Abstract
This survey study assesses physicians’ recommendations regarding overdiagnosis and overtreatment of thyroid nodules and low-risk papillary thyroid cancer.
Introduction
Overdiagnosis and overtreatment of low-risk thyroid cancer are important problems.1 American Thyroid Association (ATA) guidelines indicate that thyroid nodules less than 1 cm should not be biopsied, nodules 1 cm to 1.5 cm should be biopsied only when features concerning for a malignant tumor exist, and papillary thyroid cancer (PTC) nodules 1 cm or less should be managed with active surveillance or lobectomy.2 Biopsy and treatment with total thyroidectomy or radioactive iodine (RAI) outside these recommendations have been associated with overdiagnosis and overtreatment, respectively. Because physician-level factors associated with overdiagnosis and overtreatment of thyroid cancer are poorly understood, we conducted a national survey examining physicians’ recommendations for thyroid nodules and low-risk PTC.
Methods
In this survey study, surveys were mailed to 1500 endocrinologists, general surgeons, and otolaryngologists (500 each) randomly selected from the American Medical Association Physician Masterfile in August 2018. Survey development and administration were previously described (eAppendix in the Supplement).3 Respondents who were actively practicing, had treated thyroid cancer since 2015 (ATA guidelines publication date), and had responded to questions about overdiagnosis (biopsy outside ATA guideline for nodules <1 cm with suspicious features or nodules <1.5 cm without suspicious features) and overtreatment (total or completion thyroidectomy, central neck dissection, and/or RAI for 1 low-risk PTC <1 cm) were included. Responses were calculated using the AAPOR guideline (response rate 2), in which all nonresponders are considered eligible. Questions considered demographics, guideline use, and management of thyroid nodules and cancer. Statistical analysis included Fisher exact, Wilcoxon rank sum, and t tests as appropriate (2-sided P < .05 was significant). The University of Wisconsin institutional review board deemed the study exempt because use of surveys involved minimal risk to participants. Survey participation was voluntary, and survey completion indicated consent; responses were deidentified. R statistical software, version x.y.z., was used. Data were analyzed from December 2019 to August 2020.
Results
Of 1500 individuals sent surveys, 487 (32.5%) responded; 439 were eligible for analysis (Table 1). Respondents’ demographics were similar to those of Association of American Medical Colleges active physicians in each specialty. Nonrespondents were demographically similar to respondents but more likely to be female.3
Table 1. Survey Respondent Characteristics by Diagnostic Preferences.
| Characteristic | Respondentsa | P value | ||
|---|---|---|---|---|
| Overdiagnosis (n = 280)b | Appropriate care (n = 159) | Total (N = 439) | ||
| Age, mean (SD), y | 53.0 (9.1) | 54.4 (8.9) | 53.5 (9.1) | .12 |
| Gender | ||||
| Female | 56 (20.4) | 36 (23.2) | 92 (21.5) | .64 |
| Male | 217 (79.2) | 118 (76.1) | 335 (78.1) | |
| Other | 1 (0.4) | 1 (0.6) | 2 (0.5) | |
| Race and ethnicityc | ||||
| American Indian/Alaskan Native | 0 | 0 | 0 | .27 |
| Asian | 40 (14.7) | 18 (12.2) | 58 (13.8) | |
| Black | 4 (1.5) | 2 (1.4) | 6 (1.4) | |
| Hispanic/Latino | 9 (3.3) | 5 (3.4) | 14 (3.3) | |
| White | 211 (77.3) | 111 (75.0) | 322 (76.5) | |
| Otherd | 8 (2.9) | 8 (5.4) | 16 (3.8) | |
| >1 Race or ethnicity | 1 (0.4) | 4 (2.7) | 5 (1.2) | |
| Time in practice, mean (SD), y | 20.1 (9.1) | 21.5 (9.0) | 20.6 (9.1) | .13 |
| Time since training, y | ||||
| 0 to <5 | 12 (4.4) | 6 (3.8) | 18 (4.2) | .16 |
| 5 to <10 | 45 (16.4) | 21 (13.5) | 66 (15.3) | |
| 10 to <20 | 90 (32.8) | 39 (25.0) | 129 (27.9) | |
| ≥20 | 127 (46.4) | 90 (57.7) | 217 (50.4) | |
