ACTIVE SURVEILLANCE FOR LOW RISK THYROID CANCER?

Akin to prostate cancer, active surveillance is coming to early-stage, low-risk thyroid cancer, experts predict, but physicians will need protocols and decision aids to facilitate what would be a major change in care.

The incidence of thyroid cancer in the United States has tripled in the past 30 years, recent research shows. The vast majority of these incident cancers are small, low-risk papillary thyroid cancers that are unlikely to ever progress enough to cause symptoms or death.

"This is the most indolent type of cancer, but because we are finding more of these cancers, we are treating everybody with surgery. From that perspective, we are overtreating these cancers," said Juan Brito Campana, MBBS, an endocrinologist at the Mayo Clinic, Rochester, Minnesota, who was asked for comment by Medscape Medical News.

But change is afoot, with a "watch and wait" approach proposed for appropriate patients with low-risk papillary thyroid tumors.

"We are heading in that direction," Brendan C. Stack Jr, MD, a surgeon at the University of Arkansas for Medical Sciences, in Little Rock, told Medscape Medical News.

In a viewpoint article published online November 5 in JAMA Otolaryngology ― Head and Neck Surgery, Dr Stack and Peter Angelos, MD, PhD, a surgeon at the University of Chicago, offer their views on the ethics of disclosure and counseling of patients with low-risk thyroid cancer on treatment options, including active observation.

Observation is currently not the standard of care for thyroid cancer in the United States. Although the American practice is likely headed in that direction, Dr Stack and Dr Angelos think it should "only be considered with full disclosure for carefully selected patients on institutional review board (IRB)-approved protocols" until more evidence of risks and benefits is known.

But the Mayo Clinic's Dr Brito disagrees that observation should only be in accordance with IRB protocols. "We now we have more than 10 years of data that support the notion that active surveillance is safe," he told Medscape Medical News. Not everyone needs to be managed with active surveillance, but the option should be offered to all appropriate patients, said Dr Brito.

Dr Stack and Dr Angelos also say consideration should be given to a doctor-patient "surveillance contract." It could be "an effective tool to educate patients, codify a clinician-patient relationship, and document a plan for medicolegal protection," they argue.

Dr Stack and Dr Angelos say that the elements of the surveillance contract might include ultrasonographic features of thyroid nodule(s) and cytologic results, if biopsy results are already available. Agreed-on thresholds that would dictate a change from observation should be clearly outlined. These might include a specified increase in the greatest measured diameter from baseline over a defined period, evidence of extrathyroidal capsular spread, and/or appearance of a new, suspiciously enlarged lymph node. "The time of surveillance needs to be included in the contract," they also argue.

Dr Brito has trouble with the idea of a surveillance contract. "When you are actively engaging patients in the decision, you are actually achieving the best way to get a consent that is very well informed. A contract actually is a very limited view of that engagement and puts the patient in a different position than the clinician. A contract puts the clinician in a powerful position and the patient in a weak position. I don't think that is the best way to do it," he opined.

Dr Brito said he "completely agrees" with the viewpoint authors that both active surveillance and surgery have to be presented in an equal manner. "Both are good options, and the best option for an individual patient is one that fits their values and preferences. That is the ethical way to present the options," he said.

"In my personal point of view," Dr Brito added, "the most important thing to do with a patient is not to push for any of the options, either surgery or active surveillance. When physicians push for surgery, this probably leads to overtreatment, because they are not really considering the patient's preferences and values of the possible alternatives. And when physicians push for active surveillance, they probably do the same."

Dr Brito said conversations about observation for low-risk thyroid cancer largely are not happening right now in the United States because it is a fairly new concept. However, newly released guidelines from the American Thyroid Association suggest that active surveillance is an option for small papillary thyroid cancers, Dr Brito noted.

Physicians also need a decision aid to facilitate conversations about surveillance. Dr Brito said he and his colleagues at the Mayo Clinic have developed one that "will be ready to go public in the next year.

"With the new guidelines endorsing active surveillance, with the tool that we will provide to facilitate that, I think that active surveillance will gain traction in the United States in the following years, but for now, it's not happening, because clinicians do not have the tools, and that is understandable. But in the future, I believe it will become a typical conversation," Dr Brito said.

The authors and Dr Brito have disclosed no relevant financial relationships.

JAMA Otolaryngol Head Neck Surg. Published online November 5, 2015. Abstract