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Barriers and motivations for doctors to use active surveillance in patients with thyroid cancer

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Surgery is the usual recommendation for treatment of thyroid cancer. However, there is evidence that patients with small, low-risk thyroid cancers may not need surgery if they can be followed with ultrasound monitoring. This option is called active surveillance. Doctors in Japan first studied how these low-risk thyroid cancers tend to stay the same size and not to spread after being followed for many years. Then, doctors in many other countries, including the United States, were able to show similar results when following their patients over several years without surgery. Active surveillance was introduced into the American Thyroid Association guidelines for the treatment of thyroid cancer in 2015, but many doctors who treat patients with thyroid cancer have not yet started to use it. The purpose of this study was to find out what motivates or prevents thyroid cancer doctors to use active surveillance.

Jensen CB et al 2021 Active surveillance for thyroid cancer: A qualitative study of barriers and facilitators to implementation. BMC Cancer 21:471. PMID: 33910527.

Doctors who treat thyroid cancer were selected for interview at a meeting of the American Thyroid Association. The study coordinators picked 12 endocrinologists and 12 surgeons for the study. The doctors were asked their opinions about several possible patient scenarios and asked questions about the guidelines for active surveillance, any thoughts or concerns they have about active surveillance, and how they use active surveillance with their own patients.

After the interviews, the researchers then analyzed and grouped together factors that might have been motivations to using active surveillance and factors that might have been barriers. They found that many doctors were worried that they would feel guilty if a bad outcome occurred, that a patient might get lost to follow-up, or that other doctors might not refer patients to them if they learned that this thyroid cancer specialist uses active surveillance with their patients. Other doctors were concerned that the evidence behind the guidelines did not have enough data from the United States or that the guidelines were not clear enough on how active surveillance should be done safely. In addition to these barriers to active surveillance, the doctors also identified some motivations to use active surveillance with their patients. They would be able to make a shared decision with their patients about active surveillance, the process could be done in a multidisciplinary approach— meaning that doctors from different specialties would work together, and that this would be good for patients who have a fear of the risks of surgery.

This study shows that there were many factors that either motivated or were barriers to thyroid cancer doctors in adding active surveillance to their practice. This study is important for patients because it shows that discussing the options for treatment of small, low-risk thyroid cancer with their doctors is crucial to making a decision that is best for both the doctor and the patient.

—Dana Larsen, MD and Maria Brito, MD


Active surveillance: the term for avoiding surgery for small thyroid cancers by monitoring them over time with ultrasound and physical exam

Thyroidectomy: surgery to remove the entire thyroid gland. When the entire thyroid is removed it is termed a total thyroidectomy. When less is removed, such as in removal of a lobe, it is termed a partial thyroidectomy.

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