Not Working? Shared Decision Making on RAI for Thyroid Cancer

Nancy A. Melville

July 17, 2019

Amid concerns of overtreatment of thyroid cancer with radioactive iodine (RAI) comes a new study that reports patients' dissatisfaction with the process of deciding whether or not to undergo this extra step after surgery.

The study was published online on July 8 in the Journal of Clinical Oncology.

"In this population-based sample of patients with differentiated thyroid cancer (DTC) in whom selective use of RAI is recommended and shared decision-making is encouraged, more than half of patients reported that they did not feel they had a choice about whether to receive RAI," the authors report.

First author Lauren P. Wallner, PhD, MPH, an assistant professor with the Departments of Medicine and Epidemiology, University of Michigan, Ann Arbor, said several factors probably contribute to these findings.

A common reason for failing to adequately involve a patient in a decision regarding RAI in thyroid cancer — particularly when the risk is not low — is concern on the part of the clinician about not having the time or ability to effectively communicate the full, sometimes complex scope of implications regarding treatment vs nontreatment, she said.

"It is difficult to convey nuanced treatment information in a way that aligns with patients' information needs and preferences," Wallner told Medscape Medical News.

"Assessing these needs and preferences so that information can be tailored to them takes quite a bit of time, which is increasingly difficult in the constraints of brief clinic visits," she said.

For their study, Wallner and colleagues used Surveillance, Epidemiology and End Results (SEER) data from Georgia and Los Angeles registries from 2014 to 2015. They identified 2632 patients with DTC, including 1319 for whom selective RAI was recommended.

The study focused on this group of patients because the recommendation to undergo selective RAI is particularly emphasized with respect to shared decision making between the clinician and patient, the authors explain.

Patients were excluded from the study if they did not undergo complete resection of the thyroid or if use of RAI was either not recommended because of low risk or was recommended because of high risk.

The researchers posed several questions: Patients were asked whether they felt as if they had a choice to receive RAI (yes or no), how strongly their physician recommended RAI (5-point Likert-type scale), whether they received RAI (yes or no), and how satisfied they were with their RAI decision (more [score of 4 or greater] vs less).

Upon being asked about their perceptions of the decision-making process for treatment with RAI, more than half (55.8%) of the DTC patients overall reported feeling that they did not have a choice in the decision. Most of those patients (75.9%) had received RAI.

Patients who felt they had no input in the decision were more than twice as likely to have received RAI (odds ratio [OR], 2.50; 95% confidence interval [CI], 1.64 – 3.82), and they were more likely to report lower satisfaction regarding the decision.

Furthermore, the odds of patients' perceiving that they had no choice regarding RAI were higher when RAI was strongly recommended by the physician (adjusted OR, 1.56; 95% CI, 1.13 – 2.17).

"Taken together, our findings support the notion that although these conversations may be challenging, physicians have an important opportunity to engage in shared decision making with patients about RAI use," the authors say.

What Would Help With These Conversations?

"There is a body of literature that suggests that both patient- and physician-level characteristics influence treatment decision making and that these conversations do not happen as often as they should in routine clinical practice," Wallner commented.

"Therefore, it is critical that we ensure that physicians receive appropriate training in having these difficult conversations with patients and are sufficiently supported to have them within the context of their practice."

Evidence on interventions that could help facilitate shared decision making about thyroid cancer treatment options is lacking, the authors comment in their article.

They do point to one randomized controlled trial conducted in Canada in 2015 that showed that exposure to a decision aid for adjuvant RAI decision making was effective in improving patient knowledge compared to usual care.

This study suggests that communication problems can be effectively tackled, but more research is needed, Wallner and colleagues comment.

"Because patient perception of not having a treatment choice is a problem that is modifiable, research focused on the development and implementation of interventions to improve thyroid cancer treatment decision making and support physicians in engaging in shared decision making is warranted," they add.

Two experts who have published extensive research on thyroid cancer and RAI utilization, Emad Kandil, MD, chief of the General, Endocrine and Oncological Surgery Division in the Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, and Zaid Al-Qurayshi, MD, MPH, resident physician with the Department of Otolaryngology–Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, agree that, particularly in such cases, patients' interests should have top priority with regard to discussions and decision making.

"Patients' autonomy in making a decision about their health is an indisputable basic tenant of practicing medicine, and a physician should always act in the best interest of the patient without causing harm and help the patient make the decision that aligns with the patient's goals," they told Medscape Medical News.

The study was supported by grants from the National Cancer Institute. The studies' authors, Kandil, and Al-Qurayshi have disclosed no relevant financial relationships.

J Clin Oncol. Published July 8, 2019. Abstract

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