Abstract
Purpose
Typically formulated by investigators from “world centres of excellence,” differentiated thyroid carcinoma (DTC) management guidelines may have more limited applicability in settings of less expert care and fewer resources. Arguably the world’s leading DTC guidelines are those of the American Thyroid Association, revised in 2009 (“ATA 2009”) and 2015 (“ATA 2015”). To further explore the issue of “real-world applicability” of DTC guidelines, we retrospectively compared indications for ablation using ATA 2015 versus ATA 2009 in a two-centre cohort of ablated T1–2, M0 DTC patients (N = 336). Based on TNM status and histology, these patients were low–intermediate risk, but many ultimately had other characteristics suggesting elevated or uncertain risk.
Methods
Working by consensus, two experienced nuclear medicine physicians considered patient and treatment characteristics to classify each case as having “no indication,” a “possible indication,” or a “clear indication” for ablation according to ATA 2009 or ATA 2015. The physicians also identified reasons for classification changes between ATA 2015 versus ATA 2009. Classification was unblinded, but the physicians had cared for only 138/336 patients, and the charts encompassed September 2010–October 2013, several years before the classification was performed.
Results
One hundred of 336 patients (29.8 %) changed classification regarding indication for ablation using ATA 2015 versus ATA 2009. Most reclassified patients (70/100) moved from “no indication” or “clear indication” to “possible indication.” Reflecting this phenomenon, “possible indication” became the largest category according to the ATA 2015 classification (141/336, 42.0 %, versus 96/336, 28.6 %, according to ATA 2009). Many reclassifications were attributable to multiple clinicopathological characteristics, most commonly, stimulated thyroglobulin or anti-thyroglobulin antibody levels, multifocality, bilateral involvement, or capsular/nodal invasion.
Conclusions
Regarding indications for ablation, ATA 2015 appears to better “acknowledge grey areas,” i.e., patients with ambiguous or unavailable data requiring individualised, nuanced decision-making, than does ATA 2009.
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Acknowledgments
The work of one of the authors (RJM) in developing this paper, including descriptive statistical analysis, organisation/presentation of data, drafting/editing the manuscript, and handling part of manuscript submission logistics, was supported by a grant from Genzyme, a Sanofi company, the manufacturer of recombinant human thyrotropin (Thyrogen). This author is an independent medical editor, whose clients include Genzyme. The other authors declare no potential conflicts of interest.
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Funding
This was an investigator-initiated study funded from the regular budgets of the Departments of Nuclear Medicine of the participating centres.
Conflict of interest
The work of one of the authors (RJM) in developing this paper, including descriptive statistical analysis, organisation and presentation of data, drafting and editing the manuscript, and handling part of manuscript submission logistics, was supported by a grant from Genzyme, a Sanofi company, the manufacturer of recombinant human thyrotropin (Thyrogen). This author is an independent medical editor, whose clients include Genzyme. The other authors declare that they have no conflict of interest.
This was a retrospective study, involving no additional procedures. However, all procedures described herein were in accordance with the ethical standards of the institutional and/or national research committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. However, before the radioiodine treatment described herein, written informed consent was obtained from all individual study participants. This consent included allowing use of their data in analyses such as the present study.
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Frangos, S., Iakovou, I.P., Marlowe, R.J. et al. Acknowledging gray areas: 2015 vs. 2009 American Thyroid Association differentiated thyroid cancer guidelines on ablating putatively low-intermediate-risk patients. Eur J Nucl Med Mol Imaging 44, 185–189 (2017). https://doi.org/10.1007/s00259-016-3495-1
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DOI: https://doi.org/10.1007/s00259-016-3495-1
Keywords
- Differentiated thyroid cancer management guidelines
- 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer
- 2009 revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer
- Thyroid remnant ablation
- Decision-making
- Recommendations