THYROID Volume X, Number X, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2014.0388
LETTER TO THE EDITOR
Practice Patterns in the Surgical Treatment of Papillary Thyroid Microcarcinoma Chau Nguyen1 and Marilene Wang 2,3
performing thyroidectomies annually. We queried physician decision-making for, among other scenarios, the finding of a 3 mm focus of PTMC on final pathology after hemithyroidectomy. We sought to compare this with recommendation 26 of the 2006 ATA guidelines, which had been restated in the 2009 guidelines, for which ‘‘lobectomy alone may be sufficient treatment for small ( < 1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas (4).’’ We found that 70.3% of responders agreed no further treatment to be necessary, in keeping with the current guidelines, while 29.7% felt completion thyroidectomy to be necessary. Interestingly, when asked about what motivations were behind these choices, the ease of patient follow-up and multifocality of disease were judged to be very significant by most responders. Notably, influence from national published guidelines and current literature or from nationally or internationally recognized authorities was rated as only somewhat or minimally significant by most responders. Surgeons from the south and west, otolaryngologists, and low volume surgeons were more likely to recommend completion thyroidectomy. In summary, we found through a different study technique very similar issues to that of Goffredo et al. (1). There is a wide variety of practice patterns in the current treatment of thyroid cancer in the United States. We commend their careful study and agree with their conclusion that ‘‘Ongoing efforts should be undertaken to propagate guidelines to reduce variation in care and improve overall quality of care.’’
Dear Editor: We read with great interest the article by Goffredo et al. (1). As the authors correctly point out, ‘‘There is a wide variability in the degree of adherence to guideline recommendations among caregivers.’’ They sought to determine the impact of the 2006 American Thyroid Association (ATA) guidelines on the management of differentiated thyroid cancer (DTC) in the United States. They utilized the Surveillance, Epidemiology and End Results (SEER) database (2004–2009) to assess compliance with specific recommendations of the 2006 ATA guidelines, including Recommendation 26, which states that total or near-total thyroidectomy should be the initial surgical procedure for most patients with thyroid cancer and that thyroid lobectomy alone may be considered for small ( < 1 cm), low risk, isolated, intrathyroidal papillary tumors in the absence of cervical nodal metastases (2). Examining papillary thyroid cancer (PTC) tumors larger than 1 cm, they found that overall compliance with Recommendation 26 tended to increase slightly in the 2007–2009 time period to 83.2% versus 82.2% in the 2004–2006 time period. Patients with smaller tumors received treatment more adherent to the guidelines; 85.5% of tumors 2 cm or less in size underwent total thyroidectomy. Factors associated with discordant practice to guidelines were older patient age, treatment in the northeast, having more than one primary cancer, tumor size larger than 4 cm, and follicular thyroid cancer and Hu¨rthle cell thyroid cancer histologies. They stated that, ‘‘To our knowledge, the current study is the first to analyze practice patterns and potential changes in clinical practice associated with the publication of the 2006 ATA guidelines for the management of patients with thyroid nodules and DTC.’’ We would like to highlight our experience studying practice patterns in the treatment of papillary thyroid microcarcinoma (PTMC) published in 2010 (3). We utilized a survey methodology including members of the American Association of Endocrine Surgeons, American Academy of Otolaryngology-Head & Neck Surgery, and general surgeons on the online physician forum Sermo.com. We had 438 responses distributed fairly evenly across the geographic United States and encompassing an estimated 14.5% of surgeons
Author Disclosure Statement
The authors declare no competing financial interests. References
1. Goffredo P, Roman SA, Sosa, JA 2014 Have 2006 ATA practice guidelines affected the treatment of differentiated thyroid cancer in the United States? Thyroid 24:463–471. 2. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM 2006 American Thyroid Association Guidelines Taskforce, Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 16:109– 142.
1
Division of Otolaryngology-Head & Neck Surgery, Ventura County Medical Center, Ventura, California. Department of Head and Neck Surgery, UCLA David Geffen School of Medicine; 3VA Greater Los Angeles Healthcare System, Los Angeles, California. 2
1
2
3. Wu AW, Wang MB, Nguyen CT 2010 Surgical practice patterns in the treatment of papillary thyroid microcarcinoma. Arch Otolaryngol Head Neck Surg 136:1182– 1190. Erratum in: Arch Otolaryngol Head Neck Surg 2011;137:123. 4. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. 2009 American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated
LETTER TO THE EDITOR
thyroid cancer [published correction appears in Thyroid 2010;20:942]. Thyroid 19:1167–1214.
