Abstract
Objective:
Active surveillance for low-risk papillary thyroid cancer (PTC) was endorsed by the American Thyroid Association guidelines in 2015. The attitudes and beliefs of physicians treating thyroid cancer regarding the active surveillance approach are not known.
Methods:
A national survey of endocrinologists and surgeons treating thyroid cancer was conducted from August to September 2017 via professional society emails. This mixed-methods analysis reported attitudes toward potential factors impacting decision-making regarding active surveillance, beliefs about barriers and facilitators of its use, and reasons why physicians would pick a given management strategy for themselves if they were diagnosed with a low-risk PTC. Survey items about attitudes and beliefs were derived from the Cabana model of barriers to guideline adherence and theoretical domains framework of behavior change.
Results:
Among 345 respondents, 324 (94%) agreed that active surveillance was appropriate for at least some patients, 81% agreed that active surveillance was at least somewhat underused, and 76% said that they would choose surgery for themselves if diagnosed with a PTC of ≤1 cm. Majority of the respondents believed that the guidelines supporting active surveillance were too vague and that the current supporting evidence was too weak. Malpractice and financial concerns were identified as additional barriers to offering active surveillance. The respondents endorsed improved information resources and evidence as possible facilitators to offering active surveillance.
Conclusion:
Although there is general support among physicians who treat low-risk PTC for the active surveillance approach, there is reluctance to offer it because of the lack of robust evidence, guidelines, and protocols.
Keywords: thyroid cancer, microcarcinoma, active surveillance, low-risk, survey, papillary
Introduction
In 2015, the American Thyroid Association (ATA), for the first time, endorsed active surveillance as a management option for select patients with low-risk papillary thyroid cancer (PTC), including papillary microcarcinoma (≤1 cm).1 The data supporting active surveillance at that time included 2 cohort studies of patients from Japan with a biopsy-proven PTC of ≤1 cm in size, which collectively showed no deaths among more than 1200 patients managed with active surveillance, some of whom were followed up for more than 10 years.2–8 In these case series, 7% to 8% of cancers grew over time, eventually requiring surgery. Since the publication of the ATA guidelines, additional data from the first North American cohort of patients managed with active surveillance has been published, this time including patients with tumors of up to 1.5 cm in size.9 These data again showed no deaths among 291 patients followed up for a median of 25 months (range: 6–166), with 11 of 291 (3.8%) showing growth of tumors >3 mm and 36 (12.7%) showing growth of tumors >50% in volume. Collectively, data from Italy, Japan, and North America have shown that younger patients’ tumors are more likely to grow and that the rate of cancer spread to lymph nodes during active surveillance is between 0% and 3.8%.10
Despite the endorsement of active surveillance in the respected guidelines, much remains unknown about active surveillance for low-risk PTC. The published cohorts have been from single institutions, and there have been no trials, randomized or otherwise, directly comparing patients managed with active surveillance versus those managed with surgery. Because the protocols, guidelines, and outcome data regarding active surveillance are not yet mature, physicians who manage patients with low-risk PTC in the current era face uncertainty about the best practices. Physicians’ attitudes and beliefs regarding active surveillance have not been studied. Their attitudes and beliefs are likely to be important in elucidating both how patients diagnosed with low-risk PTC are managed today and the trajectory of future efforts to study and advance the practice of active surveillance.
We performed a national survey of surgeons and endocrinologists who manage patients with thyroid cancer to understand the current landscape of physicians’ beliefs during the early years since the introduction of the active surveillance approach. This analysis reports data on physicians’ attitudes and beliefs regarding active surveillance, barriers and facilitators to increasing its use, and a qualitative analysis of physicians’ beliefs related to why they would choose various management strategies for themselves if diagnosed with low-risk PTC.
