Overtreatment of Early Papillary Thyroid Neoplasms Continues, Despite Preventive Strategies

By Marilynn Larkin

December 01, 2021

NEW YORK (Reuters Health) - Strategies to prevent overtreatment of papillary thyroid carcinomas (PTCs) have had mixed success, a cohort study shows.

"Both of our major findings surprised us," Dr. Louise Davies of the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire, told Reuters Health by email. "We thought that we would see wider application of the new noninvasive follicular thyroid neoplasm with papillarylike nuclear features (NIFTP) diagnosis and broader use of hemithyroidectomy in cases that are suitable for treatment de-escalation."

"The NIFTP diagnosis category, intended to identify thyroid growths that are extremely low risk for recurrence or spread, is not being used nearly as much as we thought it would be, based on the research used to develop the category," she said. "Many people eligible to have their thyroid cancer treated with hemithyroidectomy are still undergoing total thyroidectomy."

To determine the adoption rates of NIFTP and for hemithyroidectomy for selected PTCs up to 4 cm, Dr. Davies and colleagues conducted a cross-sectional analysis of 3,368 pathology records of two patient cohorts from 18 hospitals in six countries during 2015 and 2019.

They reviewed records of the first 100 patients per institution who underwent thyroid-directed surgery (hemithyroidectomy, total thyroidectomy, or completion thyroidectomy) in both study years.

The total proportion of PTCs was similar in the 2015 and 2019 cohorts (47.1% vs. 44.5%), according to a report in JAMA Otolaryngology-Head and Neck Surgery.

Introduction of the NIFTP category was anticipated to affect an estimated 18.6% of PTCs globally. However, of the 790 papillary thyroid neoplasms in the 2019 cohort, only 38 (4.8%) were diagnosed as NIFTP, specifically in the U.S., South Africa, and India.

In both cohorts, the proportion of PTCs eligible for hemithyroidectomy but treated with total thyroidectomy showed a decreasing trend from 2015 to 2019 (75.3% vs. 58.3%). Compared with 2015, the odds ratio of receiving a total thyroidectomy when eligible for a hemithyroidectomy in 2019 was 0.4.

The authors conclude, "The 2 mitigation strategies for preventing overtreatment of early-stage thyroid cancer have had mixed success. The diagnosis of NIFTP has only been applied to a small proportion of thyroid neoplasms compared with expected rates. However, more patients eligible for hemithyroidectomy received it in 2019 compared with 2015, showing some success with this de-escalation strategy."

Dr. Davies advised, "Talk with your pathologist colleagues to understand what they are seeing in the specimens they receive, how they approach the NIFTP category, and how they are making their diagnostic categorizations. When meeting with patients, share all guideline options that are available for a particular diagnosis and stage, become familiar with the outcomes associated with each approach, and engage them in a discussion to elicit which treatment approach will fit their values and priorities best."

Dr. Arturo Loaiza-Bonilla, National Director of the CTCA Research Program, based in Atlanta, commented on the study in an email to Reuters Health. "This analysis highlights the importance of working in a multidisciplinary team aligned with current diagnostic and treatment strategies," he said. "Teams should also consider appropriate de-escalation as a quality metric for optimal delivery of care. Education of all stakeholders in a patient-centric approach is key to prevent unnecessary procedures while maintaining outcomes for our patients."

"However, changes take time," he said. "Multiple approaches and institutions - particularly when a decision requires a multidisciplinary team from the initial diagnosis to the surgical approach - can affect adoption rate (and) patient preferences."

"We are seeing encouraging signs, however, such as the relative increase in eligible patients undergoing hemithyroidectomy," he noted. "Time has also passed since this data was collected, which may translate to higher adoption if we look into more hospitals and countries close to 2021."

"We need more real-world, real-time data from a larger sample and more diverse institutions, including those where the rationale for total thyroidectomy can be explained from both surgeon and patient perspectives," he said. "Also, (we need to assess) the impact of national and institutional guidelines in the adoption of such strategies."

SOURCE: https://bit.ly/3ElMKxu JAMA Otolaryngology-Head and Neck Surgery, online November 24, 2021.

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