Surgical (or Non-Surgical) Managment of Thyroid Cancer in the Era of "Over-Diagnosis" by Lawrence Andrew "Drew" Shirley

Lawrence Andrew “Drew” Shirley
October 14th, 2016
Surgical (or Non-Surgical)
Management of Thyroid Cancer in the
Era of “Over-Diagnosis”

The Problem of Thyroid
Cancer in the 21st Century
2

The Rise of Thyroid Cancer
New Cases of
Differentiated
Thyroid Cancer in
the US:
2009 = 37,200
2014 = 63,000

The Future of Thyroid Cancer
4
Lubitz, et al. Cancer. 2014 May 1;120(9):1345-52
Rahib L, et al. Cancer Res. 2014 74:2913-21.

The Outcomes of Thyroid Cancer
5

The Cost of Thyroid Cancer
 Estimated Cost of Care in 2013 in the US
 $1.6 BILLION
 Projected Cost in 2030
 $3.5 BILLION
6
 2.5 x more likely to file
for bankruptcy than
those without cancer
(highest incidence rate
for any cancer)
Lubitz et al. Cancer. 2014 May 1;120(9):1345-52
Ramsey et al. Health Affairs. 2013 6:1143-52.

Summary of The Problem
 Increasing Incidence
 Increasing Costs
 Stable, Excellent Outcomes
 OVER-TREATMENT
7

How to Slow Over-Treatment of
Differentiated Thyroid Cancer
 Watch It
 Rename It
 Stop Looking for It
8

Watch It
(Extent of Surgery)
9

Sosa, et al. 2014 National Cancer Database
Review
 PTC 1-4cm
 1998-2006
 54,926 total thyroidectomies
 6849 lobectomies
 Assessed for differences in overall survival
10

No Significant Difference in Survival
11

Wang, et al. 2014 Papillary Thyroid
Microcarcinoma Treatment
 Review of 29,512 patients with PTCs <1cm in SEER
 73.4% had total thyroidectomy
 Radioactive Iodine given to 31.3%
 No sig diff in DSS for extent of surgery
 5 and 10 y DSS 99.6, 99.3%
12

Survival of Patients with microPTC Similar to
General Population
13

2015 ATA Guidelines - Let’s Take it Down a
Notch
14
 For Low-risk Differentiated Thyroid Cancers 1-4cm
 “Initial surgical procedure can be either a bilateral
procedure (near total or total thyroidectomy) or a
unilateral procedure (lobectomy)”
 For Microcarcinomas (<1cm)
 “If surgery is chosen”, lobectomy alone is sufficient

Ito et al. 2010 – Observation Trial
 1395 pts with microPTC (<1cm)
 340 observation
 1055 immediate surgery
 Mean observation period 74 months
 109 (32%) observed -> surgery
15

Ito, et al. – 5 and 10 Year Data
 At 10 years, 15.9% tumor grew >3mm and 3.4% with
new LN mets
16
% Tumor Enlargement % Developed Lymph Node Mets

Concurrent Observation Studies
 Sugitani et al, 2010, Japan
 230 patients
 5 year
 4.6% tumor growth, 1.5% LN mets
 15.5% surgery
 Pace et al, 2013 - Memorial Sloan Kettering Group
 Ongoing
 71 patients
 15 months – 1.4% tumor growth and 1.4% LN mets
 8.5% surgery
17

When Papillary Microcarcinomas are Still
Dangerous…
 Clinical presentation, especially vocal cord paralysis
 Present with clinically apparent lymphadenopathy
 Present with distant mets (very rare)
 Present with tall cell variant or poorly differentiated
on FNA (very rare as well)
18

Patients and the “C” Word
19

Patient’s Perception of Thyroid Cancer vs.
Reality
 279 Patients with thyroid cancer given QoL questionnaire 15
years after diagnosis
 19 (7%) had recurrence
 134 (48%) had concerns about recurrence
 Those with concerns has lower HRQoL in 5 areas
22
Hedman et al, Acta Oncol 2015

Thyroid Nodules in the Mainstream Media
23

How Common is EFVPTC?
 Encapsulated follicular variant of papillary thyroid
cancer
 Incidence increased 2-3 fold over 2-3 decades
 Currently, 10-20% of all thyroid cancers
24

Nikiforov, et al. 2016
 24 pathologists reviewed specimens from 109
patients with noninvasive encapsulated follicular
variant of papillary thyroid cancer (EFVPTC)
 Also 101 with invasive EFVPTC
 Assessed for outcomes
25
Nikiforov et al, JAMA Oncology 2016

No Adverse Events for Noninvasive
EFVPTC
26
Nikiforov et al, JAMA Oncology 2016

No More “Cancer”
 Noninvasive encapsulated follicular variant papillary
thyroid cancer has now become…
 Noninvasive follicular thyroid neoplasm with
papillary-like nuclear features or…
 NIFT-P
27

Renaming MicroPTCs?
 5-10% Adults
 Per Mayo Group (Brito, et al), for cancers:
 <2cm
 No family history
 No radiation exposure
 They should now be called…
 Micropapillary lesions of indolent course, or…
 MicroPLICs
28
Brito et al, 2014 Future Oncol. 2014 10:1-4

