Most patients who undergo thyroid surgery initially present as asymptomatic: JAMA
Dr Sajisevi and colleagues reported the findings of a retrospective analysis of 1328 patients in 16 centers in 4 countries who underwent thyroid surgery for thyroid pathology in 2019. Patients were classified by the mode of detection of the thyroid findings that led to surgery: endocrinopathic condition, patient-requested screening, clinician-screening physical examination, radiologic serendipity, diagnostic cascade, symptomatic thyroid disease, and under surveillance. The primary outcomes were the mode of detection and the proportion and size of thyroid cancers discovered in patients who were asymptomatic. The authors found that 41% of patients were asymptomatic at the time of the detection of the thyroid condition, while 34% of patients had structural thyroid symptoms at the time of detection. The remaining 25% of patients were either under surveillance for known thyroid pathology, such as thyroid nodules, or had an endocrinopathic condition, such as hyperthyroidism, hyperparathyroidism, or multiple endocrine neoplasia syndrome. Of the 1328 cases, 613 (46%) revealed thyroid cancer. The authors also found that 51% of these cancers were in asymptomatic patients, while only 30% were in symptomatic patients. Finally, the mean tumor size was significantly larger in symptomatic compared with asymptomatic patients (3.2 cm vs 2.1 cm).
Dr Sajisevi and colleagues examined an important clinical question: What begins the process that eventually leads to thyroid surgery? Interestingly, most patients initially presented without any thyroid-related symptoms. These asymptomatic patients formed 4 groups: patient-requested screening, clinician-screening physician examination, radiologic serendipity, and diagnostic cascade. Within each of the 4 groups, clinical evaluation can be classified as either appropriate or inappropriate. Both patient-requested screening and diagnostic cascade may lead to inappropriate clinical evaluation with a thyroid ultrasonography. The US Preventive Services Task Force recommends against screening for thyroid cancer with ultrasonography in asymptomatic patients because of the potential for increased harms without clinical benefit. Fortunately, this study found that patient-requested screening was a rare event, although it is still occurring and leading to thyroid surgery. Diagnostic cascade, such as ordering a thyroid ultrasonography for evaluation of hypothyroidism, is also an inappropriate clinical evaluation. A thyroid ultrasonography is used to evaluate structural thyroid disease, not functional thyroid disease, such as hypo- or hyperthyroidism, but is often ordered in error for evaluation of these conditions. This, in essence, is screening for thyroid cancer. A focus on these 2 areas to address inappropriate thyroid ultrasonography would lead to fewer unnecessary thyroid surgeries.
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