American Thyroid Association 88th Annual Meeting:

Matching Expectations and Guidelines to Treatment-Worthy Thyroid Cancers

With E. Michael Tuttle, MD

The American Thyroid Association (ATA) bestowed E. Michael Tuttle, MD, professor and clinical director of the endocrine service, at Memorial Sloan Kettering Cancer Center in New York City, with the 2018 Lewis Braverman Distinguished Lectureship Award during the ATA 88th Annual Meeting in Washington, DC.

It is time to challenge the status quo with regard to thyroid tumor management; in particular, Dr. Tuttle focused on the use of current terminology to make a case for change in screening for and treating the vast majority of small thyroid nodules.1

Time to Reevaluate the Drive Toward More Sensitive Thyroid Cancer Detection  

To dramatize the point, Dr. Tuttle used papillary thyroid cancer as an example: How might patients with thyroid disease be so doing well with such different approaches to treatment—a surgeon’s minimalist approach, total thyroidectomy, nuclear medicine, active surveillance, or not doing anything?1

“Today, we must consider minimal disease detection and whether or not it’s critical to find every little ‘spot' that might suggest thyroid cancer both in the primary setting and as recurring disease,” Dr. Tuttle said.

“It behooves us to define actionable versus non-actionable findings,” Dr. Tuttle told EndocrineWeb. “You’ll notice, I didn’t say actionable disease or inactionable disease because I’m not even convinced some [findings] are disease, which is a powerful word.”

“Consider, when you tell a patient she has a thyroid tumor that doesn’t need treatment or you say he has inactionable disease, when what we are really saying that there is no cause for concern, then that is a hard concept for patients to understand,” he said. “But if you say, ‘you have inactionable findings,’ then that allows you to decide whether or not there is malignant disease, whether or not the findings dictate a need for treatment, and whether or not the finding is a nonspecific or benign result.”

The issue comes down to differentiating diagnostic results that warrant treatment from that which doesn’t, specifically when communicating with patients. In fact, it is the syntax used in communicating findings that merit reconsideration, Dr. Tuttle said, in emphasizing the distraction that occurs when a clinician presents the report as “detectable disease rather than actionable findings.’

Given the evidence of overtreatment of thyroid nodules, there is both an urgency and necessity to avoid terminology that may mean one thing to the clinician and a completely different interpretation by the patient.1

“Reporting disease when in actually the circumstance doesn’t warrant raising unnecessary concern with the patient, requires a change in practice,” he said.

Set Responsible Diagnostic Goals Limited to Actionable Findings 

In reassessing treatment strategies, we must ask: Are fine needle aspiration biopsy (FNA) and immediate surgery really necessary for very low-risk thyroid cancer? Is total thyroidectomy the best and only option for moderate thyroid cancers? Is radioactive iodine (RAI) required for immediate risk thyroid cancer?

There are important clinical implications for each treatment path, which begins with a diagnostic plan that should aim to identify only “actionable findings,” said Dr. Tuttle, “in order to be able to recommend in favor of intervention only for actionable results and to recommend against treatment in cases of nonactionable findings.”

In defense of this position, Dr. Tuttle offered the following recommendations in support:1

  • Current guidelines (2015) recognize early diagnosis and immediate treatment for certain clinical findings is not the best management approach.2,3
  • No fine needle aspiration biopsy for thyroid nodules: (< 5 mm);2 (< 10 mm)3
  • Active surveillance for Intrathyroidal papillary microcarcinomas and small volume central lymph node metastasis
  • Biochemically incomplete results (eg, stable/declining abnormal Tg or Tg antibodies)
  • Distant metastasis (eg, asymptomatic, stable, or slow growing)

While there has been a move toward active surveillance, even this is not necessary in many cases because detectable findings are quite different from those requiring a therapeutic response.2,3

Highly sensitive screening tools find many more non-actionable "spots", than disease necessitating treatment. Figure: EM Tuttle.

This clinical opportunity is lost when a patient is told: “your disease is benign,” since as soon as the concept of “disease” is mentioned, the takeaway is that there is thyroid cancer, and the patient often will demand treatment when often no intervention is warranted, said Dr. Tuttle.

“In effect, whenever any of the following small volume disease is observed (albeit it in certain clinical circumstances) including: subcentimeter, intrathyroidal persistent small volume, cervical lymph node metastasis, stable or declining abnormal tumor markers, stable or slowing growing distant metastases,” said Dr. Tuttle, “ask the following questions:1

  • Is observational management a viable alternative to immediate treatment in patients with small volume disease?
  •  Will clinician and patient endorse observation as viable management options for small volume disease?
  • If immediate intervention for small volume disease is not mandatory, what would the indications be for intervention?”

When Diagnostic Results Raise Avoidable Patient Concerns    

 “Clinicians will want to consider if there is sufficient benefit in widely adopting increasingly sensitive diagnostic tools that uncover ‘spots’. In this age of detection any finding has the propensity to induce an automatic reaction for more aggressive treatment: more thyroid surgeries, neck dissections as primary therapy and recurrent disease, prophylactic next dissections for occult disease, repeated dosing of RAI, early initiation of systemic therapy,” he said. “As such, guidelines must evolve to indicate when it is acceptable to NOT to do something.”   

In the age of reason, there are four factors that ought to be used in evaluating whether findings are actionable or not:1

  • Tumor size in volume
  • Tumor growth rate (doubling time)
  • Location
  • Patient preference

“It is time for a change both in language and diagnostic approach,” he said. “We need to place a greater reliance on volume change and location [of nodules] so that the treatment helps more than harms, and detection doesn’t automatically imply treatment. The question to ask, according to Dr. Tuttle is, ”if it grows and by how much, will it create a problem?’”

In speaking with patients, it is critical that we adopt more effective and appropriate terminology that more accurately reflects the disease status for non-actionable findings versus cancer.1 “Stronger consideration as to when a nodule can be left alone, rather than labeling people with cancer that don’t actually have treatment worthy disease,” he said. And follow through by refining guidelines to provide a better foundation to reflect these distinctions as well as to assist in managing patients who arrive with preferences based on “Dr. Google,” Dr. Tuttle said

“My hope, as we move forward, is that clinicians will focus our detection tools on actionable findings that necessitate treatment, while trying to minimize detecting, diagnosing, and treating findings that are, for all intents and purposes, inactionable findings,” he said. “This approach will move us toward a conversation that recognizes the limits and advantages of our modern technology so we can focus on identifying findings that truly do not need to be treated and in many cases, do not even need to be diagnosed,” Dr. Tuttle told EndocrineWeb.

“In effect, terminology is critically important in patient care, so I propose that we consider that certain types of actionable disease that we should act on but there are also other non-actionable findings that won’t require either a diagnosis or treatment,”1 he said.

In concluding, Dr. Tuttle urged practitioners to learn from our past. In the  presentation address at the 1998 American Association of Endocrine Surgeons,4 Blake Cady, MD, said, “Our background in medical school and surgical training drives us to strive for perfection; this laudable goal, however, should be accompanied by our understanding that perfectionism is the enemy of good, and that, in particular, attempted perfection for a few individuals may well be the enemy of good for the entire group. 

The routine application of excessive measures to save possibly one life of 100 may jeopardize the health, comfort, lifestyle, and sanity of the other 99.”4

Next Summary:
Thyroid Surgeries Avoidable with Comprehensive Ultrasound Protocol
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