Active surveillance viable for low-risk thyroid cancer
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Active surveillance of newly diagnosed thyroid cancer appeared to be a viable alternative to surgery for certain patients with low-risk disease, results of a prospective trial published in JAMA Oncology showed
Patients who underwent active surveillance also exhibited less anxiety — both at baseline and long term, according to investigators.
Background
Clinicians are “tiptoeing toward active surveillance” for certain patients with thyroid cancer, but hesitancy toward the approach by both patients and clinicians means its role in thyroid cancer care remains controversial, according to Allen S. Ho, MD, professor of surgery and director of the head and neck cancer program at Cedars-Sinai Cancer.
“It strikes me as bizarre why some in the field firmly believe that many thyroid cancers are low risk yet advocate for aggressive treatment that includes surgery and radioactive iodine,” Ho told Healio. “In parallel, similarly low-risk cancers — such as prostate cancer — are monitored.”
Ho and colleagues conducted a nonrandomized study to determine whether active surveillance is a viable first-line strategy for patients with low-risk thyroid cancer. Researchers assessed tumor growth parameters and patient anxiety levels as part of the analysis.
“I felt it was important that surgeons and surgical oncologists take an important role in asking questions and conducting studies on management options,” Ho said.
Methodology
The trial included 222 patients (median age, 46.8 years; interquartile range, 36.6-58; 76.1% female) with low-risk thyroid cancer treated at Cedars-Sinai Medical Center from 2014 to 2021. Study participants chose surgery or active surveillance.
Investigators enrolled patients with 20-mm or smaller Bethesda grade 5 to grade 6 thyroid nodules and established nodule growth cutoffs for recommending surgery of 5-mm diameter or 100% volume. Criteria from prior studies generally recommended 3-mm diameter or 50% volume growth for immediate surgery.
Researchers used the 18-item Thyroid Cancer Modified Anxiety Scale to evaluate patient anxiety in the active surveillance and surgery groups.
Cumulative incidence and rate of size or volume growth of thyroid nodules served as the study’s primary outcomes.
Mean follow-up was 37.1 ± 23.3 months.
Key findings
About half (50.5%; n = 112) of patients opted for active surveillance.
Sixty-seven patients (59.8%) had larger tumors (10.1-20 mm), with median tumor size of 11 mm (interquartile range, 9-15 mm) for the entire study population.
Investigators reported disease-specific survival and OS of 100% in both study groups.
At last follow-up, the majority (90.1%; n = 101) of patients who opted for active surveillance continued with that approach. In this group, 46 (41%) patients showed evidence of tumor shrinkage. None developed regional or distant metastases.
Researchers observed tumor growth of 5 mm or greater among 3.6% of patients, with cumulative incidence of 1.2% at 2 years and 10.8% at 5 years.
Volumetric tumor growth greater than 100% occurred among 7.1% of patients, with cumulative incidence of 2.2% at 2 years and 13.7% at 5 years.
Multivariable analysis showed patients who opted for immediate surgery had significantly higher anxiety levels than those who chose active surveillance at baseline (P < .001) and after completion of the surgical intervention (P = .001 at 4-year follow-up).
Clinical implications
Patients who underwent surgery for low-risk thyroid cancer had equivalent risk as those who opted for active surveillance, yet they exhibited similar outcomes with increased levels of anxiety, Ho said. These results indicate most patients with thyroid cancer are eligible and can safely opt for active surveillance, he added.
“Our study results suggest that cancers exist in a spectrum of risk and, in some cases — such as selected patients with thyroid cancer — we should caution that the treatment may be worse than the disease,” he told Healio. “Active surveillance for thyroid cancer can be used judiciously to best serve the interests of patients.”
Prior studies provided insight on the impact of active surveillance vs. surgery on quality of life, but the study by Ho and colleagues may be the first to examine the role anxiety plays in patients’ decision-making, according to Andrea L. Merrill, MD, surgical oncologist at Boston Medical Center, and Priya H. Dedhia, MD, PhD, assistant professor in the department of surgery at Ohio State University Comprehensive Cancer Center.
“A key barrier to use of active surveillance includes physician and patient concern for adverse outcomes,” Merrill and Dedhia wrote in an accompanying editorial. “This provocative study not only lays the groundwork for expanding active surveillance criteria for low-risk papillary thyroid cancer, but may also improve use of current American Thyroid Association guidelines for active surveillance by demonstrating that use of active surveillance for Bethesda 5 or 6 nodules 20 mm or smaller was not associated with an increase in staging or disease-specific mortality.”
References:
- Ho AS, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.3875.
- Merrill AL, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.3809.
For more information :
Allen S. Ho, MD, can be reached at Cedars-Sinai Medical Center, 8635 W. Third St., #590W, Los Angeles, CA 90048.
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.Ho AS, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.3875.
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