A scenario similar to Case 4, but the post-operative USS demonstrated several contralateral thyroid nodules, measuring 2cm maximally, classified as U2/3 and confirmed Thy2 on FNAC.

Patient Responses

The first patient questionnaire explored their experiences and perspectives during their treatment pathway. Responses were received from 74 patients nationwide. The responses are represented in Table 2.1.
Question 1: Were the ‘pros and cons’ of the different treatment options explained to you in full and the reasoning behind them?
Question 2: Was the final decision on treatment/management a ‘shared-decision-making’ process between you and the doctor or was it mainly the doctor’s recommendation?
Question 3: Is there any information that you would have liked to have known before that you weren’t told about? Especially regarding the different treatment options?
The second patient survey explored patient preferences for treatment choice in LRDTC. A total of 135 different patients responded, with their responses seen in Table 2.2.
Question 1: What was their preferred choice between total thyroidectomy vs hemi-thyroidectomy if diagnosed with LRDTC?
Questions 2, 3 and 4 asked - What was the main reason(s) behind the preferred surgical choice (hemi- or total-thyroidectomy)?

Discussion

The aim of this study was to investigate how UK surgeons and MDTs interpret the latest BTA and ATA guidelines on the surgical management of low-risk thyroid cancers (LRDTC) and how this impacts patient experiences across the UK.
This study canvassed opinion from 74 thyroid surgeons (the majority being core members of regional thyroid cancer MDTs) and their region of practice covered most of the UK, thereby allowing an accurate reflection on current national practice. The BTA guideline was the most popular, which is to be expected as this survey was performed in the UK. When asked what specific risk factors were taken into consideration when assessing recurrence risk, interestingly, the cut off for patient’s age (> 45 years) was considered by only about half the surgeons/MDTs. This perhaps reflects the increasing evidence that a specific age cut-off is less important (reflected in 8th TNM change to >55 years) than age being considered a continuously variable risk factor15. It also seems that central neck node involvement is considered in the UK to be an important risk factor (85%), with about 50% specifying that they would consider it a significant risk only if more than five nodes were involved. This variability appears to affect the management of patients as shown by the variability in the responses to the five case scenarios of typical LRDTCs.
For scenario one, despite both BTA and ATA guidelines supporting treatment de-escalation, only 58% offered a hemi-thyroidectomy (HT), whilst 33% preferred the traditional approach of a total thyroidectomy (TT). Scenario two presented a similar case but with a larger T2 (3cm) PTC and interestingly, this resulted in 54% favouring, with only 24% favouring HT.
Scenario three demonstrated that the presence of incidentally excised microscopically positive lymph nodes, regardless of number, affected management strategy. Over 90% of respondents recommended TT (+/- RAI). The BTA and ATA guidelines differ here and may explain the observed responses. The ATA suggest that incidental sampling and less than five involved lymph nodes still constitute a ‘low-risk’ case, whereas BTA have no such qualification and thus indirectly advocate TT and RAI. UK MDTs clearly feel any central lymph node involvement, is a significant risk factor, warranting more extensive surgery, despite the ATA guidance, as well as the lack of clear evidence that CND or TT have any additional benefit to survival outcomes in such cases. Based on this preference, it is clear the results of the current IoN trial16 (which include N1a patients) will affect management in patients with positivity in incidentally sampled lymph nodes and may further change attitudes towards role of prophylactic CND.
Scenarios four and five presented a patient with a T1a(m) multifocal mPTC, where 63% favoured HT. The ATA and BTA guidelines again differ for multifocal mPTC. The ATA guidelines stratify such patients as ‘low-risk’ suitable for HT, whereas BTA guidelines promote TT. This reflects the current conflicting evidence in the prognostic impact of multifocal and bilateral disease. Studies have shown better disease-free survival after TT whilst others have suggested HT may be equally effective17–19. Despite BTA guidelines promoting TT for multi-focal mPTC, as it is a predictor for contralateral/bilateral disease (up to 50% of cases) only 32% recommended TT, with the remainder recommending clinical surveillance. However, in the presence of contralateral benign thyroid nodules, responses changed towards TT (66%), presumably due to the concern of potential contralateral disease. This is despite current evidence demonstrating that multifocal disease is not an independent prognostic factor for long-term outcomes and those managed with HT alone demonstrate rates of regional recurrence and overall survival to be comparable to unifocal disease20,21. The BTA and ATA guidelines differ here and consider multifocality as warranting TT, which may partly explain this preference. This again highlights the concern for inconsistency in practice nationally as a direct result of the lack of high-quality clinical data and the current surgical equipoise introduced by the both guidelines.
A diagnosis of cancer causes a considerable amount of stress to patients. Even more so with LRDTCs; a situation of clinical equipoise and multiple treatment options, all with their associated risks.“When the evidence for or against a treatment is inconclusive and no randomised or prospective national studies are ongoing to address this issue…” the BTA & ATA recommend a personalised approach to decision-making via a ‘shared-decision-making’ model. Our survey demonstrated that 40% of patients felt the ‘pros and cons’ of different management options were not fully explained to them. We also found that 47% of patients felt that they did not have a significant voice in their management plan and that the final treatment plan was primarily the surgeon’s choice (53%). Nickel et al.2,22reported that patients and the general public demonstrated a low pre-existing general awareness of the concept of overdiagnosis and overtreatment of LRDTCs, and a major point of conflict/confusion for patients was that LRDTCs were being described to them as a “good result”, despite the association of the word “cancer”2. Therefore, it is paramount that clear and comprehensive information is provided to patients who are having to make difficult decisions. Our survey reported that thorough explanation of different treatment options and their respective side-effects, the more satisfactory the decision-making process. These issues may have to be addressed by providing patients with clinical decision aids23,24 and by future qualitative research.
The second patient survey explored patients’ preferred treatment choice if they were theoretically diagnosed with LRDTC and what factors would be important for their decision. Contrary to the clinical shift towards treatment de-escalation, 60% pf patients preferred TT; the overwhelming reasons (80%) being “to ensure there was no cancer left ”, “to prevent recurrence ” and “to avoid the anxiety and worry of having another cancer in the other side ”. Only 20% preferred HT, with their main reason (46%) being “to avoid lifelong thyroid replacement medication ”. These findings are consistent with a qualitative study by Nickel et al. exploring patient attitudes to thyroid cancer treatment2. They suggested that the observed treatment preferences may be due to the implications that the word “cancer” has in society, and observed, like other groups, that the majority of patients perceived thyroid cancer to be similar to other types of cancer in terms of morbidity and mortality22.