| Specialty | ||||
| Endocrinology | 93 (33.2) | 46 (28.9) | 139 (31.7) | .26 |
| General surgery | 65 (23.2) | 48 (30.1) | 113 (25.7) | |
| Otolaryngology | 122 (43.6) | 65 (40.9) | 187 (42.6) | |
| Location | ||||
| Northeast | 53 (19.8) | 36 (23.8) | 89 (21.2) | .21 |
| Midwest | 66 (24.6) | 47 (31.1) | 113 (27.0) | |
| South | 101 (37.7) | 48 (31.8) | 149 (35.6) | |
| West | 48 (17.9) | 20 (13.3) | 68 (16.2) | |
| Practice setting | ||||
| Academic tertiary hospital | 38 (13.7) | 24 (15.4) | 62 (14.3) | .46 |
| Academic-affiliated hospital | 32 (11.6) | 11 (7.1) | 43 (9.9) | |
| Community | 57 (20.6) | 36 (23.1) | 93 (21.5) | |
| Private practice | 144 (52.0) | 79 (50.6) | 223 (51.5) | |
| Other | 6 (2.2) | 6 (3.8) | 12 (2.8) | |
| Access to tumor board to discuss patient management | ||||
| Yes | 202 (72.7) | 109 (69.9) | 311 (71.7) | .17 |
| No | 71 (25.5) | 47 (30.1) | 118 (27.2) | |
| Not applicable | 5 (1.8) | 0 | 5 (1.2) | |
| Uses 2015 ATA guidelines | ||||
| Yes | 223 (86.4) | 119 (82.1) | 342 (84.9) | .25 |
| No | 35 (13.6) | 26 (17.9) | 61 (15.1) | |
| Primarily responsible for deciding whether a thyroid nodule needs FNA | ||||
| Myself | 224 (80.0) | 128 (80.5) | 352 (80.2) | >.99 |
| Other | 56 (20.0) | 31 (19.5) | 87 (19.8) | |
| Primarily performs FNA for patients with thyroid nodules | ||||
| Myself | 100 (35.7) | 62 (39.0) | 352 (36.9) | .54 |
| Other | 180 (64.3) | 97 (61.0) | 87 (63.1) | |
Abbreviations: ATA, American Thyroid Association; FNA, fine-needle aspiration.
Data are reported as number (percentage) of respondents unless otherwise indicated. Totals in each category may not sum to column total because some respondents omitted responses to survey questions in that category.
Defined as recommending fine-needle biopsy for patients outside the 2015 ATA guidelines for nodules less than 1 cm with features concerning for papillary thyroid cancer or nodules less than 1.5 cm without concerning features.
Race and ethnicity were self-reported.
Other includes Arab American, Indian American, Indian subcontinent, multiracial (identifying as 50% Asian and 50% White), and Pakistani.
Overdiagnosis was recommended by 280 respondents (64.0%). No significant demographic, specialty, or regional differences existed between respondents recommending overdiagnosis vs appropriate care (Table 1). Regarding low-risk PTC treatment, 178 (42.5%), 265 (63.3%), and 263 (63.7%) respondents believed total thyroidectomy, total thyroidectomy with central neck dissection, and RAI, respectively, were overused (Table 2). Beliefs regarding overuse did not vary significantly based on propensity for overdiagnosis.
Table 2. Respondents’ Beliefs About, Recommendations for, and Factors Influencing Treatment for Low-Risk Thyroid Cancer.
| Respondents, No. (%) | P value | |||
|---|---|---|---|---|
| Overdiagnosis (n = 280)a | Appropriate care (n = 159)a | Total (N = 439)a | ||
| Beliefs | ||||
| Total thyroidectomy | ||||
| Overused | 104 (39.0) | 74 (48.7) | 178 (42.5) | .15 |
| Appropriately used | 156 (58.4) | 75 (49.3) | 231 (55.1) | |
| Underused | 7 (2.6) | 3 (2.0) | 10 (2.4) | |
| Total thyroidectomy with central neck dissection | ||||
| Overused | 159 (60.0) | 106 (68.8) | 265 (63.3) | .18 |
| Appropriately used | 89 (33.6) | 42 (27.3) | 131 (31.3) | |
| Underused | 17 (6.4) | 6 (3.9) | 23 (5.5) | |
| Radioactive iodine | ||||
| Overused | 166 (63.4) | 97 (64.2) | 263 (63.7) | >.99 |
| Appropriately used | 91 (34.7) | 52 (34.4) | 143 (34.6) | |
| Underused | 5 (1.9) | 2 (1.3) | 7 (1.7) | |
| Recommends overtreatmentb | ||||
| Yes | 119 (43.0) | 56 (35.4) | 175 (40.2) | .004 |
| No | 158 (57.0) | 102 (64.6) | 260 (59.8) | |
| Factors influencing decision to recommend a particular treatment | ||||
| Risk of complications | ||||
| A great deal/quite a bit | 127 (46.2) | 68 (43.9) | 195 (45.4) | .09 |
| Some | 104 (37.8) | 49 (31.6) | 153 (35.6) | |
