Choose wisely: Tailor thyroid cancer treatments to minimize harms
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Endocrinologists must do more to reduce overdiagnosis of common, low-risk thyroid cancers and tailor any treatments to reduce potential harm, according to a speaker at the American Association of Clinical Endocrinology virtual meeting.
Approximately 44,280 new cases of thyroid cancer will be diagnosed in 2021, with 75% of cases occurring in women, Megan R. Haymart, MD, professor of medicine, metabolism, endocrinology and diabetes and the Nancy Wigginton Endocrinology Research Professor of Thyroid Cancer at the University of Michigan and Endocrine Today Editorial Board Member, said during a presentation. Although there are a few accepted risk factors, most thyroid cancers are sporadic and typically low-risk papillary thyroid cancer. In the past, there has been overdiagnosis of thyroid cancer, which can subsequently lead to overtreatment, Haymart said.
“For thyroid cancer, there is a very big reservoir — meaning that if we looked hard enough, we would find thyroid cancer in a large proportion of individuals, people who may have lived their whole lives and died of something else,” Haymart told Healio. “We need to do a better job of not picking up the cancers that would cause more harm [by treating], but instead pick up those cancers that would progress and be detrimental to the patient. That is what we need to differentiate.”
Risks of overdiagnosis
The word “cancer” can be troubling to a patient and brings an emotional response, even in a low-risk setting, Haymart said. Additionally, physicians and patients make decisions in an environment where intervention and aggressive behavior are rewarded, she said. All of this can lead to additional treatments, such as surgery, radioactive iodine, and thyroid hormone suppression and surveillance, all of which can be associated with harms.
“We want to find the place where we minimize harm for treatment and diagnose the correct patients for management,” Haymart told Healio.
Haymart said there are different points to intervene in the pathway to a thyroid cancer diagnosis that can reduce overdiagnosis and aggressive interventions. Members of the Endocrine Society, along with representatives of AACE, formed a joint task force (American Board of Internal Medicine’s Choosing Wisely campaign) to identify tests or procedures which should only be used in specific circumstances. The first step, she said, is to avoid performing unnecessary ultrasounds in adults with abnormal thyroid function if there is no palpable abnormality of the thyroid gland.
“There is good data from Korea that shows it is not good to conduct universal screenings,” Haymart told Healio. “It is important that we do not perform ultrasounds unnecessarily. There are clear indications for ultrasound use, and there are other times when it may not be appropriate.”
If a thyroid cancer is detected, overtreatment can still be avoided with active surveillance if the tumor is small, Haymart said. The American Thyroid Association’s clinical guidelines offer guidance for clinicians on tailored treatments for the management of thyroid nodules and cancers, Haymart said.
“One could follow the cancer if it is really small with active surveillance,” Haymart said. “If you are going to intervene with surgery, maybe do less aggressive treatment, like a lobectomy instead of total thyroidectomy. We want to make sure the correct patients are managed with the right treatment.”
Barriers to active surveillance
In a recent survey published online in Annals of Surgery in October 2020, 76% of 654 surveyed endocrine surgeons and endocrinologists reported that active surveillance was an appropriate option in low-risk thyroid cancer, yet only 44% said they used it in their practice.
“Most of the data on active surveillance is for cancers smaller than 1 cm,” Haymart told Healio. “If following American Thyroid Association guidelines, those cancers should not be picked up as fine needle aspiration (FNA) of nodules < 1 cm is not recommended. Ideally, we would not be seeing those patients anyway. Then, there is less data on active surveillance for larger tumors. One thing that might improve active surveillance uptake is if there was more data on who are the appropriate candidates, especially if their tumors size is over 1 cm.”
Haymart said several barriers prevent the use of active surveillance.
“A major one for endocrinologists is we are concerned about loss to follow-up,” Haymart said. “If you are following a patient with thyroid cancer, what happens if they move? We also worry if active surveillance will lead to more patient worry. Do patients sometimes just want [the tumor] out? We know from prostate cancer that some patients will start with active surveillance, there will be patient concerns, and then they switch to surgery.”
There is also a lack of strong guidance defining what is optimal long-term follow-up, she said.
“We have data from the trial setting, but if someone is aged 40 years, how long do you keep following them?” Haymart said. “Presumably they will live another 40 years. Do you follow them for 40 years? There are many unknowns. In theory, physicians recognize that yes, we are diagnosing low-risk cancers and yes, the cancer is unlikely to cause harm to the patient, but then there is some uncertainty about how to execute active surveillance in the real world.”
Haymart said understanding the management of thyroid cancer has evolved and there has been great progress, but there is still more that must be done.
“We must tailor our treatment to the individual; the extent of disease they have and the patient’s opinion should play a role,” Haymart said. “We do need therapy that is tailored appropriately as we want to minimize harm.”
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Haymart MR. Epidemiology of thyroid cancer 2021. Presented at: American Association of Clinical Endocrinology Annual Scientific and Clinical Conference; May 26-29, 2021 (virtual meeting).
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