Re: “Barriers and Facilitators to the Choice of Active Surveillance for Low-Risk Papillary Thyroid Cancer in China: A Qualitative Study Examining Patient Perspectives” by Zhu et al.: Clinical Factors Affecting Patients’ Decision Between Active Surveillance and Surgery: A Surgeon’s View from China

Dear Editor:

Currently, active surveillance (AS) has been adopted as an alternative treatment option to immediate surgery for the management of select patients with low-risk papillary thyroid microcarcinoma (PTMC) in different countries. However, there are still some disputes about this approach, which is rarely carried out in China.

A qualitative study published in Thyroid was conducted by Zhu et al. to investigate the barriers and facilitators to selecting AS as a treatment strategy for select patients with low-risk PTMC in China. ¹ Reading this study caused us to reflect on clinical factors that may affect patient choice between AS and surgery.

First, some patients included in the study by Zhu et al. lacked a definitive pathological diagnosis, which may impel them to choose AS. Observation without fine-needle aspiration cytology (FNAC) is recommended for nodules ≤5 mm, whereas FNAC is recommended for nodules 5–10 mm in size that are strongly suspected to represent malignancy on ultrasonography (US), as per a position paper from the Japan Association of Endocrine Surgery. ² Thus, patients with a pathological diagnosis by FNAC or core needle biopsy were enrolled in previous relevant studies. ³ We wonder whether the lack of a definitive pathological diagnosis for patients could affect their choices.

Second, not all PTMCs are suitable for AS. PTMCs with aggressive clinical characteristics or at high risk of tracheal or recurrent laryngeal nerve invasion are not suitable for AS and such patients are recommended immediate surgery. ² We wonder whether the patients who chose AS included in this study have been strictly evaluated and excluded the aforementioned indications for immediate surgery.

Third, as stated by the authors, the perception of thyroid carcinoma as a “good carcinoma” facilitated the choice of AS. We wonder whether the information that patients believe PTMC is a good tumor comes from the clinicians and whether the clinicians' explanation of the characteristics of PTMCs may reduce patients' fear of this disease. Some PTMCs exhibit more aggressive behavior (accompanied by lymph node metastasis or distant metastasis), frequently recur, and can even cause carcinoma-related death. ^4,5 The knowledge of the existence of at least two distinct entities of PTMC with different outcomes, requiring different treatments, may affect the choice of the patients.

Therefore, the ability of clinicians to reduce patients' fear about disease progression and provide the details of the AS follow-up protocol also affects patients' choices. The improvement of this ability requires systematic training, including extensive professional knowledge and good communication skills. Furthermore, providing greater empathy and emotional support may facilitate meeting patients' needs and increase patients' preference to AS, given that patients with thyroid cancer are known to have unmet psychosocial support needs at the time of diagnosis. ³ Patient counseling as well as provision of empathy and support are skills that clinicians need to improve.

In summary, a variety of clinical factors may affect patients' decision-making with regard to the choice of AS and surgery. We believe appropriate multidisciplinary team is necessary to accurately diagnose and evaluate primary tumors being considered for AS and AS conduct must be subject to good quality control.