br Table III br Bivariate
Bivariate and multivariable logistic regressions of having total thyroidectomy versus thyroid lobectomy (SEER 9 Registries, 2000e2014)
Thyroid cancer size (cm)
OR, odds ratio from bivariate logistic regressions; AOR, adjusted odds ratio from multivariable logistic regression; REF, reference.
Results demonstrate that the overall proportion of total thy-roidectomies performed for patients with PTC has not decreased. Even among patients with tumors <1 cm in diameter, for whom the guidelines are most clearly applicable, the proportion of total thy-roidectomy has remained static or increased since 2006. Although there are medical reasons to consider total thyroidectomy (patients who are already receiving synthroid for hypothyroidism or have bilateral thyroid nodules), it is unlikely that the proportion of pa-tients with those characteristics would have changed during the study period. It is also possible that patients may anticipate long-term surveillance in the remaining lobe to be burdensome. Finally, another potential explanation for the increase in the pro-portion of thyroidectomies is that a greater number of surgeries are being done in SYBR Safe DNA Gel Stain practices relative to academic practices, the latter of which may be more supportive of less-aggressive surgical approaches.
Over time, there have been numerous studies showing that patients have an excellent prognosis with low-risk PTC. The un-changing, high proportion of patients receiving total thyroidectomy raises concerns about the harms of overtreatment, especially
because thyroid lobectomy has been found to be equally effective when compared with total thyroidectomy.19,20,22 Compared with thyroid lobectomy, total thyroidectomy poses an increased risk for
hypoparathyroidism, vocal cord paralysis, respiratory complica-tions, hematoma, and tracheostomy.12,25,41 Thyroid lobectomy
substantially decreases the rate of biochemical hypothyroidism and the need for lifelong thyroid replacement medication. Financially, thyroid lobectomy also comes with a significantly lower average pricetag ($19,365 vs $15,602, P < .0001).12 Thyroid lobectomy has also been shown to be more cost-effective in the long term, after only 3 years, among 1- to 4-cm PTCs.13
In addition to the surgical complications and potential financial toxicity associated with the treatment of thyroid cancer, an emerging body of evidence suggests that the diagnosis and treat-
ment of thyroid cancer is associated with a negative impact upon quality of life and financial health.13e15,17 One study shows that
thyroid cancer may have similar or worse quality-of-life outcomes compared with both breast and colorectal cancer.16 Future study should be performed to determine whether thyroid lobectomy may be associated with improved quality of life or reduced financial burdens. Notably, PTC is generally clinically silent, and the survival rate for patients with uncomplicated PTC who are not treated in the first year of diagnosis has been reported as 97% at 20 years.42 The lack of change in practice may be related to both patient and provider factors. The fear of a cancer diagnosis may impact patient preferences for a more aggressive surgical approach, and provider resistance may exist regarding deliveringdor even dis-cussingdmore conservative approaches. Comparison can be made with other types of cancer treatment guidelines to contextualize the slow rate of change observed in clinical practice. In 2010, the National Comprehensive Cancer Network released guidelines rec-ommending active surveillance for very lowerisk prostate cancer.43 Among a low-risk group of 40,839 prostate cancer patients diag-nosed from 2010 to 2013, active surveillance was slowly but increasingly utilized, rising from 12% up to 27% of patients by 2013.44 A larger study, which was less conservative in its selection of low-risk patients, found that from 2004 to 2013 the rate of expectant management for low-risk prostate cancer increased from 27% to 60%.45 Although both of these studies show an increasing adoption of active surveillance, change has been slow and a large proportion of patients were still receiving surgical therapies for low-risk tumors in spite of changing National Comprehensive Cancer Network guidelines. As is needed in thyroid cancer, research has started to explore provider and patient explanations for genotype slow adoption, including clinician experience and opinion and patient preferences.46,47 An optimal approach to managing these choices is shared decision-making, wherein medical decision-making incorporates the preferences of informed patients.