Methods
We used Qualtrics software (Version: September 2017) to administer a pilot survey to active members of 3 medical and surgical societies representing the major specialties that treat thyroid cancer: ATA, the American Association of Endocrine Surgeons, and the American Head and Neck Society (AHNS). We distributed the survey to the members of each organization via email between August and September 2017 using the modified Dillman method,11 sending 1 initial email and 2 reminder invitations. Per the preference of the societies, ATA and AHNS distributed the emails, while the American Association of Endocrine Surgeons provided the study team with the members’ email addresses. Respondents who completed the survey entered a draw to win a small monetary prize. To be eligible for survey inclusion, the respondents had to self-report that they treated adult patients with thyroid cancer, self-identify as an endocrinologist, general surgeon, endocrine surgeon, head and neck surgeon, or otolaryngologist, and have active practice in the United States.
This study was determined to be exempt from human subjects review by the University of Wisconsin’s institutional review board (2017–0373).
Measures
To develop survey items, we utilized semistructured interviews with 24 surgeons and endocrinologists who were selected by convenience sampling. The 24 clinicians were interviewed at the 2016 annual ATA meeting; 21 (87.5%) had academic practice, and 14 (58.3%) were members of the American Association of Clinical Endocrinologists. They were from all regions of the United States. Their input, as well as 2 well-established conceptual frameworks, was used to develop survey items about attitudes and beliefs regarding active surveillance. The 2 conceptual frameworks were the Cabana Model of barriers to guidelines adherence12 and theoretical domains framework of behavior change.13 Additional questions on medical overuse were adapted from published literature.14 A group of clinician stakeholders reviewed the items and concepts to ensure face validity. Experts from the University of Wisconsin survey center provided guidance and feedback to help ensure that the question format and wording matched the concepts being measured. All the questions underwent cognitive and field testing to ensure that they were interpreted consistently and as intended.
Analysis
Demographics and answers to the attitude and belief questions were examined using descriptive statistics. The χ2 test was performed to examine differences in demographics between the surgeons and endocrinologists. For questions in which a 5-point Likert scale was used, the options were “none,” “alittle,” “someorsomewhat,” “quite a bit,” and “a great deal” (full results appear in the Supplementary Table). In the main results, the findings were dichotomized to provide more easily interpretable results such that “at least some or somewhat” included “some or somewhat,” “quite a bit,” and “a great deal.” For questions about factors that might make physicians more likely to offer active surveillance to their patients (which had yes/no/ maybe answers), the results were dichotomized such that “might” included “yes” and “maybe” (full results appear later in Table 3).
Table 3.
Interventions That Might Make Physicians More Likely to Offer the Active Surveillance Approach to Their Patients
| Intervention (response) | Total no. (%) | Endocrinologists | Surgeons | P value |
|---|---|---|---|---|
| Financial incentive | ||||
| No | 279 (81.1) | 81 (82.7%) | 198 (80.5%) | .54 |
| Maybe | 47 (13.7) | 15 (15.3%) | 32 (13%) | |
| Yes | 18 (5.2) | 2 (2%) | 16 (6.5%) | |
| Information to share | ||||
| No | 104 (30.2) | 31 (31.3%) | 73 (29.8%) | .89 |
| Maybe | 147 (42.7) | 41 (41.4%) | 106 (43.3%) | |
| Yes | 93 (27.0) | 27 (27.3%) | 66 (27%) | |
| Patient-signed consent form | ||||
| No | 100 (29.0) | 25 (25.3%) | 75 (30.5%) | .10 |
| Maybe | 117 (33.9) | 30 (30.3%) | 87 (35.4%) | |
| Yes | 128 (37.1) | 44 (44.4%) | 84 (34.1%) | |
Free-text fields asked physicians why they would choose a particular management strategy for themselves if they had cancer. Qualitative data were categorized using a conventional content analysis.15 Close reading of the free-text responses was performed inductively to develop a coding structure (M.C.S.). The coding structure was refined in conjunction with other authors (B.R.R., L.D., and S.C.P.) until an agreement was reached. The codes were then applied to the data (M.C.S.), and 3 authors (B.R.R., L.D., and S.C.P.) reviewed groups of the responses to check for coding agreement. Discrepancies were discussed and resolved among the team. For reporting the qualitative data on the physicians’ choices of management strategy for themselves, surgical options (hemithyroidectomy or total thyroidectomy) were grouped together because the qualitative differences were the strongest between surgical and nonsurgical options.
