Practice patterns in the surgical treatment of papillary thyroid microcarcinoma.

Abstract

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 Hurthle 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 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.’’