Results from a new study co-led by researchers at Dartmouth’s Geisel School of Medicine and the Department of Surgery at Kuma Hospital in Kobe, Japan show that active surveillance can be successfully implemented as a viable treatment option for patients with low-risk thyroid cancer. The study is the first to specifically analyze patient retention and adherence in an active surveillance program for thyroid cancer.
The incidence of small papillary thyroid cancers (less than 2 cm) has increased dramatically across the world over the past 25 years, without a proportional change in mortality. The research and medical communities now recognize this trend to be largely due to overdiagnosis—the detection of a disease that, had it not been detected, would have been unlikely to go on to cause symptoms or death.
In an effort to minimize the overtreatment of these small, localized cancers, many countries (led by Japan) have adopted more conservative treatment approaches. They already advocate partial rather than total surgical removal of the thyroid in certain cancers and developed the approach of active surveillance—which involves closely watching a patient’s condition without doing surgery unless the cancer grows or changes. This approach is considered a viable option for carefully selected cancers, showing promise as a way to reduce harm from overtreatment.
“Prior to this study, there has been a lack of evidence about how well patients who select active surveillance will actually adhere to the approach over time, especially in countries like the U.S. that are only a few years removed from following traditional guidelines that called for more aggressive treatment approaches,” says Louise Davies, MD, MS, associate professor of surgery and of The Dartmouth Institute at the Geisel School of Medicine at Dartmouth and lead author on the study.
To assess patient retention in the program, adherence to a schedule of follow-up ultrasounds, and the patient experience in a well-established thyroid cancer surveillance program, the researchers conducted a cohort analysis of 1,179 patients at Kuma Hospital in Kobe, Japan between February 2005 and December 2017, the largest and longest known program of its kind. The analysis evaluated attendance data, and during 2018 Dr. Davies conducted patient and physician interviews and gathered field observation data.
Patients were considered adherent if they underwent an ultrasonographic exam within at least 13 months of their previous exam, and were considered retained if they came for their ultrasound examination at least every two years.
After completing their data analysis, the study team found that 91 percent of the patients adhered to the prescribed ultrasonography schedule. Retention in the program was also high—with only 4.5 percent of patients choosing surgery after two years and 8.5 percent stopping their follow-up care after a median of four years.
A number of factors were identified as key to program success by patients and physicians in the study—including prebiopsy education, receiving detailed test results (confirming stability of the cancer) at follow-up visits, and a supportive and collaborative communication style between physicians and patients.
Since active surveillance is a pronounced de-escalation of thyroid cancer care for many settings, those programs looking to implement it may benefit from this specific educational and supportive approach to care, which Davies and her colleagues propose be called the “guide framework.”
“It’s analogous to a traveler (the patient) and their guide (clinician),” she explains. “The clinician advises on options and advocates for the optimal path over time, and supportively reaffirms the care plan or recommends alternatives as conditions change and they continue on the care path together.”
The Dartmouth Institute for Health Policy and Clinical Practice is a world leader in studying and advancing models for disruptive change in healthcare delivery. The work of Dartmouth Institute faculty and researchers includes developing the concept of shared decision-making between patients and healthcare professionals, creating the model for Accountable Care Organizations (ACOs), and introducing the game-changing concept that more healthcare is not necessarily better care.