Survey eligibility and response rates were not calculable using the American Association for Public Opinion Research calculation approaches. The 3 organizations approached for the survey had a significant overlap in membership, and ATA and AHNS do not directly share names, specialties, and country of practice of their members.
Results
A total of 345 physicians responded, who were eligible for the analysis. An additional 39 respondents were ineligible because they were not treating adults with thyroid nodules or cancers, were not attending physicians, or were not in the specialties of interest. The analyzed group consisted of 246 thyroid surgeons and 99 endocrinologists. The demographics of the respondents are shown in Table 1. Compared to the endocrinologists, the surgeons were younger, more likely to work in academic tertiary centers, and saw a lower volume of thyroid cancer patients per year.
Table 1.
Demographics
| Variable | Surgeons | Endocrinologists | Total |
|---|---|---|---|
| No. (%) | 246 (71.3) | 99 (28.7) | 345 |
| Mean age ± SD | 46.0 ± 10.3 | 51.4 ± 14.9 | 47.5 ± 12.0 |
| Sex | |||
| Male | 172 (70.8) | 60 (62.5) | 232 (68.4) |
| Female | 71 (29.2) | 36 (37.5) | 107 (31.6) |
| Race/ethnicity | |||
| White | 170 (70.5) | 63 (65.6) | 233 (69.1) |
| Black | 2 (0.8) | 0 (0.0) | 2 (0.6) |
| American Indian/Alaska native | 3 (1.2) | 0 (0.0) | 3 (0.9) |
| Asian | 42 (17.4) | 22 (22.9) | 64 (19.0) |
| Hispanic | 16 (6.6) | 7 (7.3) | 23 (6.8) |
| Other | 8 (3.3) | 4 (4.2) | 12 (3.6) |
| Practice setting | |||
| Academic tertiary | 168 (69.4) | 48 (49.5) | 216 (63.7) |
| Academic-affiliated hospital | 38 (15.7) | 18 (18.6) | 56 (16.5) |
| Community hospital | 15 (6.2) | 3 (3.1) | 18 (5.3) |
| Private practice | 18 (7.4) | 25 (25.8) | 43 (12.7) |
| Other | 3 (1.2) | 3 (3.1) | 6 (1.8) |
| Mean years in practice ± SD | 12.5 ± 11.0 | 19.1 ± 14.6 | 14.3 ± 12.4 |
| Annual thyroid cancer patient volume | |||
| <25 cases | 49 (19.9) | 19 (19.2) | 68 (19.7) |
| 25–50 cases | 83 (33.7) | 26 (26.3) | 109 (31.6) |
| 51–100 cases | 69 (28.1) | 15 (15.2) | 84 (24.4) |
| >100 cases | 45 (18.3) | 39 (39.4) | 84 (24.4) |
| Familiarity with active surveillance | |||
| Yes | 234 (95.1) | 90 (91.8) | 324 (94.2) |
| Experience performing active surveillance | |||
| Yes | 157 (63.8) | 59 (59.6) | 216 (62.6) |
| No. of active surveillance patients per year | |||
| Median (interquartile range) | 2 (1–5) | 2 (2–8) | 2 (1–5) |
| Familiarity with 2015 ATA guidelines | |||
| Not at all | 0 (0.0) | 1 (1.0) | 1 (0.3) |
| A little | 2 (0.8) | 0 (0.0) | 2 (0.6) |
| Somewhat | 13 (5.3) | 5 (5.1) | 18 (5.25) |
| Quite a bit | 84 (34.3) | 34 (34.7) | 118 (34.4) |
| A great deal | 146 (59.6) | 58 (59.2) | 204 (59.5) |
| Management in line with 2015 ATA guidelines | |||
| Not at all | 1 (0.4) | 2 (2.0) | 3 (0.9) |
| A little | 3 (1.2) | 0 (0.0) | 3 (0.9) |
| Somewhat | 27 (11.0) | 15 (15.2) | 42 (12.2) |
| Quite a bit | 119 (48.6) | 46 (46.5) | 165 (48.0) |
| A great deal | 95 (38.8) | 36 (36.4) | 131 (38.1) |
Abbreviations: ATA = American Thyroid Association.
