Response to Miyauchi et al. re: “A Prospective Mixed-Methods Study of Decision Making on Surgery or Active Surveillance for Low-Risk Papillary Thyroid Cancer”

Dear Editor:

Medical decision making about primary management of low-risk papillary thyroid cancer (PTC) is complex and there may be cross-cultural differences in the process. In North America, Stack and Angelos have indicated that “one of the key roles of the physician is to educate the patient about his or her medical condition and suggest the risks, benefits, and alternatives of various treatment options” (1). Furthermore, Morris et al. (from the United States) have indicated that in the context of properly selected patients with papillary thyroid carcinoma, “all appropriate options,” including active surveillance (AS) or surgery, should be discussed with patients (2). In Canada, a legal advisory organization (the Canadian Medical Protective Association) has also emphasized the general importance of explaining all acceptable alternative disease management options to patients (including the consequences of leaving the ailment untreated) (3). Moreover, the explanations provided to patients about the benefits and risks of alternative options must be sufficient to “allow the patient to reach an informed decision” (3). The rationale for any formal clinical recommendation should also be explained (3).

We recently reported in Thyroid an interim analysis from a Canadian medical decision-making study on the choice of either surgery or AS as primary disease management options (NCT03271892) (4). Miyauchi et al. have published a letter to the editor in Thyroid (5), objecting to our description of their work (6) in the introduction and discussion of our article.

The key criticism was our interpretation of a recent report from Davies et al. describing Kuma Hospital patients' experiences using a mixed methods design (6). Davies et al. reported that “some patients reported they had been offered the option of surgical intervention or active surveillance, and others reported they were simply told, ‘they did not need an operation, because their cancer was very small’” (6). Davies et al. also interviewed Kuma Hospital physicians and reported that “some physicians said they always offered the 2 options, whereas others said they suggested 1 specific option” (6). Based on these descriptions, we interpreted that not all patients had a choice of multiple options (AS or surgery) for PTC management (4). However, in their letter to Thyroid, Miyauchi et al. have clarified that “both options were always offered,” but currently, AS is offered as “first-line management,” while surgery is still offered (5). A possible source of confusion for readers of the article by Davies et al. (6) stems from a lack of clear distinction between offering patients a true informed choice of acceptable alternative options (AS or surgery) as compared with presenting patients with a recommended treatment that patients may choose to accept or reject. Cross-cultural differences in medical decision making may also contribute to our potential misinterpretation of Japanese approaches, when viewed by readers from a strictly North American perspective (7).

We thank Miyuachi et al. for their letter clarifying their approach in the management of papillary microcarcinoma at the Kuma Hospital (5). We also appreciate this opportunity to reflect on potential cross-cultural differences in medical decision making.