Overtreatment of low-risk thyroid cancer more common according to Dutch vs. ATA guidelines
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Overtreatment of adults with low risk differentiated thyroid cancer is more common using the 2015 Dutch Thyroid Cancer guideline compared with the American Thyroid Association’s guideline, according to study findings.
“Low to intermediate intrathyroidal differentiated thyroid cancer is frequently overtreated when following the recommendations of the 2015 Dutch Thyroid Cancer guidelines,” Deborah van Dijk, MD, MSc, of the department of surgical oncology at University Medical Center Groningen in the Netherlands, and colleagues wrote in a study published in Clinical Endocrinology. “High-risk patients were generally treated adequately according to both guidelines. In the group of patients with incongruent risk classification, more adequate treatment was performed according to 2015 Dutch Thyroid Cancer recommendations, while more undertreatment was seen in the ATA guidelines.”
Researchers analyzed outcomes of 240 adults with differentiated thyroid cancer treated at University Medical Center Groningen from January 2007 to March 2017 (mean age, 51.1 years; 70% women). Using all clinical and pathological data available at diagnosis, researchers retrospectively recategorized patients into low-, intermediate- and high-risk groups according to both Dutch Thyroid Cancer and ATA guidelines. Follow-up data regarding subsequent surgery, histopathology, stimulated and unstimulated serum thyroglobulin, response to radioactive iodine therapy, and persistent or recurrent disease was acquired. Researchers used follow-up data to estimate the percentage of people who were adequately treated, undertreated and overtreated according to both guidelines.
According to ATA guideline, 33% of the cohort had low-risk thyroid cancer, 30% had high-risk thyroid cancer and 36% had intermediate-risk cancer. According to the Dutch Thyroid Cancer guideline, 28% of the cohort had low-risk thyroid cancer, and 72% had thyroid cancer classified as high risk.
A higher proportion of patients were overtreated with respect to the Dutch Thyroid Cancer guideline compared with the ATA guideline (45% vs. 35%; P < .001); conversely, more people were undertreated with respect to the ATA guideline compared with the Dutch guideline (24% vs. 8%; P < .001). Within the undertreatment group, there were fewer patients with persistent disease and recurrent disease in those classified with the Dutch guideline vs. ATA guideline.
Of the study cohort, 60 adults were classified as low risk in both groups, 73 were classified as high risk in both groups and 107 were classified as incongruent risk as a result of different classifications between ATA and Dutch guidelines. In the low-risk group, more people were adequately treated using the ATA vs. the Dutch guideline (43% vs. 20%; P < .001).
Within the incongruent risk group, more people were adequately treated with respect to the Dutch guideline compared with ATA guideline (43% vs. 12%; P < .001), and undertreatment was more common with respect to the ATA guideline (38% vs. 8%; P < .001). No differences in treatment were observed among the congruent high-risk group.
“Recommendations in future Dutch thyroid cancer guidelines could lean towards a less aggressive approach,” the researchers wrote. “As shown in this study, shared decision making towards a more deescalating treatment strategy is worthy in low-risk patients without a considerable risk of recurrent disease. Most recurrences were observed in patients within the incongruent group, who may need a more cautious strategy.”
Perspective
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Recent iterations of guidelines for the management of differentiated thyroid cancer have increasingly aimed to tailor initial treatment strategies to avoid overtreatment — thus reducing the burden of treatment-associated morbidity — without unduly increasing mortality risk. It has been challenging to strike the right balance.
This study assessed the disease course of 240 adult patients with American Joint Committee on Cancer cT1-T3aN0-1aM0 differentiated thyroid cancer followed at a single Dutch center between 2007 and 2017. These data were used to determine the likelihood of overtreatment and undertreatment when using current ATA guidelines vs. current Dutch guidelines.
It is reassuring that this analysis demonstrated that patients classified as high-risk by both guidelines’ risk stratification systems would have received appropriate initial treatment. However, in general it was estimated that following the ATA guidelines would result in lower rates of overtreatment whereas following the Dutch guidelines would result in lower rates of undertreatment.
This study is limited primarily by its retrospective nature. Revised ATA guidelines for the management of thyroid cancer are expected to be published within the next several months. It is anticipated that the updated ATA guidelines will further refine risk stratification paradigms (informed in some cases by information about specific tumor mutations) to allow for more individualized care.
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