Overall, 324 (94%) of the respondents were familiar with active surveillance, and 216 (63%) had personal experience performing active surveillance (Table 1). Only 64 (19%) of the physicians agreed that their patients were at least somewhat aware of active surveillance prior to seeing them, while 163 (48%) agreed that their patients were at least somewhat interested in active surveillance (Supplementary Table).
Among all the respondents, 314 (92%) agreed at least somewhat that they knew how to assess eligibility for active surveillance, 319 (93%) agreed that they were at least somewhat comfortable discussing active surveillance with patients, and 314 (92%) agreed at least somewhat that they knew how to follow up patients enrolled in an active surveillance approach. However, only 289 (84%) agreed at least somewhat that they felt comfortable offering active surveillance to appropriate patients, and 300 (87%) agreed at least somewhat that they had the appropriate resources to perform active surveillance (Fig. 1 and Supplementary Table).
Fig. 1.
Physicians’ level of experience with active surveillance (AS).
When asked about beliefs regarding the levels of use of different approaches to managing low-risk PTC (specifically, microcarcinomas of ≤1 cm), 279 (81%) of the physicians believed that the active surveillance approach was underused, and 251 (73%) and 310 (90%) believed that there was an overuse of total thyroidectomy or total thyroidectomy with radioactive iodine, respectively (Fig. 2).
Fig. 2.
Physicians’ beliefs about the level of use of different approaches to the management of low-risk papillary thyroid cancer measuring ≤1 cm (microcarcinomas). RAI = radioactive iodine.
Positive and Negative Views about Active Surveillance
Regarding the outcomes of the active surveillance management strategy, there was a consensus about the potential benefits, with 324 (94%) agreeing at least somewhat that it was appropriate for select patients and 75% agreeing at least somewhat that it had a chance of improving quality of life (Supplementary Table). However, 179 (52%) agreed at least somewhat that they had some reservations about the active surveillance approach, 86 (26%) agreed at least somewhat that patients undergoing active surveillance might have a poor outcome, and 232 (68%) agreed at least somewhat that the psychologic burden of active surveillance is too high for most patients (Fig. 3 and Supplementary Table).
Fig. 3.
Physicians’ beliefs about utilization, data, and guidelines related to active surveillance (AS).
Majority of the physicians felt that the guidelines and data supporting active surveillance could be stronger. When asked about the guidelines, 218 (66%) agreed at least somewhat that the guidelines were too vague. When asked about evidence supporting active surveillance, 168 (51%) agreed at least somewhat that the evidence was too weak (Fig. 3 and Supplementary Table).
The physicians were asked about potential malpractice and financial concerns related to active surveillance. A total of 137 (40%) agreed at least somewhat that they were concerned about the medical malpractice risk, while 119 (35%) agreed at least somewhat that they were concerned about the monetary costs of active surveillance. Regarding the perceived effect on physicians’ reimbursement, 75 (22%) agreed at least somewhat that performing active surveillance would negatively affect their reimbursement, and 120 (35%) agreed at least somewhat that recommending active surveillance might have a negative effect on their relationships with referring providers (Supplementary Table).
