Treatment Decisions in Thyroid Microcarcinomas: Identifying Gaps in Knowledge to Empower Our Patients

Dear Editor:

Current recommendations discourage performing universal screening for thyroid nodules. However, the widespread use of ultrasound has resulted in the detection of an increasing number of subcentimeter thyroid lesions (1). Therefore, specialists must decide how to best treat papillary thyroid microcarcinomas (PTMC) that might not have been diagnosed if current recommendations were followed (2). Current research into this topic has targeted the psychological impact of different treatment options on patients with low-risk thyroid lesions. Several publications evaluate patients' perceptions of treatment options for PTMC, and how these treatments may impact their quality of life (QoL) (3,4). At the core of this dilemma is the fact that patients are expected to participate in shared decision making with physicians who are often struggling with the counterintuitive beliefs that leaving cancer in the body is not harmful, and that larger invasive cancers presumably start as PTMCs.

Patients who select a conservative treatment course of active surveillance (AS), hoping to avoid “unnecessary” surgery and consequently hormonal replacement therapy, must undergo periodic medical examination to evaluate disease progression. The uncertainty of possible disease progression may cause persisting anxiety in patients whenever they undergo follow-up tests and imaging.

Efforts have been made to understand the differences in QoL in patients who choose to be managed with AS or immediate surgery (IS). Kong et al. recently published an interim analysis of their MAeSTro study, where the authors aimed to evaluate differences in QoL in patients with low-risk PTMC who decided to undergo AS or IS (5). To our knowledge, this is the largest cohort reported to date addressing this issue. However, we would like to highlight some factors that introduce bias and limit the strength of their results. The main limitation of this results from the inclusion criteria. According to the Korean Thyroid Association Guidelines, nodules >5 mm are recommended to undergo fine needle aspiration. However, in this study, 35% of participants were biopsied with even smaller nodules. Furthermore, from the 687 consented patients, 42% were lost to follow-up. This, in our opinion, presents a selection bias that makes this sample not representative of what the American Thyroid Association defines as low-risk PTMC. Second, although no significant differences in demographic characteristics between groups were found, difference in QoL was reported both at baseline and during follow-up. The presence of different levels of the measured outcome at baseline suggests that these groups had different psychological profiles before treatment. Assessment of QoL before diagnosis of PTMC could help clarifying whether these differences are attributable to diagnosis and/or treatment choice, or if there is an inherent psychological difference between these two groups.

We believe that efforts should be made to comprehensively explain the patients' perceptions of the disease, their treatment options, and evaluating the factors that affect QoL, such as patients' sociodemographic characteristics, frequency of follow-up visits, expenses associated with the disease, and decision regrets, among other factors.