THYROID Volume 25, Number 5, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2015.0017
EDITORIALS and COMMENTARY
Ethical Responsibilities of Caring for Patients with Incidental Thyroid Nodules Ralph P. Tufano,1 Salem I. Noureldine,1 and Peter Angelos 2
T
he worldwide incidence of thyroid cancer has increased substantially over the past 50 years, and is almost exclusively attributed to small, low-risk papillary thyroid cancers. The biological behavior of this subclinical malignancy has not changed over time. However, our capacity to detect it has. Increased use of diagnostic imaging capable of exposing subclinical disease is considered the most parsimonious explanation for this reported rise (1). For example, ultrasound screening for thyroid cancer is believed to be the key factor for South Korea’s troubling, abrupt rise in incidence. The resultant increase in healthcare expenditures related to managing these presumably low-risk cancers without a clear patient benefit has resulted in a backlash against early detection of thyroid cancer (2). Thyroid cancer is heterogeneous and can follow multiple paths; not all remain indolent during the patient’s lifetime, and include disease that progresses, resulting in a consistent 0.5 death per 100,000 individuals annually (3). We currently have no way to predict confidently which incidentally detected thyroid nodules may be the precursor to a more aggressive process. An ideal screening program is one that focuses on detection of disease that will eventually cause morbidity, will allow curative interventions if detected early, and for which treatments are more effective in the early stage of disease (4). With time, better screening will depend on our ability to characterize the biology of individual thyroid cancers detected more accurately. Until this can be accomplished, we agree that routine screening should not be performed. However, we feel this is ethically distinct from not reporting incidentally detected thyroid nodules on diagnostic imaging when performed for other medical reasons, as suggested by a recent report of the American College of Radiology (5). Withholding this information, because it is believed that it may cause the patient more harm to know about their condition, reeks of paternalism and leaves out the patient and treating physician—both key stakeholders in the process of informed decision making.
Recent initial observational studies of small thyroid cancers in Japan and the United States have provided an opportunity for the medical community to start a dialog among all stakeholders about novel management approaches for these incidentally detected cancers. The costs and psychosocial implications of prolonged surveillance versus current accepted treatments also need to be assessed. Until these studies are completed, patients must be objectively and supportively presented with all possible management options. Our ethical responsibility is to provide patients with objective, evidence-based information related to their individual disease status, rather than assuming we know what is best for an individual patient by selectively withholding known information. Including psychosocial assistance in this informed decision-making process helps the patient to make the management decision that will provide them with the most value when a small thyroid nodule/cancer is incidentally identified. Author Disclosure Statement
All authors report no conflicts of interest. References
1. Davies L, Ouellette M, Hunter M, Welch HG 2010 The increasing incidence of small thyroid cancers: where are the cases coming from? Laryngoscope 120:2446–2451. 2. Ahn HS, Kim HJ, Welch HG 2014 Korea’s thyroid-cancer ‘‘epidemic’’—screening and overdiagnosis. N Engl J Med 371:1765–1767. 3. Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds) SEER cancer statistics review, 1975–2011, National Cancer Institute, Bethesda, MD. Available at: http://seer .cancer.gov/csr/1975_2011/ (accessed December 1, 2014).
1 Division of Head and Neck Endocrine Surgery, Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. 2 Department of Surgery, The University of Chicago, Pritzker School of Medicine, Chicago, Illinois.
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4. Gates TJ 2014 Screening for cancer: concepts and controversies. Am Fam Physician 90:625–631. 5. Hoang JK, Langer JE, Middleton WD, Wu CC, Hammers LW, Cronan JJ, Tessler FN, Grant EG, Berland LL 2014 Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol 12:143–150.
TUFANO ET AL.