What Physicians Would Choose for Themselves
The physicians were asked what management strategy they would choose for themselves if they were diagnosed with a 0.8-cm PTC with no extrathyroidal extension, no lymphadenopathy or contralateral nodules on ultrasound, and assuming that there is no family history of thyroid cancer or history of head and neck radiation. In this scenario, 262 (76%) said that they would choose surgery. We examined the differences in this response according to specialty (surgeon vs endocrinologist), age, and gender. We found no statistically significant association between the respondents’ self-reported age and gender and their preference for their own treatment. However, we did find an association between physician specialty and preferred treatment: 38 (38.4%) of the endocrinologists preferred active surveillance compared to 43 (17.5%) of the surgeons (P = .0002).
The free-text field asking the physicians why they would choose a given management for themselves generated 288 responses, 218 (76%) of which were from those who would choose surgery and 70 (24%) from those who would choose active surveillance. The representative responses are shown in Table 2. The most common reasons for choosing surgery had to do with perceived safety and definitiveness; relatively low risk, especially with lobectomy in experienced surgical hands; and concordance with current guidelines. Among those choosing surgery, the most common reasons given for not choosing active surveillance included lack of data on safety; being younger in age and, therefore, having a higher chance of the cancer growing or spreading; having a long life expectancy and wanting to avoid long-term surveillance; wanting the cancer removed from their body; and wanting peace of mind or avoiding worry. The most common reasons for choosing active surveillance were related to beliefs that this management option was safe and effective, with a low likelihood of cancer progression, and wanting to avoid surgical risks.
Table 2.
Representative Quotes of Reasons Why Physicians Would Choose Different Management Strategies for Themselves If Diagnosed With a Low-Risk Papillary Thyroid Cancer of ≤1 cm
| Reasons for choosing surgery |
| [W]hile the surveillance data exists, I don’t feel confident in it; it would need to be replicated before I would readily embrace it. |
| Personally, [I] would want a curative operation and rule out multifocal microscopic disease and not have to deal with surveillance. |
| [I] prefer to have complete therapy and lower [my] risk of recurrence. |
| Surgery is the definitive treatment and can be done very safely in the hands of an experienced surgeon. |
| It is what I do in patients and [what] guidelines recommend. |
| Reasons for not choosing active surveillance (among those choosing surgery) |
| I am relatively young and would expect the cancer to grow larger during my lifetime. I would not want it to spread to lymph nodes while I am observing it. |
| I plan to live another 40 to 50 years and don’t want to have to do active surveillance forever. |
| Active surveillance is likely to be time-consuming. |
| I do not want to live with cancer even if it is small and can be observed. |
| I know I wouldn’t deal with the unknowns of surveillance (psychologically). |
| I would worry that I would be the one who later develops widely metastatic disease. |
| Reasons for choosing active surveillance |
| Unlikely to have any significant impact with progression and avoid the risks of surgical management if there is no progression—which is quite likely. |
| Because the probability of progression is very low. Disease-specific survival is excellent. |
| Can be easily monitored. Unlikely to have any major consequences if not operated now. It is just deferred intervention. |
| I’m comfortable with having a small, likely nonaggressive cancer in my thyroid as long as I get regular follow-up to ensure that it doesn’t significantly change. |
| Too busy to take time off for surgery when observation is reasonable and safe. |
| The data is quite reassuring that this is a safe practice and is unlikely to cause harm. |
| The risks and complications of surgery far outweigh the potential risks of active surveillance. |
| Why the hell get an operation that isn’t needed? |
Other Factors That Would Influence Physicians' Utilization of Active Surveillance
The physicians were asked “would you be more likely to offer active surveillance if…” Among the respondents, 244 (71%) said that having a patient sign an informed consent form when enrolling in the active surveillance approach might make them more likely to offer this approach. Seventy percent of the physicians said that having pamphlets, videos, or other information about active surveillance might make them more likely to offer this approach. For 65 (19%) of the physicians, having a financial incentive might make them more likely to offer this approach. There were no statistically significant differences according to specialty. Detailed results are shown in Table 3.
