In a single-institution study reported in JAMA Oncology, Allen S. Ho, MD, and colleagues found evidence that active surveillance may be a suitable treatment for most patients with low-risk papillary thyroid carcinoma.
Study Details
The prospective study included 222 patients enrolled at Cedars-Sinai Medical Center, Los Angeles, from 2014 to 2021 who had 20 mm or smaller Bethesda 5 to 6 thyroid nodules. Patients selected treatment with active surveillance (n = 112) or immediate surgery (n = 110). Delayed surgery was recommended for tumor growth of > 5 mm or > 100% growth in volume. Patients completed the 18-item Thyroid Cancer Modified Anxiety Scale over time.
Allen S. Ho, MD
Key Findings
Mean follow-up was 37.1 months (range = 6–94 months).
At last follow-up, 101 (90.1%) of 112 patients continued to receive active surveillance. A total of eight patients (7.1%) crossed into the delayed surgery group: four due to nodule growth > 5 mm, two due to patient preference, and two due to the recommendation of other clinicians against active surveillance. Three patients were lost to follow-up.
Among the 101 patients, 46 (41.0%) had tumor shrinkage and none developed regional/distant metastases. Among all 112 patients, size growth of > 5 mm was observed in 3.6% of cases, with a cumulative incidence of 1.2% at 2 years and estimated incidence of 10.8% at 5 years. Volumetric growth of > 100% was observed in 7.1% of cases, with a cumulative incidence of 2.2% at 2 years and estimated incidence of 13.7% at 5 years.
Among the 110 patients electing to undergo immediate surgery, 21 (19.1%) had equivocal-risk features (eg, metastatic lymph nodes, extrathyroidal extension, and aggressive histologic variants) identified on final pathology. Disease severity for these patients remained classified as stage I.
At last follow-up, all patients were disease-free, with disease-free and overall survival rates of 100% in both groups.
On multivariate analysis, patients who underwent immediate surgery exhibited significantly higher baseline anxiety levels vs active surveillance patients (estimated difference in anxiety scores between groups = 0.39, 95% confidence interval [CI] = 0.22–0.55, P < .001). Increased anxiety levels persisted in the immediate-surgery group (estimated difference in scores at 4-year follow-up = 0.50, 95% CI = 0.21–0.79, P = .001).
The investigators concluded, “The results of this nonrandomized controlled trial suggest that a more permissive active surveillance strategy encompassing most diagnosed thyroid cancers appears viable. Equivocal-risk pathologic features exist in a subset of cases that can be safely treated but suggest the need for more granular risk stratification. Surgery and surveillance cohorts possess oppositional levels of worry, elevating the importance of shared decision-making when patients face treatment equivalence.”
Dr. Ho, of Cedars-Sinai Medical Center, Los Angeles, is the corresponding author for the JAMA Oncology article.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
