Individualized Care to Prevent Overtreatment and Undertreatment in Thyroid Cancer

In thyroid cancer management, overtreatment and undertreatment can be an issue. However, the abundance of treatment options and wider understanding of molecular testing have made overtreatment and undertreatment rare occurrences, according to R. Michael Tuttle, MD.

“We certainly want to avoid overtreatment and undertreatment. In thyroid cancer, the biggest issue is overdiagnosis that leads to overtreatment, because we found ourselves in a situation 15 to 20 years ago where everybody was getting ultrasounds. We were doing biopsies all these little, small nodules, and we were making the rate of thyroid cancer go up,” explained Tuttle, an endocrinologist and chief of the Endocrinology Service at Memorial Sloan Kettering Cancer Center told Targeted Oncology™, in an interview.

Research shows that although approximately 60% of adults have at least 1 thyroidnodule, only about 5% of thyroid nodules are malignant.1 Therefore, biopsies should be performed based on the features of the nodule on a scan and based on size. Even with some nodules that are an appropriate size for biopsy, immediate treatment is not always necessary, according to Tuttle.

There are some potential solutions to overtreating and undertreating patients with thyroid cancer. According to Tuttle, the key is to look at the patient as an individual and understand the many treatment options for that patient. Also, collaborating with a multidisciplinary team helps oncologists to get a full picture of the patient and what kind of care they may need.

“When you're seeing a patient with thyroid cancer, there's likely not just 1 right answer. There are going to be a range of options that will depend on the patient preferences and the medical situation you're working in, as well as the details of the tumor. Rather than trying to find the 1 answer, find a range of answers,” Tuttle said.

In an interview with Targeted Oncology™, Tuttle, discussed the plethora of treatment option for thyroid cancer as well as over and under treatment of the disease.

TARGETED ONCOLOGY: What have been the biggest update in precision medicine for thyroid cancer in recent years?

Tuttle: The biggest thing has certainly been the targeted therapies. The ability to look at tumors and somatic mutations and have targeted therapies for that was a big improvement in the field. But I also think, in the bigger sense, it is important to get each patient the right treatment at the right time. We're in an era of lots of low-risk thyroid cancer. Really trying to target and get like the right screening, get the right biopsies, and get sense of which patients only need minimalistic management approaches has become important as the landscape of thyroid cancer has changed.

What are some of the key challenges with carrying out individualized care in this patient population?

There are several challenges. One is getting everybody to agree with what's the right treatment for the patients at the right time. Not everybody agrees on that. Then I think even once we agree on what's the right thing to do, getting that message out to our colleague is a challenge. And then in long term follow up with thyroid cancer, they're going back to primary care doctors or sometimes advanced practitioners, so getting the message out to the clinical teams, and then also getting the message out to the patients is difficult. If a patient has cancer, they figure more is better. Nobody has called me up and said, I have cancer, I can wait a couple of months to see you. It's more like, I have cancer, see me today and treat me tomorrow. So, helping patients and their families understand that more is not always better is part of the challenge.

Lastly, we certainly have barriers to implementation. If COVID has taught us anything, like with the socioeconomic and racial barriers, there are all kinds of barriers to getting that right treatment to the right person at the right time. I think we have to look at and say it's not good enough just to publish on the internet. The questions are how do you do it? How do you get that person to trust the medical team to be able to get to the medical team to be able to do those things? Or conversely, how do we get the medical team to them? Why do they always have to come to us? We must look at ways to help out to people and their families that have a hard time getting in our traditional model. I think us thinking through some of those barriers to implementation more than just what's the right answer for one patient would go a long way.

Can you talk about over treatment and under treatment, why are these problems happening?

My bias is that we don't have a lot of people over treating and undertreating. I have described what we call minimalistic management options and maximalistmanagement options. There are all good management options, but some people want to be a little more minimalistic andsome people want to be more maximalist. Even though we do a lot of arguing at the meetings, what I find is that we are generally arguing about 2 different ways that would work fine for an individual patient and may be more appropriate for 1 patient than another based on the medical team characteristics the tumor and ultrasound characteristics ,and the patient’s preferences.

We certainly want to avoid over treatment and under treatment. In thyroid cancer, the biggest issue is overdiagnosis that leads to overtreatment, because we found ourselves in a situation 15 or 20 years ago where everybody was getting ultrasounds. We were doing biopsies all these little, small nodules and we were making the rate of thyroid cancer go up, and there's no question some of those people were being over diagnosed and over treated. Patients were being exposed to treatments that were unnecessary.

It is also rare to see undertreatment in these patients. Partly, that's because we can't keep the pendulum in the middle. You swing it too far. Also, some of the more aggressive patients now, it seems like every few months, there are novel therapies for them. There's molecular testing that needs to be done, so we now can ensure that those aggressive thyroid cancer patients there’s something that can be done. The patients just need to see medical oncology and some other folks. On both sides of the spectrum, we want to try to avoid and stay in the middle, if we can.

What are some solutions that may avoid over and under treatment?

For overtreatment, its first important to recognize that it exists. For a lot of people, nobody can imagine over treatment of cancer. This concept that we can find some clinical thyroid cancer with sounds like the weirdest thing in the world, and tell patients don't worry, it's not going to hurt you. It's barely going to grow, and you'll live to be 100 years old. People will say that it doesn't sound like cancer. So, explaining that there are some cancers, in fact, not infrequent, that don't need to be treated immediately is a big component of it.

Likewise, in the under-treatment category, doing a better job with education for our peers, like people that see these thyroid cancer patients, patient support groups, and online support groups. If you work in a big center, like me, all I do is thyroid cancer every day. I see 50 to 70 thyroid cancer patients a week. That's not normal. Normal is an endocrinologist or a primary care doctor that sees 1 or 2 aggressive thyroid cancer patients in a year while they're trying to care for patients in other ways. They need to be aware of all the possible treatments that were not available 20 years ago for patients with aggressive thyroid cancer.

What other key points should oncologists know about over and under treatment?

When you're seeing a patient with thyroid cancer, there's likely not just 1 right answer. There are going to be a range of options that will depend on the patient preferences and the medical situation you're working in, as well as the details of the tumor. Rather than trying to find the 1 answer, find a range of answers. When you’re treating thyroid cancer, we need to know the natural history of the disease. We also have to consider what happens if we do nothing? If we treat the disease, how effective is the treatment? What are the side effects of the treatment, and then what does the patient think or want?

The key thing is that we must make a 360-degree view of the patient and not think about this as the single answer. We have should look at that specific patient, their life, and everything else that's going on with them to arrive at a good answer that would be within the range of optimal management for that patient. That would give us great endpoints and great outcomes, meeting the needs of that individual patient.

_REFERENCES:

_{Grani g, Sponziello M, Pecce V, et al. Contemporary thyroid nodule evaluation and management. J Clin Endocrinol Metab. 2020;105(9):2869-2883. doi:10.1210/clinem/dgaa322}