Thyroid cancer overdiagnosis might be addressed through better patient-doctor conversations
It can be a disquieting moment for a patient. A lump or bump is found on their neck. It’s a thyroid nodule. Is it cancer? Many of those patients will probably want to get a biopsy as soon as they can.
The number of people diagnosed with thyroid cancer has tripled in the last 40 years as imaging technology has become more common and nodules are often discovered incidentally in patients without symptoms.
While biopsy makes sense for some patients, physicians note, it isn’t the best option for all.
A University of Florida Health researcher is leading a team developing a conversation aid to be used during what can be a challenging clinical encounter when it’s crucial for a doctor to clearly and completely communicate a patient’s cancer risk and management options.
One of the goals is to ensure the patient understands that a biopsy or surgery, which each carry risk of complication, are often unnecessary when nonsuspicious thyroid nodules can be safely monitored over time with ultrasound. Many nodules pose no danger.
Naykky Singh Ospina, M.D., an associate professor in the UF College of Medicine’s division of of endocrinology, diabetes and metabolism, said one of the hopes is that a patient will arrive at a medical decision on either a biopsy or ultrasound follow up that will be the best for their particular situation.
“The clinicians are basically facing this conundrum,” said Singh Ospina, who also is a faculty member in the UF Health Cancer Center. “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, displayed on a computer screen, will help clinicians and their patients together navigate that difficult 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, ‘Okay, 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 ensure “the decisions that are made are more congruent with the patient’s own beliefs, values and the clinical evidence.”
A prototype conversation aid Singh Ospina and her team have developed starts by providing general information about the thyroid gland. It goes on to categorize the patient’s thyroid nodule, its features and explains the risk of thyroid cancer, ranging from very low to high.
“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 patients’ thoughts about their situation and options.”
The aid outlines management options, the risks for each path and what each option means.
For example, the conversation aid tells a patient ultrasound monitoring 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.
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 and improved clinician satisfaction and led to a fuller discussion.
Singh Ospina and colleagues are planning a randomized trial to see if a conversation aid is beneficial in a larger group of patients.
“The decision on whether to move forward with a thyroid biopsy or ultrasound monitoring is an important decision,” she 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.”