Discussion
This national survey of the members of 3 specialist organizations describes the current landscape of physicians’ attitudes and beliefs regarding the active surveillance approach to managing low-risk PTC during the early years since the introduction of this approach in the ATA guidelines. We found that while an overwhelming majority of the respondents thought that active surveillance was appropriate for some patients and an overwhelming majority also believed that active surveillance was underused, a majority said that they would choose surgery for themselves if diagnosed with low-risk PTC. We also found that the physicians agreed on potential barriers to the utilization of active surveillance, especially the weakness of current evidence and lack of guidelines and protocols supporting the approach. Malpractice and financial concerns were also barriers, with most physicians indicating that these factors played at least some role in their attitudes toward active surveillance. The physicians endorsed having patients sign an informed consent form and having informational resources about active surveillance available as potential facilitators to using the active surveillance approach.
The strengths of this study were in identifying 3 important areas where researchers and others might focus their efforts regarding the active surveillance approach. First, the findings suggest that the lack of high-quality prospective outcome data is a hindrance to the use of active surveillance. Many physicians believed that poor outcomes were possible if patients were to choose the active surveillance approach, and although this has not been borne out in single-institution cohorts,2–5,9 this study highlights the need for more robust prospective oncologic outcome evidence. For example, many physicians cited younger age as their reason for choosing surgery for themselves in the free-text answers (despite actual age not correlating with management choice), and while data does, in fact, show higher rates of disease progression in younger patients,9,16,17 prospective data are needed to determine whether this truly leads to worse oncologic outcomes.
Second, physicians believe that patient-reported outcomes, such as psychologic outcomes, might be poor with the active surveillance approach, as evidenced by their beliefs about patients and their self-reported reasons why they themselves would choose surgery. However, the literature on this subject suggests that although cancer worry is common among patients from Japan and Korea choosing an active surveillance approach, this worry diminishes over time and is comparable to patients from North America choosing surgery.18–22 Furthermore, a large majority of patients choosing active surveillance were satisfied with their decision despite some level of worry.19 These findings mirror those in prostate active surveillance cohorts. Studies have shown that patients with prostate cancer undergoing active surveillance have a similar quality of life, anxiety, depression, and short form health survey mental health component scores compared to those undergoing active treatment for prostate cancer.23,24 Given the finding in the current study that physicians believe that psychologic outcomes might be poor with active surveillance, additional high-quality evidence on these patient-centered outcomes, comparing those who undergo surgery with those who choose active surveillance in North America, will be important for informing future decision-making.
Third, the physicians endorsed the potential for several strategies that might facilitate the utilization of active surveillance, which go beyond improving the quality of outcome data and clarifying the guidelines. One strategy was making informational resources regarding active surveillance, such as pamphlets or videos, available to patients. Decision aids and similar information sources are already under development.25 The current survey suggests that these resources will be beneficial. The other strategy endorsed by the respondents was having patients sign an informed consent document when enrolling them in the active surveillance approach. This approach has been suggested in a prior debate about this subject,26,27 and although an argument was made to not require consent prior to commencing active surveillance,28 the current survey signals that having a consent document available might increase physicians’ utilization of this approach. In practice, patients signing an informed consent document in medicine usually do so in the context of a clinical trial or an invasive procedure. The implication, then, is that the wider availability of clinical trials studying the active surveillance approach might serve a dual purpose: to gather the data that physicians want to see and prior to that data being reported, to make this approach available to patients who are interested in active surveillance. A consent document may also have the benefit of reducing physicians’ worry about malpractice concerns.
Prior to this survey, no information was available regarding physicians’ beliefs about active surveillance in the United States. This study suggests that until physicians’ beliefs about what they would choose for themselves shift, it is unlikely that we will see a broader utilization of active surveillance.