| A little/none | 44 (16.0) | 38 (24.5) | 82 (19.1) | |
| Peace of mind from more extensive surgery | ||||
| A great deal/quite a bit | 76 (27.8) | 33 (21.2) | 109 (25.4) | .03 |
| Some | 97 (35.5) | 45 (28.8) | 142 (33.1) | |
| A little/none | 100 (36.6) | 78 (50.0) | 178 (41.5) | |
| Concern about doing less-extensive surgery | ||||
| A great deal/quite a bit | 77 (28.3) | 28 (18.2) | 105 (24.7) | .06 |
| Some | 120 (44.1) | 75 (48.7) | 195 (45.8) | |
| A little/none | 75 (27.6) | 51 (33.1) | 105 (24.7) | |
| Need for life-long thyroid hormone replacement | ||||
| A great deal/quite a bit | 65 (24.0) | 30 (19.2) | 95 (22.3) | .51 |
| Some | 98 (36.2) | 61 (39.1) | 159 (37.2) | |
| A little/none | 108 (39.9) | 65 (41.7) | 173 (40.5) | |
| Risk of cancer recurrence | ||||
| A great deal/quite a bit | 165 (60.0) | 97 (62.2) | 262 (60.8) | .16 |
| Some | 79 (28.7) | 34 (21.8) | 113 (26.2) | |
| A little/none | 31 (11.3) | 25 (16.0) | 56 (13.0) | |
| Ease of follow-up | ||||
| A great deal/quite a bit | 121 (45.0) | 55 (35.5) | 176 (41.5) | .14 |
| Some | 84 (31.2) | 60 (38.7) | 144 (34.0) | |
| A little/none | 64 (23.8) | 40 (25.8) | 104 (24.5) | |
| Patient reliability to follow-up | ||||
| A great deal/quite a bit | 134 (50.0) | 75 (48.1) | 209 (49.3) | .87 |
| Some | 86 (32.1) | 50 (32.1) | 136 (32.1) | |
| A little/none | 108 (39.9) | 65 (41.7) | 173 (40.5) | |
| Ability to follow thyroglobulin when recommending a completion thyroidectomy | ||||
| A great deal/quite a bit | 134 (63.8) | 48 (45.3) | 182 (57.6) | .002 |
| Some | 76 (36.2) | 58 (54.7) | 134 (42.4) | |
| A little/none | 0 | 0 | 0 | |
Totals in each category may not sum to column total because some respondents omitted responses to survey questions in that category.
Defined as recommending total thyroidectomy with or without central neck dissection for a 0.8-cm papillary thyroid cancer and/or completion thyroidectomy or radioactive iodine for patient with a solitary low-risk papillary thyroid cancer.
Overtreatment was recommended by 175 respondents (40.2%) (Table 2). Respondents who favored overdiagnosis were more likely to recommend overtreatment of low-risk PTC surgically or with RAI (119 [43.0%] vs 56 [35.4%]; P = .004) and to be influenced by peace of mind from more extensive surgery (173 of 273 [63.4%] vs 78 of 156 [50.0%]; P = .03).
Discussion
A total of 64.0% of respondents recommended overdiagnosis of small thyroid nodules. Physicians favoring overdiagnosis were more likely to recommend overtreatment of low-risk PTC with surgery or RAI, although not consistently across scenarios. Physicians favoring overdiagnosis also indicated that peace of mind from more extensive surgery influenced their recommendations. Need for diagnostic certainty and fear of missing a diagnosis have been associated with overdiagnosis and overtreatment in other contexts.4,5 Although our study may be limited by nonresponse bias, we found no differences between early and late respondents and between respondents and nonrespondents. Our study did not include primary care physicians, who may also influence the decision to pursue thyroid nodule biopsy. Successful implementation of guidelines, which can take 17 years, requires dissemination, education, and decision guides.6 Future research may provide insight into improving adherence to ATA guidelines.
Reducing overdiagnosis may be an important strategy for reducing overtreatment. However, because not all physicians who favored overdiagnosis recommended overtreating low-risk PTC, additional strategies are necessary to reduce overtreatment.
eAppendix. National Study of Providers’ Practices for Thyroid Cancer
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Associated Data
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Supplementary Materials
eAppendix. National Study of Providers’ Practices for Thyroid Cancer