The Prevalence of Thyroid Pathology
 Thyroid nodules
 Physical Exam – 4-7%
 Imaging – 30-67%
 Autopsy study (1955) – 50% had nodules
 Up to 20% of excised nodules cancer
 Thyroid Cancer
 Autopsy study (1985) – ~ 33% with thyroid cancer
 2-3mm cuts – if 1mm cuts, could approach 50%
30
Mortensen 1955 JCEM
Harach et al, 1985 Cancer 56:531-8

Diagnostic Tools vs. Incidence
32

Davies and Welch, 2014
 Reviewed SEER data from 1975 – 2009
 Incidence tripled 4.9 -> 14.3/100,000
 PTC 3.5 -> 12.5/100,000
 Mortality stable at 0.5/100,000
 Increased incidence -> increased imaging
33

Exposure to Medical Care
 Per Davies and Welch, 3 clinical pathways to
address:
 Opportunistic Screening
 Diagnostic Cascade
 Serendipitous Detection
 “Physicians’ thresholds to palpate, image, and
biopsy the thyroid have likely fallen too far.”
 “Clinicians…need to be asking themselves whether
they are looking too hard for thyroid cancer.”
34

Critics of Davies/Welch Conclusions
 “Had it covered just the last 10 years, critics say, it
would show that the death rate from thyroid disease
is increasing faster than any other cancer except
liver cancer.”
 Large tumor incidence
 Incidence in poorer countries
35

Effect of U/S Screening in South Korea
 In 1999, Korean physicians began offering routine
cancer screenings, including neck U/S
36

Decreased Screening and Thyroidectomy
Rates
37

Mayo Clinic Cohort
 Rochester Epidemiology Project
 Patient Cohort from 1935
 Evaluate How Diagnosed
38

Mayo Group – Incidence vs Mortality
39

Trends in Mayo Cohort – More Low Risk
PTC
40

Mayo Group – How Diagnosed
41

42 Vaccarella S et al. N Engl J Med 2016;375:614-617.
Observed versus Expected Changes in Incidence of
Thyroid Cancer in 12 Countries
• Approximate # of patients “overdiagnosed”
from 1988-2007 per study:
• US - 228,000
• Italy – 65,000
• France – 46,000
• Japan – 36,000
• South Korean women (1993-2007) -
77,000
• Thyroid cancer cases in women due to
“overdiagnosis”:
• South Korea - 90%
• US, Italy, France, and Australia - 70
to 80%
• Japan, the Nordic countries, and
England and Scotland - 50%
• Overall, estimate 470,000 women and
90,000 men “overdiagnosed”
• “Steady incremental increases over time
and little evidence of stabilization.”

New York Times on “Overdiagnosis”
43

Some Choice Quotes from the NYT Article
 70-80 % of women “who were told they had thyroid
cancer…actually had tumors that should have been left
alone”.
 “led doctors to actively look for such minuscule lumps by
screening healthy people”
 “Once doctors find a tiny nodule, removing the thyroid is
often the remedy”
 “Some thyroid cancers, of course, really are dangerous, but
they tend to be larger than the tiny ones found with
scans.”
 “But a rise in cancer cases while the death rate does not
budge points to overdiagnosis.”
 “And that, sadly enough, is what has happened”.
44

Is Incidence Plateauing?
 Update of SEER Data
 From 2010-2012, incidence stabilized
 Attributed to more measured work-up and
treatment
45
Morris, Tuttle, Davies. JAMA Otolaryngol Head Neck Surg. 2016 Jul 1;142(7):709-11.

The Problem with the Solutions
 Many patients will not accept “observation”
 Renaming small cancers will not completely fix, as
small cancers can still metastasize
 Avoiding imaging and further work-up of these
nodules can miss the opportunity to catch these
cancers before they spread
 “Progress, but no precision”
46

Separating Out the Bad Actors
 Imaging
 PET scan/other metabolic imaging
 Molecular testing
 Afirma and Thyroseq (but for cancers specifically)
 BRAF/RAS/TERT promoter mutations
 Other biomarkers…
48

Conclusions
 Thyroid cancer is increasing in incidence, on track to be 4th most
common cancer by 2030
 Majority of this increase in cancer incidence is due to small papillary
thyroid cancers, but they are still treated aggressively
 2015 ATA guidelines recommend more measured approach to work-
up and surgical treatment (lobectomy, possibly observation)
 Observation trials show slow rate of tumor growth and lymph node
metastases – but not ZERO
 Re-naming more indolent thyroid nodules to remove the word
“cancer” may stem aggressive treatment (NEFVPTC -> NIFT-P)
 Some groups advocate lessening imaging and biopsies of thyroid
abnormalities to “decrease” cancer rates and treatment
 Need biomarkers to determine which cancers will spread and which
will remain indolent
49

Acknowledgements
 Department of Surgery:
 Timothy Pawlik
 Steven Steinberg
 Raphael Pollock
 John Phay
 Shirley Lab:
 Sam McCarty
 Ringel Lab:
 Matthew Ringel
 Moto Saji
 Department of Pathology:
 Ben Swanson
50

Surgical (or Non-Surgical) Managment of Thyroid Cancer in the Era of "Over-Diagnosis" by Lawrence Andrew "Drew" Shirley

More Related Content

What's hot

Viewers also liked

Similar to Surgical (or Non-Surgical) Managment of Thyroid Cancer in the Era of "Over-Diagnosis" by Lawrence Andrew "Drew" Shirley

More from OSUCCC - James

Recently uploaded

Surgical (or Non-Surgical) Managment of Thyroid Cancer in the Era of "Over-Diagnosis" by Lawrence Andrew "Drew" Shirley