News
Molecular Imaging News
September 11, 2007
Thyroid Cancer Treatment May Be Overly Aggressive
Reuters Health
Clinically insignificant thyroid cancer may be managed too aggressively in some patients, according to a lecture published in the July issue of the Archives of Otolaryngology-Head and Neck Surgery.
"Physicians need to be more selective in aggressively evaluating stable elevations of thyroglobulin in low risk (AJCC Stage 1) patients and avoid sonographic biopsy of small, possibly positive nodes," Dr. Keith S. Heller told Reuters Health.
In the 2006 Hayes Martin Lecture, Dr. Heller from New York University School of Medicine, New York , discussed the role of thyroglobulin in the management of thyroid cancer.
Dr. Heller contends that several of the American Thyroid Association guidelines for the management of patients with thyroid nodules and differentiated thyroid cancer (DTC) may lead to overly aggressive treatment of clinically insignificant cancers.
Especially in need of modification, he said, are "R21, R28, and R48, which all relate to sonography as well as a reevaluation of how much of a thyroglobulin elevation requires further evaluation other than repeat thyroglobulin."
After reviewing some of the articles that led to these guidelines, Dr. Heller asserts, "All of these studies, guidelines, and recommendations lack data that prove that the presence of these minimally involved lymph nodes in any way affects the patient's prognosis, nor are there any data that the removal or treatment of these nodes improves their survival. I find these guidelines very troubling for those reasons."
In Dr. Heller's personal experience with 360 patients younger than 45 years at the time of initial treatment for DTC, 99% are alive. Three died of non-cancer-related causes, and only one died of thyroid cancer.
Similarly, among 449 of his older patients with previously untreated DTC, 91% are alive, and only 8 of the 40 who died, died of thyroid cancer.
"My objection is not that the guidelines are wrong, but that they need to be clearer in using risk stratification to determine which patients need to be the subject of which guidelines," Dr. Heller said. "In many ways the ability to detect microscopic metastatic thyroid cancer creates a dilemma similar to that faced by urologists when an elevated PSA leads to the detection of microscopic prostate cancer. Clearly, not all of these need to be treated."
In his lecture, Dr. Heller concludes: "We have embarked on a quixotic quest to rid our patients of microscopic and probably clinically unimportant thyroid cancer. We need to refocus our efforts, not to detect more occult disease, but to identify and cure those few patients whose disease is likely to shorten their lives."
