BACKGROUND
Medullary thyroid cancer (MTC) is a rare form of thyroid cancer with a worse prognosis compared to the more common papillary thyroid cancer. MTC arises from the C-cells in the thyroid. Surgery is the main treatment since radioactive iodine is not effective for MTC as the C-cells do not take up iodine. More recently, targeted molecular therapy has been approved for advanced MTC cancer.

The American Thyroid Association (ATA) published the first set of guidelines to standardize MTC management in 2009; revised guidelines were then released in 2015. The goal of this study was to evaluate national adherence to the ATA guidelines for MTC, identify factors that can affect adherence, and assess whether guideline adherence affects patient survival.

THE FULL ARTICLE TITLE
McMullin JL et al. Improved adherence to ATA medullary thyroid cancer treatment guidelines. Ann Surg Oncol 2023;30(12):7165-7171; doi: 10.1245/s10434-022- 12734-3. PMID: 36367629.

SUMMARY OF THE STUDY
The study included all MTC patients enrolled in the National Cancer Database (NCDB) between 2004 to 2015, with emphasis on data collected after 2009, when the initial ATA guidelines for MTC were released. The NCDB, which is jointly maintained by the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society, represents a comprehensive cancer database including data from patients followed at more than 1500 accredited cancer programs. More than 1 million cancer cases are added annually, which represent 70% of all newly diagnosed cancers in the US. Data used for this study included patient characteristics, demographics, socioeconomic status, and co-morbidities in addition to cancer-specific information, staging of the cancer, presence of invasion outside the thyroid and treatment type (thyroidectomy with/without central and lateral neck dissection). The primary study outcome was whether the use and extent of surgery were consistent with the 2009 ATA guidelines. Survival analysis was performed to assess the overall survival rates of patients who received treatment according to the guidelines in comparison to treatment that differed form guidelines.

The study included 3421 patients treated for MTC in 843 hospitals from 2009 to 2015. A total of 427 patients had spread of cancer outside of the neck (advanced cancer), while the rest had cancer limited to the neck region (low risk cancer). Among the 2994 patients with low risk cancer, 86% underwent total thyroidectomy and 68% lymph node dissection, as recommended by the ATA guidelines. In patients with advanced cancer, 51% underwent thyroid surgery and 54% lymph node dissection. Overall, 72% of patients received treatment according to the ATA guidelines. A small percentage of patients received treatment not recommended by the guidelines, such as chemotherapy (5.8%) and radioactive iodine therapy (2.3%).

A progressive increase in guideline adherence was noted over time, with an adherence rate of 67% before 2009 and 74% after 2009. Factors associated with non-adherence to guidelines included treatment at non-academic facilities, living within 50 miles to treatment facility, female gender, and older age. Adherence to treatment guidelines improved overall patient survival.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study shows a positive impact of the ATA guidelines for MTC management published in 2009, which resulted in improved adherence to treatment recommendations and overall patient survival. Thus, using standardized evidence-based treatment is critical for the best outcomes in patients with MTC. The identification of factors that can affect guideline adherence, such as patient characteristics and treatment location is important for finding interventions to address these barriers. Additional research is needed to further increase adherence to the ATA guidelines and improve the quality of care for MTC patients.

— Alina Gavrila, MD, MMSC

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