A clinical framework to facilitate selection of patients with differentiated thyroid cancer for active surveillance or less aggressive initial surgical management

ABSTRACT

Introduction: In the past, total thyroidectomy was usually recommended as the initial therapeutic approach in all but the lowest risk differentiated thyroid cancers. Today, many patients with low risk papillary thyroid cancers may be candidates for either an observational management approach (active surveillance/deferred surgical intervention) or a minimalist surgical approach (thyroid lobectomy/isthmusectomy).

Areas covered: After a comprehensive review of the PubMed database and based on our clinical experience, we describe a clinical framework that integrates important factors in three major inter-related domains (pre-operative imaging/clinical findings, medical team characteristics, and patient characteristics) to classify a patient as either ideal, appropriate or inappropriate for conservative treatment options. As part of this clinical framework, we examine how the medical decision making construct (minimalist versus maximalist) of the patient and clinician can impact selection of initial therapy.

Expert commentary: The dramatic rise in the incidence of very low risk differentiated thyroid cancer demands a re-evaluation of the appropriate use of more minimalistic treatment options. The selection of appropriate patients for less aggressive initial treatment options requires thoughtful, open discussions that can be aided by clinical decision making frameworks that recognize and value the medical decision making process of clinicians and patients.

KEYWORDS:

• Active surveillance
• thyroid lobectomy
• thyroid cancer
• deferred intervention
• total thyroidectomy
• low risk thyroid cancer

Acknowledgments

The authors thank Drs Richard Wong, James Fagin, Mona Sabra and Sana Ghaznavi for their critical review of the manuscript and insightful comments.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This research was funded in part by the NIH/NCI Cancer Center Support Grant P30 CA008748 (Craig Thompson, PI), the Specialized Program of Research Excellent (SPORE) in Thyroid Cancer Grant P50 CA172012-01A1 (James Fagin, PI), and Grant 81402209 from the National Natural Science Foundation of China.