C. B. Jensen1, M. C. Saucke1, J. L. Jennings1, H. J. Khokhar1, C. I. Voils1, S. C. Pitt1 1University Of Wisconsin,Endocrine Surgery Division – Surgery Department,Madison, WI, USA
Introduction: Overtreatment is a significant problem in the United States, particularly in patients with low-risk thyroid cancer. In order to reduce the harms of unnecessary care, it is essential to understand stakeholders’ attitudes and beliefs about overtreatment.
Methods: We conducted 34 semi-structured interviews with surgeons, endocrinologists, and patients with low-risk thyroid cancer. Interviews probed about decision-making for thyroid cancer, including less extensive and non-surgical management options. We used content analysis to identify themes related to overtreatment and created concept diagrams to map observed relationships between these themes.
Results: Surgeons and endocrinologists discussed overtreatment of low-risk thyroid cancer as resulting directly from overdiagnosis. They believed the process commonly starts with incidental discovery of a thyroid nodule on imaging and viewed biopsy as a habitual action driving overdiagnosis. Providers ascribed the reflexive biopsy to lack of adherence to or knowledge of guidelines, radiology recommendations, and the desire of patients and physicians to minimize diagnostic uncertainty. Providers described the subsequent diagnosis as an event that lets “the cat out of the bag” or “opens Pandora’s box.” Providers acknowledged that the resulting cancer diagnosis provokes a strong instinctive and culturally rooted need to proceed with surgery. As a consequence, most providers believed it is easier to prevent overdiagnosis than overtreatment. They suggested overdiagnosis can be addressed with provider-focused educational interventions, resetting patients’ expectations, and engaging the media. In contrast, patients did not discuss overdiagnosis or overtreatment. Some patients described the linear process from an incidental finding to surgery. Their statements confirmed the “need to know” was a major motivation for biopsying their nodule. Most patients felt that once they had a cancer diagnosis, surgery was a foregone conclusion. Patients admitted their knowledge about thyroid nodules and cancer was low, leaving room for education about the need for biopsy and less extensive treatments. They expressed significant trust in their surgeon and willingness to consider less extensive management options if recommended.
Conclusion: Surgeons’ and endocrinologists’ attitudes and beliefs about overtreatment focus on the automaticity of overdiagnosis. Both patients and providers acknowledge the established pathway that propels patients from incidental discovery of a thyroid nodule to surgery. Research is needed to determine if this seemingly inevitable progression can be interrupted with educational and behavioral interventions.
