Thyroid Cancer Treatment: What is the Best Option?

Some patients with thyroid cancer may be receiving unnecessary, invasive, and costly surgery when a safer option may be a more effective treatment, investigators from a recent study discovered.

For patients who had a biopsy suspicious for papillary thyroid carcinoma, a total thyroidectomy may not be the best option. This procedure, which completely removes the thyroid gland, is more expensive and may severely affect quality of life compared with a lobectomy that only removes the cancerous lobe, according to the study presented at the 2016 Clinical Congress of the American College of Surgeons.

“Our findings are showing that from the economic standpoint, performing lobectomy instead of total thyroidectomy in patients who have had a biopsy suspicious for papillary thyroid carcinoma is associated with a lower cost and better effectiveness,” said lead investigator Zaid Al-Qurayshi, MD, MPH. “It is important to note, this finding does not mean that lobectomy is only a cost-effective alternative; we call a strategy ‘cost-effective’ compared with the alternative if it costs more, or the same, but is associated with better effectiveness.”

Papillary thyroid carcinoma accounts for approximately 4 out of 5 cases of the 62,000 newly-diagnosed cases of thyroid cancer per year. This type of cancer is typically not aggressive, and grows slowly with little risk of metastasizing.

Papillary thyroid carcinoma also has higher survival rates compared with medullary thyroid cancer, according to the study. American Thyroid Association guidelines currently recommend that patients with stage 1 and 2 papillary thyroid carcinomas undergo lobectomy.

“Lobectomy is a shorter operation typically performed on an outpatient basis and with less risk factors than total thyroidectomy,” said study coauthor Ralph P. Tufano, MD, MBA, FACS. “American Thyroid Association Clinical Guidelines now support lobectomy alone for differentiated thyroid cancers, like papillary thyroid carcinoma, of 4 cm or less in carefully selected situations.”

However, complete thyroidectomy is the most common procedure for patients with thyroid cancers. In the study, investigators used a Markov model to find the efficacy of the treatments in quality of adjusted life year (QALY), which can help determine costs and effectiveness of treatment options.

“QALY is a standardized value from 0 to 1 that represents the burden of certain disease,” Dr Al-Quarayshi said. “It is based on 2 elements: quality of life and time. A value of 0 represents death, and a value of 1 represents a year of perfect health without any diseases.”

According to the study, lobectomy had a QALY that was 0.25 higher than the total thyroidectomy in the model, which assumed 20 years of follow-up. A lobectomy was also $2678 less than a total thyroidectomy.

This figure accounts for a 12% risk of a patient with stage 3 or 4 cancer needing to undergo thyroidectomy after receiving a previous lobectomy, according to the study.

“Cost-analysis studies are designed to answer questions at the administrative and policy-making levels,” Dr Al-Quarayshi said. “However, they do not assess which strategy is clinically better for patients at the individual level.”

These findings may suggest that patients with stage 1 or 2 papillary thyroid carcinoma may benefit the most from a lobectomy.

“This population represents the overwhelming majority of patients with suspicious-for papillary thyroid carcinoma on biopsy,” Dr Al-Quarayshi said. “Avoiding total thyroidectomy in those patients not only will have better clinical outcomes as shown previously, but will also have economic advantage at the population level as shown in the current analysis.”

Further analyses are needed to validate their findings.

“If these outcomes are consistently proven to hold true, it would be worthwhile to assess potential cost savings that are attainable given the number of patients who have suspicious papillary thyroid carcinoma annually in the United States,” Dr. Al-Quarayshi concluded. “On the other hand, if the American Thyroid Association Clinical Guidelines become widely adopted, further study is warranted to re-evaluate the clinical outcomes on long-term follow-up in patients who underwent lobectomy instead of total thyroidectomy.”