Study Limitations

The main limitation was the relatively small number of respondents. However, the authors do not feel that a larger number of responses was necessary for this study, as this was a snapshot of clinical decision-making and patient experiences in relation to LRDTCs. For the two patient surveys, there may be selection bias, as the patients were approached through a patient support group website which may bias the type of respondent and their experience of treatment. For questionnaire three, even if a patient who answered the questionnaire was not “low-risk”, their answers remain valid as the aim of the questionnaire was to investigate what patients would want if they were diagnosed with LRDTC. It was not possible to identify the geographical location of the respondents to investigate any regional variation in experiences, which may have been useful for future quality improvement.

Conclusions

This study has demonstrated significant variation in the interpretation of the ATA 2015 & BTA 2014 guidelines in risk assessment and surgical management of “low-risk” thyroid cancer by different thyroid MDTs/surgeons throughout the UK. There is clear clinical equipoise in the management of LRDTC due to conflicting evidence and the lack of high-quality prospective randomised controlled trial data. It is likely that differences between international and national guidelines (as a result of equipoise in evidence) and differences in interpretation across the UK are contributing to the observed practice variation.
We have also observed that current guidelines seem to be at odds to what patients may prefer (TT over HT). In addition, the variation in surgical practice throughout the country may adversely affect patient experiences. Our findings provide further evidence that improved delivery of pertinent information to patients within a ‘shared-decision-making’ process is paramount to achieve thorough informed consent and optimal management for each patient. It also highlights the need for better evidence from randomised prospective studies to clarify the current guidelines, particularly in the use of hemi-thyroidectomy, for both the clinicians and patients.

Tables