One limitation of our study is the inability to calculate a response rate and, therefore, a lack of understanding about the cross-section of physicians who responded compared with those who did not. Relatedly, there might have been a selection bias among the respondents, namely, those physicians who were familiar with active surveillance might have been more likely to respond to our survey than physicians who were unfamiliar with the practice. For these reasons, the findings are not generalizable to the population of physicians who are members of the medical societies that were targeted or to the probable larger population of physicians outside these societies who interact, perhaps less frequently, with patients with low-risk PTC (including surgeons, endocrinologists, primary care doctors, and others). Nonetheless, this study does provide novel, valuable information on the beliefs of physicians who frequently manage patients with low-risk PTC, a group that, in theory, would be early adopters of a novel approach such as active surveillance but who, according to these findings, still have significant reservations. Furthermore, regardless of the magnitude or frequency of the documented physicians’ beliefs, they are important for elucidating future research and implementation efforts. Another limitation is that this survey was conducted in 2017, and our findings may not fully and accurately depict the current beliefs held by practicing physicians.
This study reports the results of a national survey of physicians who treat low-risk PTC based on an era when data, protocols, and guidelines regarding this approach were not yet mature. In this context, physicians’ beliefs about the potential benefits, harms, and barriers to and facilitators of this approach are important for exploring ongoing research strategies as well as supporting protocol and guideline development. While the survey demonstrated general support for the idea of active surveillance, it also highlighted physicians’ reluctance about the approach, which needs to be addressed with more robust evidence, as well as guideline and protocol development before more widespread adoption of this approach in eligible, appropriately selected patients can occur.
Supplementary Material
Acknowledgments
This study was supported in part by the Memorial Sloan Kettering Cancer Center Support Grant P30 CA008748 from the National Institutes of Health/National Cancer Institute (Drs Roman, Lohia, and Tuttle). The support for this research also included the University of Wisconsin Carbone Cancer Center Support Grant P30 CA014520 and the National Cancer Institute of the National Institutes of Health (NIH) award number K08CA230204. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. In addition, NIH did not play a role in the design or conduct of the study; data collection, management, analysis, or interpretation; manuscript preparation, review, or approval; and decision to submit the manuscript for publication. We would like to acknowledge Margarete Wichman, PhD, and Kelly M. Elver, PhD, from the University of Wisconsin Survey Center for their assistance with survey preparation and critical review.
Abbreviations:
- AHNS
American Head and Neck Society
- ATA
American Thyroid Association
- PTC
papillary thyroid cancer
Footnotes
Disclosure
The authors have no multiplicity of interest to disclose.
References
- 1.Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1–e33. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid. 2003;13(4): 381–387. [DOI] [PubMed] [Google Scholar]
- 3.Ito Y, Miyauchi A, Inoue H, et al. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World J Surg. 2010;34(1):28–35. [DOI] [PubMed] [Google Scholar]
- 4.Sugitani I, Toda K, Yamada K, Yamamoto N, Ikenaga M, Fujimoto Y. Three distinctly different kinds of papillary thyroid microcarcinoma should be recognized: our treatment strategies and outcomes. World J Surg. 2010;34(6): 1222–1231. [DOI] [PubMed] [Google Scholar]
