UCI Health thyroid surgeon Dr. Dawn M. Elfenbein explains how new American Thyroid Association guidelines provide physicians with a comprehensive review of the current important scientific evidence so that they can work together with patients to develop a care plan that is right for them.
A major challenge in managing patients with thyroid nodules and thyroid cancer is avoiding potential harm from overtreatment. In recent years, we have seen an increase in the number of people being diagnosed with thyroid nodules and, ultimately, thyroid cancer due to the increasing use of medical imaging such as ultrasound. Last week, the New England Journal of Medicine published a study highlighting an international epidemic of overtreatment.
Our goal is to avoid overtreatment in the majority of patients that have low risk while appropriately treating and monitoring those patients at higher risk.
Slow growing tumor
Despite the surge in the number of people being diagnosed with and treated for thyroid cancer, the number of people worldwide who die of the disease has remained consistently low for many years. This is because thyroid cancer often can grow very slowly or not at all, so many of these small cancers that were previously undetected were not necessarily causing any problems for patients and don’t necessarily require aggressive treatment.
Published in the journal Thyroid, the American Thyroid Association guidelines update and replace the organization’s six-year-old recommendations. They are extensive — the article is well over 100 pages, contains 101 detailed recommendations, and is based on a review of more than 1,000 scientific studies. It is the most comprehensive guidelines ever published for managing thyroid malignancy.
Thyroid surgery has never been ‘one size fits all’ and the new guidelines help care providers by including guidance on the newest technologies and treatments. New recommendations address molecular testing of thyroid nodules that are indeterminate (that is, when biopsy alone cannot determine if it is cancer or not), risk of recurrence of thyroid cancer, and the management of cancer that is resistant to the traditional treatment course of radioactive iodine after surgery.
Evidence-based thyroid treatment
While there is still a lot that we do not know about the disease, the guidelines’ scientific evidence helps me now weigh the values and preferences of my patients and their understanding of their own health against what we do and do not know about this disease.
The document has detailed evidence for each step along the way, from whether or not to even biopsy a nodule within the thyroid gland based on how likely it is to be benign from just the imaging characteristics, to how much of the thyroid should be removed at the time of surgery, to whether or not patients should receive radio-active iodine as additional therapy after surgery.
There is a good historical perspective for this. When the first mastectomy was done for breast cancer around the turn of the 20th century, the surgery was very aggressive. Surgeons removed not only the breast, but the underlying muscles of the chest and all of the lymph nodes, leaving some women disfigured. Decades later, it was understood that women who had less aggressive surgery did as well in the long run as those who had really aggressive, disfiguring surgery.
A similar thing is happening with thyroid cancer treatment in the last 10 years. We are learning that not all cancers need to have everything thrown at them, and that for some small cancers, we can be more thoughtful about how we treat individuals.
Taking an individualized approach is among the most important evolutions in treatment. There are different surgical risks to a total thyroidectomy versus removing only half of the thyroid gland, and there are different recommendations for follow up after surgery. What is right for one person may not feel best for another. The new guidelines allow that kind of personalized discussion about what is the best treatment for many different situations, and allow for real shared decision making between patients and providers.
If you are found to have a thyroid nodule, it is important to seek a specialist who is familiar with the new guidelines early on in the process — before you even get a biopsy.