'Blanket biopsying' of thyroid nodules may cause more harm than good in older adults

NEW ORLEANS — Most patients aged at least 70 years with thyroid nodules will benefit from the use of high-quality ultrasound and judicious use of fine-needle aspiration, as the likelihood of thyroid carcinoma decreases with age and the rate of other comorbidities increases, according to a speaker at the Endocrine Society Annual Meeting.

Erik K. Alexander

“Older patients frequently have thyroid nodules, but also have many other comorbidities,” Erik K. Alexander, MD, chief of the thyroid section at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, told Endocrine Today. “A blanket approach to biopsying all thyroid nodules greater than 1 cm likely causes more harm than good. By applying ultrasound assessment to most nodules, up to 50% can be classified as very low risk and avoid a need for any further intervention beyond watchful monitoring.”

Thyroid nodules are increasingly common with age; however, they are much less likely with age to be cancerous, Alexander said during a presentation.

Conversely, when thyroid cancers occur among older adults, they are much more likely to be classified as high-risk carcinomas and are more likely to be refractory to traditional treatment, in particular iodine therapy, he said.

The situation presents thyroidologists with a dilemma, Alexander said: In an aging population with increasing comorbidities, there will be more testing and imaging, resulting in more thyroid nodules detected in a system in which incentives often align with more procedures and treatment.

Yet, in the end, he said, aggressive intervention may cause more harm than benefit for older patients.

“We simply cannot ignore nodules; certainly, some of them will be more dangerous and pose a risk,” Alexander said. “But we should increasingly try to be selective in who we identify and how we identify who to send for further treatment.”

For most of these older patients, Alexander said, high-quality thyroid ultrasound should be performed because it can be helpful in detecting what is most often a low-risk, benign pattern — one which he said should prompt no further intervention.

In select patients without a very low-risk profile, fine-needle aspiration (FNA) is safe and easy and should be performed to identify those patients aged at least 70 years with high-risk cancer at risk for future harm, Alexander said. Further, patients with Bethesda III or Bethesda IV cytology should also be considered candidates for minimal or no intervention, given the low risk to older patients.

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“I’ll even push the limit one more time to show you that even when the data is positive for papillary carcinoma ... under 10 cm and low risk ... these small papillaries do not do much over time, even if they are not intervened upon,” Alexander said. “Perhaps the most important thing is, for the small subset that does grow, intervening at a later point does not appear to be any more dangerous than intervening at an earlier point.”

High-risk finds on ultrasound or FNA should prompt treatment, Alexander said, given the mortality risk posed by high-risk thyroid cancer. He noted that studies have demonstrated that virtually all high-risk thyroid cancers are identifiable via high-quality ultrasound or by FNA.

“Individualized, evidence-based approaches to care in this older population can reduce harm and improve overall health,” Alexander said in an interview. – by Regina Schaffer

Reference:

Alexander EK. Thyroid nodules in older adults: When to move from “watch and wait” to treatment. Presented at: The Endocrine Society Annual Meeting; March 23-26, 2019; New Orleans.

Disclosure: Alexander reports he has received advisory board fees, consultant fees and research support from Asuragen, Diasoron, Genzyme, NPS Pharma, Roche Diagnostics and Veracyte.