Ethical Considerations When Counseling Patients With Thyroid Cancer About Surgery vs Observation

To the Editor

In a recent Viewpoint, Stack and Angelos¹ remind physicians about ethical obligations to outline risks, benefits, and alternatives of all treatment options to patients. Discussing the option of observation for papillary microcarcinoma (PMC), the authors assert that “this approach is not the standard of care in the United States,”^1(p957) and, if considered, should only be offered under an institutional review board-approved research protocol or if patients sign a “surveillance contract.”

On behalf of the multidisciplinary thyroid cancer team at Memorial Sloan Kettering Cancer Center (MSKCC) (a letter dated November 24, 2015, was signed on behalf of all attending physicians of the MSKCC Disease Management Team for Thyroid Cancer [https://www.mskcc.org/cancer-care/types/thyroid], including senior leadership in surgery [Dr Ashok Shaha and Dr Jatin Shah] and in endocrinology [Dr James Fagin]), we write to express our concerns about these opinions. While we certainly agree that physicians must comprehensively educate patients about the fullest possible set of treatment options for thyroid cancer, we dispute the misguided assertion that anything short of immediate biopsy and resection of subcentimeter suspicious thyroid nodules is outside the “standard of care.” This extreme position disregards the public health ramifications of aggressive therapy for indolent PMCs, present in 5% to 30% of the adult population, very few of which ever cause clinically significant disease.²

In fact, the 2015 American Thyroid Association (ATA) clinical practice guidelines recommend observation rather than immediate fine-needle aspiration (FNA) and surgery for most intrathyroidal, subcentimeter, sonographically suspicious thyroid nodules (most of which are presumed to be thyroid cancers). For biopsy-proven cancers, “an active surveillance management approach” can be “considered as an alternative to immediate surgery” in patients with very low-risk tumors, at high surgical risk, with relatively short lifespans, or concurrent medical issues taking priority.^3(p18) The decades-long experience of our Japanese colleagues confirms excellent clinical outcomes with an observational management approach for PMC.⁴ For years, MSKCC has offered active surveillance as an alternative to immediate surgery in properly selected patients with PMC as part of routine clinical care.⁵

Mandating that patients sign a surveillance contract to avoid immediate FNA and surgery jeopardizes patient autonomy and the patient-physician relationship by stigmatizing certain patient choices and placing undue pressure on patients to undergo surgery. Patient autonomy requires that patients be able to choose a treatment plan freely, without coercion, particularly when physicians may stand to benefit financially from interventions.

The ethical principles of autonomy, beneficence, nonmaleficence and justice are best served when we offer properly selected patients all appropriate options—such as active surveillance or surgery for PMC. Mutual trust, open communication, and accurate exchange of information, are the sine qua non of counseling patients facing complex health care choices. Withholding an accepted alternative to surgical intervention does not serve the ethical interests to which the authors appeal.