Re: “A Prospective Mixed-Methods Study of Decision-Making on Surgery or Active Surveillance for Low-Risk Papillary Thyroid Cancer” by Sawka et al.

Dear Editor:

The aforementioned article was published in the July 2020 issue of Thyroid (1). Sawka et al. prospectively used standardized medical information to offer a choice between active surveillance (AS) and surgery to eligible patients at their practice in Toronto, Canada, and reported their experiences using a mixed methods analytic approach using this intervention. We respect their pioneering study. They kindly cited four articles from Kuma Hospital on AS of low-risk papillary thyroid microcarcinoma (PTMC).

We were, however, very dismayed to see that they twice misrepresented one of our recent publications. In the introduction, Sawka et al. said “Davies et al. reported that in Kuma Hospital series, patients under AS did not always receive a choice of AS or surgery.” In fact, during the semistructured interview, participants were not asked a yes/no question of whether they were offered a choice because it was already clear that both options were always offered based on prior publications and this was confirmed through audiotaping as well as direct observations as reported in the Davies et al. article (2). When AS was begun in 1993, thyroidectomy was the only standard management option for PTMCs (3). Thus, it was and is impossible to perform AS without offering surgery as an option. At the beginning of our AS trial, we proposed these two options almost equally (3). However, with the accumulation of the favorable evidence for AS, we have gradually shifted toward recommending AS (4). Currently, at Kuma Hospital we propose AS as the first-line management for newly diagnosed patients with PTMC, although we still offer the surgical treatment option and some patients do choose it. We did report in the Davies article that some patients recalled being told “they did not need an operation, because their cancer was very small” (2). But this is a recollection of what was recommended, it does not mean they were not offered a choice.

In their discussion, Sawka et al. say, “Davies et al. recently reported that patients with papillary microcarcinoma, who were under AS at the Kuma Hospital, worried about disease progression or the possibility of needing surgery, however, not all of these patients were given a choice in disease management, which may potentially contribute to the findings”(1). Given that patients had two options for treatment and chose AS, this is not how we interpreted our findings. We noted that levels of worry were similar between those on surveillance and those who underwent surgery, quoting earlier research from Sawka et al., which speaks of the concerns of cancer patients more broadly, regardless of the treatment undertaken. We were very pleased to find that in our trial, which has now been conducted for 27 years and has been offered by all the surgeons and endocrinologists who work at Kuma Hospital, the Davies et al. article found that 87% of patients felt adequately informed and 83% said the decision was the best for them personally (2).