying more cancers and going straight to total thyroidectomies? Her data allow us to start to ask these questions."

Dr. Sosa has reported no relevant financial relationships. Two of the coauthors are Veracyte employees; the other coauthors have received research grant support from the company, and one of them is also a consultant to the company and holds equity in it. Dr. Grubbs has reported no relevant financial relationships.

American Association of Endocrine Surgeons 2013 Annual Meeting. Abstract 36, presented April 16, 2013.

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