Address correspondence to: Chau Nguyen, MD, FACS Division of Otolaryngology-Head & Neck Surgery Ventura County Medical Center 3291 Loma Vista Rd Ste 401 Ventura, CA 93003 E-mail: [email protected]
LETTER TO THE EDITOR
Practice Patterns in the Surgical Treatment of Papillary Thyroid Microcarcinoma Chau Nguyen1 and Marilene Wang 2,3
performing thyroidectomies annually. We queried physician decision-making for, among other scenarios, the finding of a 3 mm focus of PTMC on final pathology after hemithyroidectomy. We sought to compare this with recommendation 26 of the 2006 ATA guidelines, which had been restated in the 2009 guidelines, for which ‘‘lobectomy alone may be sufficient treatment for small ( < 1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas (4).’’ We found that 70.3% of responders agreed no further treatment to be necessary, in keeping with the current guidelines, while 29.7% felt completion thyroidectomy to be necessary. Interestingly, when asked about what motivations were behind these choices, the ease of patient follow-up and multifocality of disease were judged to be very significant by most responders. Notably, influence from national published guidelines and current literature or from nationally or internationally recognized authorities was rated as only somewhat or minimally significant by most responders. Surgeons from the south and west, otolaryngologists, and low volume surgeons were more likely to recommend completion thyroidectomy. In summary, we found through a different study technique very similar issues to that of Goffredo et al. (1). There is a wide variety of practice patterns in the current treatment of thyroid cancer in the United States. We commend their careful study and agree with their conclusion that ‘‘Ongoing efforts should be undertaken to propagate guidelines to reduce variation in care and improve overall quality of care.’’
Dear Editor: We read with great interest the article by Goffredo et al. (1). As the authors correctly point out, ‘‘There is a wide variability in the degree of adherence to guideline recommendations among caregivers.’’ They sought to determine the impact of the 2006 American Thyroid Association (ATA) guidelines on the management of differentiated thyroid cancer (DTC) in the United States. They utilized the Surveillance, Epidemiology and End Results (SEER) database (2004–2009) to assess compliance with specific recommendations of the 2006 ATA guidelines, including Recommendation 26, which states that total or near-total thyroidectomy should be the initial surgical procedure for most patients with thyroid cancer and that thyroid lobectomy alone may be considered for small ( < 1 cm), low risk, isolated, intrathyroidal papillary tumors in the absence of cervical nodal metastases (2). Examining papillary thyroid cancer (PTC) tumors larger than 1 cm, they found that overall compliance with Recommendation 26 tended to increase slightly in the 2007–2009 time period to 83.2% versus 82.2% in the 2004–2006 time period. Patients with smaller tumors received treatment more adherent to the guidelines; 85.5% of tumors 2 cm or less in size underwent total thyroidectomy. Factors associated with discordant practice to guidelines were older patient age, treatment in the northeast, having more than one primary cancer, tumor size larger than 4 cm, and follicular thyroid cancer and Hu¨rthle cell thyroid cancer histologies. They stated that, ‘‘To our knowledge, the current study is the first to analyze practice patterns and potential changes in clinical practice associated with the publication of the 2006 ATA guidelines for the management of patients with thyroid nodules and DTC.’’ We would like to highlight our experience studying practice patterns in the treatment of papillary thyroid microcarcinoma (PTMC) published in 2010 (3). We utilized a survey methodology including members of the American Association of Endocrine Surgeons, American Academy of Otolaryngology-Head & Neck Surgery, and general surgeons on the online physician forum Sermo.com. We had 438 responses distributed fairly evenly across the geographic United States and encompassing an estimated 14.5% of surgeons
Author Disclosure Statement
The authors declare no competing financial interests. References
1. Goffredo P, Roman SA, Sosa, JA 2014 Have 2006 ATA practice guidelines affected the treatment of differentiated thyroid cancer in the United States? Thyroid 24:463–471. 2. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM 2006 American Thyroid Association Guidelines Taskforce, Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 16:109– 142.
1
Division of Otolaryngology-Head & Neck Surgery, Ventura County Medical Center, Ventura, California. Department of Head and Neck Surgery, UCLA David Geffen School of Medicine; 3VA Greater Los Angeles Healthcare System, Los Angeles, California. 2
1
2
3. Wu AW, Wang MB, Nguyen CT 2010 Surgical practice patterns in the treatment of papillary thyroid microcarcinoma. Arch Otolaryngol Head Neck Surg 136:1182– 1190. Erratum in: Arch Otolaryngol Head Neck Surg 2011;137:123. 4. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. 2009 American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated
LETTER TO THE EDITOR
thyroid cancer [published correction appears in Thyroid 2010;20:942]. Thyroid 19:1167–1214.
Address correspondence to: Chau Nguyen, MD, FACS Division of Otolaryngology-Head & Neck Surgery Ventura County Medical Center 3291 Loma Vista Rd Ste 401 Ventura, CA 93003 E-mail: [email protected]
