New Qualitative Study on Clinicians’ Views about Papillary Microcarcinoma: What’s in a Name?

A new qualitative study was published in Thyroid exploring the views of clinicians in Australia regarding papillary thyroid microcarcinoma.  The lead author of the article is Brooke Nickel, a public health researcher and PhD candidate from The University of Sydney. Other authors are Juan Brito, endocrinologist of the Mayo Clinic, USA;  Alexandra Barratt, University of Sydney; Susan Jordan, University of Queensland; Ray Moynihan, journalist and academic researcher, and Kirsten McCaffery of the University of Sydney.

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The study involved telephone interviews with 22 surgeons and endocrinologists who treat thyroid cancer patients.  The authors were interested in learning more about the attitudes of these clinicians regarding thyroid cancer overdiagnosis and treatment options for PMC (papillary microcarcinoma). PMCs (usually defined as papillary thyroid cancers which measure less than 1 cm) are regarded in the medical literature as being a major cause of overdiagnosis.  Many PMCs are discovered incidentally when patients undergo imaging for various medical conditions.  They are also found due to opportunistic ultrasound screening and subsequent fine needle aspiration.

In this writer’s view, the authors were able to parse a central issue with respect to finding solutions for the problem of overdiagnosis – people react negatively to the word “cancer”. As the authors iterate, observational studies have found that  patient outcomes for observing a properly selected microcarcinoma are statistically the same as outcomes for those who get immediate surgery:

 Evidence from observational studies show that the rate of loco-regional metastases with active surveillance is comparable to the rate that can occur after thyroid surgery; and that outcomes of surgery for PMC are the same whether surgery is undertaken immediately or after any progression (19-21, 28, 29). Furthermore, patients who develop local recurrence after surgery will still require a second surgery, and having only one surgery after progression may be better for patients since their final outcomes are similarly excellent. – Nickel et al., Thyroid (2017).

Yet most clinicians preferred treatment with surgery anyway. Interestingly, the physicians who were interviewed for the study were mostly aware of overdiagnosis and agreed that nodules under 1 cm should not be biopsied.  However, once a PMC was identified, most interviewees endorsed surgical intervention:

This implies that the driver to treat a biopsy-proven PMC is not really the underlying biology of the disease, but rather the knowledge of cancer and the perceived need that something has to be done. – Nickel et al., Thyroid (2017).

These findings are in accord by a recent qualitative study by Louise Davies and colleagues in which patients stated that they had been discouraged by their doctors and others from observing their thyroid cancers.

The authors suggest that patient decision-aids would be useful in helping both doctors and patients to quantify likely outcomes and to help patients to better understand their true risk.  Although physicians in the study did not favor a name change for thyroid papillary microcarcinoma, Nickel et al. opine that such a change in nomenclature might be a very effective strategy to mitigate overdiagnosis nonetheless.

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