Low level of regret for treatment decision for most adults with low-risk thyroid cancer
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Key takeaways:
- Treatment regret scores were similar between adults with low-risk thyroid cancer who chose active surveillance vs. surgery.
- Decision regret was higher for those switching from active surveillance to surgery.
Adults with low-risk papillary thyroid cancer reported low levels of decision regret for their disease management choice at 1 year, regardless of whether they chose active surveillance or surgery, according to findings published in Thyroid.
In a prospective observational study from a single health system in Canada, levels of decision regret as determined through the Decision Regret Scale were similar between adults who had surgery and adults who opted for active surveillance 1 year after surgery. Adults who chose to have active surveillance had a mean decision regret score of 21.5 of 100, and adults who underwent surgery had a mean score of 20.9. Researchers considered a decision regret score of 25 or less to be low.
“One factor that could have contributed to low levels of decision regret and the lack of a significant difference between groups could be the fact that all of the patients had the opportunity to participate in the decision-making about management of their thyroid cancer, and ultimately the choice was up to them,” Anna M. Sawka, MD, PhD, professor of medicine at University Health Network and University of Toronto, told Healio. “Furthermore, most patients avoided the consequences that they initially feared the most, such as avoiding surgery for those patients who wanted to avoid it and decided to undergo active surveillance, or avoiding the cancer recurring for patients who feared the cancer and decided to have surgery.”
Researchers enrolled 191 adults aged 18 years and older with low-risk papillary thyroid cancer attending a University Health Network clinic in Toronto who consented to a short-term follow-up about their thyroid cancer treatment choice at 1 year (77% women; mean age, 53 years). All participants were offered the choice of active surveillance or surgery. Participants completed a questionnaire at 1 year after making their treatment decision. The questionnaire included a section on thyroid cancer treatment status, the Decision Regret Scale, and other components assessing fear of disease progression, anxiety, depression, disease-specific quality of life and body image perception.
Regret similar between treatment options
Of the participants, 79.1% opted to undergo active surveillance at baseline, with the remaining 20.9% of adults undergoing surgery. Of those who chose active surveillance at baseline, 7.2% later underwent surgery or radiofrequency ablation. Histologic evidence of papillary thyroid cancer was found for 98% of adults who underwent surgery.
After adjusting for age, sex and follow-up duration, there was no difference in mean level of decision regret between adults who chose active surveillance and those who had surgery. Adults who initially chose active surveillance and later had surgery reported higher decision regret than those who remained under active surveillance, (beta = 10.1; 95% CI, 1.3-18.9; P =. 02).
“Our finding was not unexpected as it is known that decision regret can be associated with changing one’s mind about a decision,” Sawka said. “We believe that longer-term follow-up examining the level of decision regret in the group of patients who crossed over from active surveillance to surgery is needed to better understand if this finding changes with time, particularly as patients recover from surgery.”
Adults who had surgery reported worse scores for symptoms interfering with life functioning than those who chose active surveillance (P = .02). At baseline, adults who had surgery had a greater fear of disease progression than those who opted for active surveillance (mean score, 29.9 vs. 24.2; P < .001). However, no difference in fear of disease progression was seen at 1 year. No other differences for patient-reported outcomes were observed between the two groups during follow-up.
Importance of patient education
Sawka said the study supports giving people with low-risk papillary thyroid cancer an option to pursue either active surveillance or surgery as long as they qualify for active surveillance from a medical standpoint. She said it is important for patients to understand the consequences of both treatment decisions.
“Patients who choose active surveillance need to understand that this is not simply a ‘do nothing’ approach and that their involvement in regularly scheduled follow-up is critical,” Sawka said. “Furthermore, patients offered active surveillance need to be fully informed about the criteria for recommending surgery after initiation of active surveillance, particularly for progression of the cancer. Patients also need to understand that they may change their mind about active surveillance at any time, and choose to have surgery, even if their cancer does not progress.”
For more information:
Anna M. Sawka, MD, PhD, can be reached at annie.sawka@uhn.ca.
Perspective
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In this study of 191 adults with low-risk papillary thyroid cancer of less than 2 cm, a total of 151 chose active surveillance and 40 chose surgery. Interestingly, mean level of decision regret at 1 year did not differ between patients who chose active surveillance vs. surgery. However, on the Body Image Scale questionnaire, those who had surgery felt “body less whole” and dissatisfaction with scar appearance.
This study is important because clinicians sometimes use limited anecdotal evidence to make assumptions about how active surveillance may impact all patients. Contrary to what many may assume, this study in 191 low-risk papillary thyroid cancer patients reveals no difference in decision regret and potential for greater psychological impact in the surgical cohort as compared with the active surveillance cohort. However, there is a risk of selection bias in the sense that patients selected the treatment that allowed them to avoid what they most feared.
This study reinforces the importance of patient involvement in decision-making while also suggesting that for some patients, active surveillance may be a reasonable alternative to surgery.
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