UF Health MedMatters

An Important Patient Conversation About Thyroid Nodules

An extremely important conversation endocrinologists often have with their patients is a discussion about the diagnosis of a thyroid nodule.Naykky Singh Ospina, MD, UF College of Medicine uses ultrasound to examine patient's thyroids

The patient might be frightened. Is this cancer? The first thoughts will invariably focus on a biopsy or even surgery to remove the nodule. The physician understands that for some patients biopsy will be necessary and can help clarify their situation. For others, an unnecessary biopsy can lead to harm. In fact, the overwhelming majority of thyroid nodules present no serious risk and can be monitored over time with ultrasound without biopsy or surgery.

In these circumstances, it can be challenging to communicate the estimated thyroid cancer risk and management options to the patient, said University of Florida Health endocrinologist Naykky Singh Ospina, MD.

Singh Ospina is leading a team of researchers who want to provide a framework for that delicate clinical encounter by developing a conversation aid to help better and more completely inform patients about their thyroid nodules and the cancer risk they face.

Ospina said one of their goals is that a patient will arrive at a medical decision best for their particular situation if they understand their options for biopsy or ultrasound follow up. The way they can accomplish this is by developing a better understanding of their risk profile and improving collaboration with their clinician.

“The clinicians are basically facing this conundrum,” said Singh Ospina, an associate professor in the UF College of Medicine’s division of endocrinology, diabetes and metabolism. “Do you order biopsies in a very liberal sort of way and risk all the problems related to thyroid cancer overdiagnosis and overtreatment?

“On the other hand,” she added, “if you are too strict selecting patients for biopsy, there will be a concern that we might miss a clinically relevant thyroid cancer.”

The conversation aid will help clinicians and their patients together navigate that rocky terrain.

“The whole idea is to make this conversation flow better and allow the patient and clinician to discuss all the sensitive and important topics so they can decide, ‘OK, what’s best for me, a biopsy or ultrasound monitoring?’” Singh Ospina said. “We want to make the clinical encounter more personalized to the patient’s needs.”

The conversation aid, she said, seeks to improve the quality of these conversations and ensures the decisions that are made are more congruent with the patient’s own beliefs, values and the clinical evidence.

The prototype conversation aid that Singh Ospina and her team have developed starts by providing general information about the thyroid gland. It also helps categorize the patient’s thyroid nodule and its features, and it explains why it poses a risk for thyroid cancer that ranges from very low to high.

“We want to support conversations and collaboration between patients and clinicians to assure they feel comfortable and confident in the path that they choose." - Naykky Singh Ospina, MD

“Then the conversation aid gives you options based on those risks and provides the good and bad things about each,” she said. “It supports the conversation between patients and clinicians and seeks to elicit the patient’s thoughts about their situation and options.”

For example, the conversation aid tells a patient that, if they decide ultrasound monitoring is their best option, a follow-up ultrasound scan should be completed every six to 24 months, depending on their risk.

Patients are walked through the potential downside of each possible choice. Removing a nodule, for example, will leave a small neck scar and could lead to complications affecting the voice.

The aid, displayed on a computer screen, is simply a framework, leaving the physician free to guide the conversation to suit the patient’s needs. The aid also offers the patient management options, outlining the risks for each path.

Singh Ospina recently completed an observational pilot study that found the prototype conversation aid her group developed was associated with increased patient involvement in the decision-making process, improved clinician satisfaction and led to a fuller discussion of relevant topics.

Singh Ospina and colleagues are planning a larger randomized trial to see if a conversation aid is beneficial in a larger group of patients.

Singh Ospina encouraged endocrinologists to reflect on how they counsel patients with thyroid nodules and whether using a conversation aid could enhance their current practice and help them better collaborate with their patients. The current prototype of the conversation aid is outlined in the pilot study, which is published in Clinical Endocrinology.

She cautioned, however, that the conversation aid prototype is currently undergoing further prototyping and validation before it is employed in clinical care. If the conversation aid proves useful in the second stage of testing, it would be available for broader clinical adoption.

“The decision on whether to move forward with a thyroid biopsy or ultrasound monitoring is an important decision,” Singh Ospina said. “We want to support conversations and collaboration between patients and clinicians to assure they feel comfortable and confident in the path that they choose. This requires a good understanding of the clinical evidence and the patient’s situation.”

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University of Florida Health Shands Hospital has been recognized among the nation’s best hospitals in seven adult medical specialties. Overall, UF Health Shands Hospital was recognized as one of the best hospitals in Florida. In addition to being ranked among the nation’s top 50 hospitals in seven specialties, UF Health Shands Hospital also was listed as “high performing” in seven specialties, including abdominal aortic aneurysm repair, colon cancer surgery, COPD, heart failure, lung cancer surgery, neurology & neurosurgery and orthopaedics.