Address correspondence to: Ralph P. Tufano, MD, MBA, FACS Department of Otolaryngology—Head and Neck Surgery The Johns Hopkins School of Medicine Johns Hopkins Outpatient Center 601 N. Caroline Street, 6th floor Baltimore, MD 21287 E-mail: [email protected]
EDITORIALS and COMMENTARY
Ethical Responsibilities of Caring for Patients with Incidental Thyroid Nodules Ralph P. Tufano,1 Salem I. Noureldine,1 and Peter Angelos 2
T
he worldwide incidence of thyroid cancer has increased substantially over the past 50 years, and is almost exclusively attributed to small, low-risk papillary thyroid cancers. The biological behavior of this subclinical malignancy has not changed over time. However, our capacity to detect it has. Increased use of diagnostic imaging capable of exposing subclinical disease is considered the most parsimonious explanation for this reported rise (1). For example, ultrasound screening for thyroid cancer is believed to be the key factor for South Korea’s troubling, abrupt rise in incidence. The resultant increase in healthcare expenditures related to managing these presumably low-risk cancers without a clear patient benefit has resulted in a backlash against early detection of thyroid cancer (2). Thyroid cancer is heterogeneous and can follow multiple paths; not all remain indolent during the patient’s lifetime, and include disease that progresses, resulting in a consistent 0.5 death per 100,000 individuals annually (3). We currently have no way to predict confidently which incidentally detected thyroid nodules may be the precursor to a more aggressive process. An ideal screening program is one that focuses on detection of disease that will eventually cause morbidity, will allow curative interventions if detected early, and for which treatments are more effective in the early stage of disease (4). With time, better screening will depend on our ability to characterize the biology of individual thyroid cancers detected more accurately. Until this can be accomplished, we agree that routine screening should not be performed. However, we feel this is ethically distinct from not reporting incidentally detected thyroid nodules on diagnostic imaging when performed for other medical reasons, as suggested by a recent report of the American College of Radiology (5). Withholding this information, because it is believed that it may cause the patient more harm to know about their condition, reeks of paternalism and leaves out the patient and treating physician—both key stakeholders in the process of informed decision making.
Recent initial observational studies of small thyroid cancers in Japan and the United States have provided an opportunity for the medical community to start a dialog among all stakeholders about novel management approaches for these incidentally detected cancers. The costs and psychosocial implications of prolonged surveillance versus current accepted treatments also need to be assessed. Until these studies are completed, patients must be objectively and supportively presented with all possible management options. Our ethical responsibility is to provide patients with objective, evidence-based information related to their individual disease status, rather than assuming we know what is best for an individual patient by selectively withholding known information. Including psychosocial assistance in this informed decision-making process helps the patient to make the management decision that will provide them with the most value when a small thyroid nodule/cancer is incidentally identified. Author Disclosure Statement
All authors report no conflicts of interest. References
1. Davies L, Ouellette M, Hunter M, Welch HG 2010 The increasing incidence of small thyroid cancers: where are the cases coming from? Laryngoscope 120:2446–2451. 2. Ahn HS, Kim HJ, Welch HG 2014 Korea’s thyroid-cancer ‘‘epidemic’’—screening and overdiagnosis. N Engl J Med 371:1765–1767. 3. Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds) SEER cancer statistics review, 1975–2011, National Cancer Institute, Bethesda, MD. Available at: http://seer .cancer.gov/csr/1975_2011/ (accessed December 1, 2014).
1 Division of Head and Neck Endocrine Surgery, Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. 2 Department of Surgery, The University of Chicago, Pritzker School of Medicine, Chicago, Illinois.
467
468
4. Gates TJ 2014 Screening for cancer: concepts and controversies. Am Fam Physician 90:625–631. 5. Hoang JK, Langer JE, Middleton WD, Wu CC, Hammers LW, Cronan JJ, Tessler FN, Grant EG, Berland LL 2014 Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol 12:143–150.
TUFANO ET AL.
Address correspondence to: Ralph P. Tufano, MD, MBA, FACS Department of Otolaryngology—Head and Neck Surgery The Johns Hopkins School of Medicine Johns Hopkins Outpatient Center 601 N. Caroline Street, 6th floor Baltimore, MD 21287 E-mail: [email protected]
