Thyroid Cancer Detection and Surgery Called Too Aggressive

Diagnoses have tripled over the past 25 years, mainly as the result of increased detection of small papillary thyroid cancers. Is it time for a less-aggressive approach?

A pair of physician researchers are urging the adoption of less intensive detection and treatment of thyroid cancer.

Total thyroidectomy is the most common surgical procedure for thyroid cancer, accounting for 80% of operations. It is also the highest-risk surgical treatment, with potential complications including hypoparathyroidism and risk of injury to the recurrent laryngeal nerves.

In the New England Journal of Medicine this week, H. Gilbert Welch, MD, MPH, of Dartmouth College and Gerard M. Doherty, MD, of Dana Farber Cancer Institute say the prevalence of total thyroidectomy procedures and the potential for harm are unjustifiable.

"The basic problem is the belief that more is always better—particularly in the treatment of cancer," Welch told HealthLeaders Media this week.

The primary surgical alternative to total thyroidectomy is thyroid lobectomy, which removes about half the thyroid gland.

Thyroid lobectomy has several advantages over total thyroidectomy, the researchers wrote.

"This surgery carries a lower risk of nerve damage, avoids the risk of hypoparathyroidism altogether, and preserves thyroid tissue—for many patients, obviating the need for permanent thyroid hormone-replacement therapy."

Data for the 25-year risk of death from thyroid cancer also indicate the preferability of thyroid lobectomy, Welch and Doherty found. "First, the risk of death from thyroid cancer is extremely low (roughly 2% over 25 years), and second, that risk is unaffected by the choice of procedure."

Removing less of the thyroid gland makes more sense than total thyroidectomy procedures, Welch says. "More is just that—more—and carries more harm. In the whole vs. half thyroid question, half is as good and produces less problems."

Overzealous detection
 

This year, more than 50,000 Americans are expected to receive a thyroid cancer diagnosis. Over the past 25 years, diagnoses of thyroid cancer have tripled—mainly as the result of increased detection of small papillary thyroid cancers.

Welch and Doherty say there is overdiagnosis of thyroid cancer.

"Despite [the] dramatic rise in incidence, mortality due to thyroid cancer has remained stable, which suggests that there is widespread overdiagnosis—detection of disease that is not destined to cause clinical illness or death."

The researchers call for less aggressive detection activity. "Efforts to reduce thyroid-cancer detection are clearly warranted—for example, refraining from screening for cancers and from biopsying small thyroid nodules."

Treatment should take an equally conservative approach, the researchers wrote.

"We support the option of active surveillance for selected patients with small papillary thyroid cancers, but we recognize that some patients will prefer to have their cancer removed. In such cases, the question becomes how much thyroid to resect."

Changing standard of care
 

Welch and Doherty say the preference for total thyroidectomy is at least partly due to insufficient knowledge.

"Surgeons may underestimate their own complication rates, particularly if they rarely perform the operation. Furthermore, low-volume surgeons may be unaware of new practice guidelines, since thyroid surgery represents a small part of their practice."

Surgeons also appear to be clinging to an outdated view of thyroid cancer risk, the researchers wrote.

"Conventional practice pathways and surveillance strategies were designed for patients with higher-risk disease. It is hard for providers to de-intensify care. To do less for today's patients than for the patients of the past may make clinicians feel exposed."

A less intensive approach to thyroid cancer also could increase patient anxiety, and primary care can play a key role in alleviating concerns, Welch and Doherty say.

"Primary care practitioners can help by educating patients about the heterogeneity of the conditions we call 'cancer,' as well as by shepherding patients through a system that was designed for more advanced disease."

Several research studies over the past four years have drawn similar conclusions. The field is moving toward widespread acceptance of the overdiagnosis problem, Welch told HealthLeaders.

"Both the American Thyroid Association and the American College of Radiology now recommend that small thyroid nodules not be biopsied. And thyroid cancer doctors are now beginning to offer active surveillance—just like urologists do for low-risk prostate cancer."