Abstract
Background: Guidelines recommend using fine-needle aspiration cytology (FNAC) to guide thyroid nodule surgical indication. However, the extent to which these guidelines are followed remains unclear. This study aimed to analyze the quality of the preoperative care pathway and to evaluate whether compliance with the recommended care pathway influenced the relevance of surgical indications. Methods: Nationwide historical cohort study based on data from a sample (1/97th) of French health insurance beneficiaries. Evaluation of the care pathway of adult patients operated on between 2012 and 2015 during the year preceding thyroid nodule surgery. The pathway containing only FNAC was called “FNAC”, the pathway including an endocrinology consultation (ENDO) with FNAC was called “FNAC+ENDO”, whereas the no FNAC pathway was called “NO FNAC”. The main outcome was the malignant nature of the nodule. Results: Among the 1080 patients included in the study, “FNAC+ENDO” was found in 197 (18.2%), “FNAC” in 207 (19.2%), and “NO FNAC” in 676 (62.6%) patients. Cancer diagnosis was recorded in 72 (36.5%) “FNAC+ENDO” patients and 66 (31.9%) “FNAC” patients, against 119 (17.6%) “NO FNAC” patients. As compared to “NO FNAC”, the “FNAC+ENDO” care pathway was associated with thyroid cancer diagnosis (OR 2.67, 1.88–3.81), as was “FNAC” (OR 2.09, 1.46–2.98). Surgeries performed in university hospitals were also associated with thyroid cancer diagnosis (OR 1.61, 1.19–2.17). Increasing the year for surgery was associated with optimal care pathway (2015 vs. 2012, OR 1.52, 1.06–2.18). Conclusions: The recommended care pathway was associated with more relevant surgical indications. While clinical guidelines were insufficiently followed, compliance improved over the years.
Highlights
The high clinical prevalence of thyroid nodules reaches 5.3–6.4% in women and 0.8–1.3% in men in countries in which iodine intake is sufficient
The association of care pathway type with thyroid cancer diagnosis was stronger for “fine-needle aspiration cytology (FNAC)+endocrinology consultation (ENDO)” (OR 2.67; 95% Confidence interval (CI) 1.88–3.81; p-value < 0.001) and “FNAC” than for “NO FNAC”, but the “FNAC+ENDO” care pathway was not significantly more associated with thyroid cancer diagnosis than “FNAC”
The majority of surgeries were performed for benign pathology, as approximately only one-quarter were associated with a thyroid cancer diagnosis, suggesting an overtreatment of thyroid nodules
Summary
The high clinical prevalence of thyroid nodules reaches 5.3–6.4% in women and 0.8–1.3% in men in countries in which iodine intake is sufficient. The increase in the number of surgeries coupled to the improvement in histology techniques has led to an increase in thyroid cancer incidence over the past 30 years, while thyroid cancer mortality remains low and stable. Guidelines should allow for better targeting of surgical indications, leading to fewer avoidable surgeries and fewer fortuitous microcancer discoveries This would have a beneficial effect on patient quality of life, which can be impaired following thyroid surgery or when a thyroid cancer is discovered [29,30]. Guidelines recommend using fine-needle aspiration cytology (FNAC) to guide thyroid nodule surgical indication. As compared to “NO FNAC”, the “FNAC+ENDO” care pathway was associated with thyroid cancer diagnosis (OR 2.67, 1.88–3.81), as was “FNAC” (OR 2.09, 1.46–2.98). While clinical guidelines were insufficiently followed, compliance improved over the years
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