Rise in Incidence of Thyroid Cancer Blamed on Overdiagnosis

According to Dr. Tuttle, it is still unclear in which patients tumors may grow, and part of the study is to help figure that out. Preliminary data suggest that tumors may grow more in younger patients than in older ones, and that pregnancy may also influence tumor growth.

For Dr. Brito, the key is to educate patients and work with them to tailor the treatment so that it fits. “Clinicians need to elicit the preference of the patient and accommodate the treatment that fits the patient’s context,” he said. “For instance, a 70-year-old man with another more aggressive malignancy might want to opt for active surveillance, as may a 32-year-old actress who is concerned about a neck scar from surgery. A 43-year-old executive, on the other hand, may be too concerned about metastasis and opt for surgery.”

Brian Burkey, MD, head and neck surgeon in the Cleveland Clinic Head and Neck Institute in Ohio, agreed that treatments for individual patients should be determined by specific patient factors and by “rich and meaningful discussions with the patient concerning subsequent options for treatment and their respective risks and benefits,” but he also emphasized the need to follow the ATA’s current evidenced-based guidelines on the treatment of thyroid nodules and well-differentiated thyroid cancer.

“Active treatment of thyroid cancer is currently the standard of care and, as such, should be the default method,” he said. “Novel treatments of thyroid cancer, such as observation alone, should be studied by the experts in a protocol setting before being widely adopted.”

Although most otolaryngologists currently do not offer active surveillance in patients with biopsy-proven thyroid cancer, Dr. Tuttle thinks otolaryngologists are heading in that direction. “Most otolaryngologists wish that endocrinologists were not biopsying these small nodules in 70-year-old patients,” he said.

He also emphasized that, once a lesion is biopsied, otolaryngologists do not need to rush to surgery. “The data show we don’t have to hurry,” he said. “Things are not going to get out of control in a year or two, and so the treating otolaryngologist can feel comfortable telling the patient that it is reasonable to watch the lesion, just as we tell men with prostate cancer and older patients with lymphoma.”

Looking Too Hard for Thyroid Cancer?

According to Dr. Morris, current guidelines by the ATA, the American Association of Clinical Endocrinologists, and the Society of Radiologists in Ultrasound clearly recommend against performing a fine needle biopsy of a thyroid nodule smaller than 1 cm, except in rare cases such as those involving patients with prior radiation exposure (see “Guidelines for Management of Thyroid Cancer,” below).

Although he thinks most otolaryngologists are aware that these small nodules should not be biopsied, he said that many endocrinologists and other clinicians, including some otolaryngologists, still persist in biopsying them.