Wednesday, November 4, 2015

New Thyroid Cancer Guidelines Reflect Altered Treatment Landscape

By Miriam Falco
on Monday, November 2, 2015

Newly released thyroid cancer treatment recommendations from the American Thyroid Association (ATA) suggest that monitoring an early-stage papillary thyroid tumor — instead of removing it — can be a very reasonable option.

For nodules or tumors smaller than one centimeter that appear to be confined to the thyroid gland, the new guidelines say, patients may be able to avoid immediate surgery and instead have the tumor observed to see if it grows.

This suggestion is one notable aspect of the ATA guidelines, published in October, which consist of treatment recommendations that address screening, staging, risk assessment, and surgical approaches for thyroid cancer.

“The new guidelines are all about risk stratification and are completely removing one-size-fits-all treatment recommendations,” says Memorial Sloan Kettering endocrinologist Michael Tuttle, who has been actively involved in shaping these guidelines. “Now treatment will be individualized for high- and low-risk patients.”

In many cases, the new recommendations reflect a prevailing sentiment among thyroid cancer experts that less extensive treatment often produces the best outcomes for patients because most very small thyroid cancers grow quite slowly and never pose a threat.

In fact, the ATA guidelines advise that growths smaller than one centimeter that do not need treatment should not even be biopsied. And in cases in which surgery is required, the guidelines say that partial removal of the thyroid (lobectomy) should be considered instead of always performing a total thyroidectomy.

Richard Wong, Chief of MSK’s Head and Neck Service, says the guidelines will help prevent unnecessary ultrasounds and needle biopsies and will help reduce the “overdiagnosis of a condition in which the treatment could be more problematic than the underlying disease.”

Overdiagnosis and Overtreatment

Thyroid cancer has been on the rise in the United States over the last several decades, more than doubling between 1973 and 2002. The detection of small thyroid cancers especially increased with the introduction of ultrasounds into routine practice in the 1990’s. Since that time, it has become clear that most of these very small thyroid cancers grow slowly and never pose a threat.

As a result, physicians at MSK and elsewhere have come to recognize that a large number of patients were being biopsied or treated unnecessarily. The new ATA guidelines will help patients and physicians figure out when to intervene and when to take a more conservative approach.

The guidelines recommend practices that in most cases are already followed at MSK. For example, the watchful waiting technique — also known as “active surveillance”— used with early-stage papillary thyroid tumors is already part of MSK’s approach. The new ATA guidelines are significant because they “formally endorse observation” as a possible treatment option, Dr. Tuttle says.
 “If at some point we decide that a tumor we have been watching should be removed, the surgical treatment will almost certainly be just as effective in the future as it would have been if we took it out when it was diagnosed,” he says “While some small tumors are not appropriate for this method — depending on location and other factors — these make up a tiny group.”

Dr. Wong points out that most physicians and hospitals do not currently have an active-surveillance program. He adds that the new ATA guidelines will make practitioners more comfortable with the concept of observing a tiny cancer that is statistically highly unlikely to ever cause harm.
MSK has also been on the forefront with the approach of selecting the more conservative surgery, lobectomy, for low-risk thyroid cancers, Dr. Wong explains. The ATA guidelines are now more supportive of this concept for selected cancers.  Research published more than two decades ago by former MSK Head and Neck Service Chief Jatin Shah and surgical oncologist Ashok Shaha supported such an approach, which was somewhat controversial at the time. “It is gratifying to see how the academic thyroid community has finally followed their lead,” Dr. Wong says.

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