Active Surveillance

The epidemic of new thyroid cancers is not supported by autopsy findings reported below.The incidence of incidental papillary cancer seen at autopsy has not changed. The increase in cancers seen today is not due to increase in tumor formation, but due to diagnostic detection by physicians using advanced images methods such as ultrasound, CT.MR and PET.

Richard Guttler MD,FACE,ECNU

Purpose Differentiated thyroid cancer (DTC) incidence has been reported to have increased three- to 15-fold in the past few decades. It is unclear whether this represents overdiagnosis or a true increase in incidence. Therefore, the current study aimed to estimate the prevalence of incidental DTC in published autopsy series and determine whether this prevalence has been increasing over time.

Materials and Methods PubMed, Embase, and Web of Science were searched from inception to December 2015 for relevant studies. Two authors searched for all autopsy studies that had included patients with no known history of thyroid pathology and reported the prevalence of incidental DTC (iDTC). Two authors independently extracted the data, and discrepancies were resolved by another author. The pooled prevalence of iDTC was assessed using a fixed-effects meta-analysis model with robust error variance. The time effect was studied using an inverse-variance weighted logit-linear regression model with robust error variance and a time variable.

Results Thirty-five studies, conducted between 1949 and 2007, met the inclusion criteria and contributed 42 data sets and 12,834 autopsies. The prevalence of iDTC among the partial and whole examination subgroups was 4.1% (95% CI, 3.0% to 5.4%) and 11.2% (95% CI, 6.7% to 16.1%), respectively. Once the intensiveness of thyroid examination was accounted for in the regression model, the prevalence odds ratio stabilized from 1970 onward, and no time effect was observed.

Conclusion The current study confirms that iDTC is common, but the observed increasing incidence is not mirrored by prevalence within autopsy studies and, therefore, is unlikely to reflect a true population-level increase in tumorigenesis. This strongly suggests that the current increasing incidence of iDTC most likely reflects diagnostic detection increasing over time.

OBJECTIVE: Active Surveillance of Micro-Papillary Ca
The dramatic increase in papillary thyroid carcinoma

(PTC) is primarily a result of early diagnosis of small

cancers. Active surveillance is a promising management

strategy for papillary thyroid microcarcinomas (PTMCs).

However, as this management strategy gains traction in

the U.S., it is imperative that patients and clinicians be

properly educated, patients be followed for life, and

appropriate tools be identified to implement the strategy.

METHODS:
We review previous active surveillance studies and the

parameters used to identify patients who are good

candidates for active surveillance. We also review some

of the challenges to implementing active surveillance

protocols in the U.S. and discuss how these might be

addressed.

RESULTS:
Trials of active surveillance support nonsurgical

management as a viable and safe management

strategy. However, numerous challenges exist, including

the need for adherence to protocols, education of

patients and physicians, and awareness of the impact of

this strategy on patient psychology and quality of life.

The Thyroid Cancer Care Collaborative (TCCC) is a

portable record keeping system that can manage a

mobile patient population undergoing active

surveillance.

CONCLUSION:
With proper patient selection, organization, and patient

support, active surveillance has the potential to be a

long-term management strategy for select patients with

PTMC. In order to address the challenges and

opportunities for this approach to be successfully

implemented in the U.S., it will be necessary to consider

psychological and quality of life, cultural differences.

” May you live all the days of your life.”

Jonathan Swift ( 1667-1745 )

The incidence of thyroid cancer has tripled over the past 3 decades, with the vast majority of the increase noted to be among small, indolent papillary thyroid carcinomas. Substantial overdiagnosis and potential overtreatment have led to a shift in clinical practice toward less aggressive approaches and a focus on improved risk stratification. This shift in practice may be associated with recent evidence suggesting that the increase in the incidence of thyroid cancer is slowing. Because patients are often young when they are diagnosed with thyroid cancer and because there is excellent long-term, disease-specific survival, there is an ever-growing population of survivors of thyroid cancer in the United States who accumulate substantial associated health care costs as they undergo surveillance and/or remedial treatment. Survivors of thyroid cancer can experience significant detriments to their quality of life and endure financial hardship. Future research should focus on the appropriateness of treatment as well as the financial and quality-of-life effects of thyroid cancer survivorship.

Annual financial impact of well-differentiated thyroid cancer care in the United States.

Well-differentiated thyroid cancer (WDTC) is a prevalent disease, which is increasing in incidence faster than any other cancer. Substantial direct medical care costs are related to the diagnosis and treatment of newly diagnosed patients as well as the ongoing surveillance of patients who have a long life expectancy. Prior analyses of the aggregate health care costs attributable to WDTC in the United States have not been reported. A stacked cohort cost analysis was performed on the US population from 1985 to 2013 to estimate the number of WDTC survivors in 2013. Incidence rates, and cancer-specific and overall survival were based on Surveillance, Epidemiology, and End Results (SEER) data. Current and projected direct medical care costs attributable to the care of patients with WDTC were then estimated. Health care-related costs and event probabilities were based on Medicare reimbursement schedules and the literature. Estimated overall societal cost of WDTC care in 2013 for all US patients diagnosed after 1985 is $1.6 billion. Diagnosis, surgery, and adjuvant therapy for newly diagnosed patients (41%) constitutes the greatest proportion of costs, followed by surveillance of survivors (37%), and nonoperative death costs attributable to thyroid cancer care (22%). Projected 2030 costs (in 2013 US dollars) based on current incidence trends exceed $3.5 billion.Health care costs of WDTC are substantial. Unlike other cancers, the majority of the cost is incurred in the initial and continuing phases of care. With the projected increasing incidence, population, and survival trends, costs will continue to escalate.

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