A. K. Price1, R. W. Randle1, D. F. Schneider1, R. S. Sippel1, S. C. Pitt1 1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA
Introduction: Thyroid cancer is the fastest growing malignancy in the United States largely due to a 4-fold increase in papillary thyroid microcarcinoma (PTMC), tumors ≤1 cm. Nationally, 73% of PTMC patients undergo total thyroidectomy (TT) despite equivalent long-term outcomes with less extensive surgery. Little is known about what drives these treatment decisions. The objective of this study was to investigate patient and surgeon decision-making about the extent of surgery for PTMC.
Methods: We conducted a retrospective review of all thyroid cancer patients operated on at a single institution from 2008 to 2016. Patients were included if their largest tumor was ≤1 cm and no other type of thyroid cancer was present. For PTMC patients diagnosed preoperatively, decision-making about the extent of surgery was reviewed in all available documentation and categorized into patient or surgeon reasons. Data analysis was performed using Fisher’s exact, Chi-square, or Student’s t-tests as appropriate.
Results: Of the 853 thyroid cancer patients, 125 (14.7%) had a PTMC as their largest tumor. The mean (± SD) age of the PTMC patients was 50.1 (± 14.6) years, and 85.6% (n=107) were female. The mean tumor size was 0.51 (± 0.3) cm. Overall, 27.2% of patients underwent a thyroid lobectomy (TL; n=34), while 72.8% had a TT (n=91). Of the PTMC patients, 19 (15.2%) were diagnosed preoperatively. These patients were similar to the rest of the cohort with respect to all preoperative variables; however, a significantly higher proportion of these patients had a TT (94.7% vs. 68.9%, p=0.01). In all documented cases, patients chose the extent of surgery because of the surgeon’s recommendation. Analysis of surgeon decision-making demonstrated that a TT was most commonly recommended because of the potential for multifocal disease (8.7%), ease of follow up (8.7%), and patient history (8.7%). The graph depicts all of the reasons for which surgeons’ recommended a TT. Only one preoperatively diagnosed patient had a TL, which was recommended because a history of gastric bypass increased the risk for permanent hypocalcemia. Analysis of outcomes revealed that 5.3% (n=1) of preoperatively diagnosed PTMC patients had a permanent complication, which was nearly double that of the rest of the cohort (2.8%, n=3; p=0.5).
Conclusion: These data suggest that surgeons drive decision-making about the extent of thyroidectomy in patients with preoperatively diagnosed PTMC. With recent guidelines recommending TL or active surveillance as primary treatment and a known decrease in quality of life after TT, closer examination of decision-making is needed to ensure that PTMC patients make well-informed, preference-based decisions.