- 5.Ito Y, Miyauchi A, Kihara M, Higashiyama T, Kobayashi K, Miya A. Patient age is significantly related to the progression of papillary microcarcinoma of the thyroid under observation. Thyroid. 2014;24(1):27–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Miyauchi A. Clinical trials of active surveillance of papillary microcarcinoma of the thyroid. World J Surg. 2016;40(3):516–522. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kwon H, Oh HS, Kim M, et al. Active surveillance for patients with papillary thyroid microcarcinoma: a single center’s experience in Korea. J Clin Endocrinol Metab. 2017;102(6):1917–1925. [DOI] [PubMed] [Google Scholar]
- 8.Ito Y, Miyauchi A, Oda H. Low-risk papillary microcarcinoma of the thyroid: a review of active surveillance trials. Eur J Surg Oncol. 2018;44(3): 307–315. [DOI] [PubMed] [Google Scholar]
- 9.Tuttle RM, Fagin JA, Minkowitz G, et al. Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol Head Neck Surgery. 2017;143(10):1015–1020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Molinaro E, Campopiano MC, Pieruzzi L, et al. Active surveillance in papillary thyroid microcarcinomas is feasible and safe: experience at a single Italian center. J Clin Endocrinol Metab. 2020;105(3):e172–e180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Dillman DA, Smyth JD, Christian LM. Internet, Phone, Mail, and Mixed-Mode Surveys: The Tailored Design Method. 4th ed. Wiley; 2014. [Google Scholar]
- 12.Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15): 1458–1465. [DOI] [PubMed] [Google Scholar]
- 13.Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Fowler FJ Jr, Collins MM, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. JAMA. 2000;283(24): 3217–3222. [DOI] [PubMed] [Google Scholar]
- 15.Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288. [DOI] [PubMed] [Google Scholar]
- 16.Miyauchi A, Ito Y, Oda H. Insights into the management of papillary microcarcinoma of the thyroid. Thyroid. 2018;28(1):23–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Miyauchi A, Kudo T, Ito Y, et al. Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance. Surgery. 2018;163(1):48–52. [DOI] [PubMed] [Google Scholar]
- 18.Bresner L, Banach R, Rodin G, Thabane L, Ezzat S, Sawka AM. Cancer-related worry in Canadian thyroid cancer survivors. J Clin Endocrinol Metab. 2015;100(3):977–985. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Davies L, Roman BR, Fukushima M, Ito Y, Miyauchi A. Patient experience of thyroid cancer active surveillance in Japan. JAMA Otolaryngol Head Neck Surg. 2019;145(4):363–370. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sawka AM, Tsang RW, Brierley JD, et al. Concerns of low-risk thyroid cancer survivors. Acta Oncol. 2016;55(9–10):1252–1253. [DOI] [PubMed] [Google Scholar]
- 21.Yoshida Y, Horiuchi K, Okamoto T. Patients’ view on the management of papillary thyroid microcarcinoma: active surveillance or surgery. Thyroid. 2020;30(5):681–687. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Jeon MJ, Lee Y-M, Sung T-Y, et al. Quality of life in patients with papillary thyroid microcarcinoma managed by active surveillance or lobectomy: a cross-sectional study. Thyroid. 2019;29(7):956–962. [DOI] [PubMed] [Google Scholar]
- 23.Bellardita L, Valdagni R, van den Bergh R, et al. How does active surveillance for prostate cancer affect quality of life? a systematic review. Eur Urol. 2015;67(4): 637–645. [DOI] [PubMed] [Google Scholar]
- 24.Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375(15):1425–1437. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Pitt SC, Lee CN. Medical decision-making research in surgery. In: Dimick JB, Lubitz CC, eds. Success in Academic Surgery: Health Services Research. 2nd ed. Springer; 2020. [Google Scholar]
- 26.Stack BC Jr, Angelos P. The ethics of disclosure and counseling of patients with thyroid cancer. JAMA Otolaryngol Head Neck Surg. 2015;141(11):957–958. [DOI] [PubMed] [Google Scholar]
- 27.Stack BC Jr, Angelos P. Ethical considerations when counseling patients with thyroid cancer about surgery vs observation—reply. JAMA Otolaryngol Head Neck Surg. 2016;142(4):407–408. [DOI] [PubMed] [Google Scholar]
- 28.Morris LGT, Wong RJ, Tuttle RM. Ethical considerations when counseling patients with thyroid cancer about surgery vs observation. JAMA Otolaryngol Head Neck Surg. 2016;142(4):406–407. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.