BACKGROUND
There has been an increase in thyroid cancer diagnosis in the last 30 years without an increase in thyroid cancerrelated deaths. This is believed to be due to detection of very small papillary thyroid cancers that are unlikely to grow or cause harm. Traditional treatment for thyroid cancer is surgery to remove the thyroid gland completely or partially. Surgery is sometimes followed with radioactive iodine therapy. Side effects with these treatments are small but present.

On the other hand, there is new information that most of the small papillary thyroid cancers may be growing so slowly that patients may live out their life without having any symptoms due to the thyroid cancer. Active surveillance (close observation without surgery) may be a good alternative to surgery for these patients and there are multiple ongoing studies investigating the safety of this option. Since this is a relatively new approach, authors designed this study to answer 2 main questions: 1) if it is offered as an alternative, how often do patients choose active surveillance over surgery and 2) what are the reasons for their choices.

THE FULL ARTICLE TITLE
Sawka AM et al 2020 A prospective mixed-methods study of decision-making on surgery or active surveillance for low-risk papillary thyroid cancer. Thyroid. Epub 2020 Apr 8. PMID: 32126932.

SUMMARY OF THE STUDY
The patients were recruited from thyroid cancer specialty clinics at the University Health Network in Toronto. The study is still ongoing and the results from the first 100 patients were analyzed and reported. Patients were 18 years or older with low risk papillary thyroid cancers <2 cm. Only the patients without evidence of spread of the cancer outside of thyroid were included in the study. Patients were given detailed information about prognosis and options of surgery (standard of care) or active surveillance (alternative as part of the study).

Clinical information was obtained from medical records review. Characteristics of patients (such as age, gender etc) and level of confidence in making an informed management decision were assessed by questionnaires. Level of satisfaction with the decision was determined using a scale. As the last step patients were asked “what is the main reason why you decided to have surgery or active surveillance (no surgery) for your thyroid cancer?”

The average age was 52 years, and ~75% of participants were female, married and had an undergraduate college degree or higher. Active surveillance was the choice of 71% of patients. These patients were older and more likely had very small (<1cm) papillary thyroid cancers. Patients were satisfied and confident in the ability to make the decision.

Opportunity to be involved in the treatment choice and to receive medical information were important in their decision for both groups. In the active surveillance group concerns were worry about surgical risk, possibility of taking thyroid medications, and potential impact on quality of life. Patients who chose surgery had concerns about anxiety from having cancer and not curing it.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
In this study, the majority of patients with small, low risk papillary thyroid cancers preferred active surveillance over surgery if given the option. They valued receiving medical information and participating in the final decision. Personal perceptions about cancer or surgery, family considerations and trust in their healthcare team were important in making the treatment decision.

As we find more than one good management option based on evidence, it is important for the patients to receive and understand the information about their condition and to share their values and preferences with their physician to make the best possible treatment decisions

— Ebru Sulanc, MD

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