Can We Discharge Dynamically Risk-Stratified Low-Risk (Excellent Response to Treatment) Thyroid Cancer Patients After 5 Years of Follow-Up?

Abstract

Aims: The 2014 British Thyroid Association thyroid cancer guidelines recommend lifelong follow-up of thyroid cancer patients. This is probably unnecessary, can cause patient anxiety, is time consuming and places significant demand on National Health Service resources. It has been suggested that low-risk differentiated thyroid cancer (DTC) patients could be discharged to primary care once they are 5 years from diagnosis and treatment. The aim of this study was to investigate the potential safety of this practice. Materials and methods: In total, 756 patients with dynamically risk-stratified (DRS) low-risk/excellent response to treatment DTC treated over 2001e2013 in the Leeds region were followed after diagnostic surgery and the recurrence rate calculated. Results: The median follow-up time was nearly 10 years (5e17 years). Radiological recurrence occurred in 13/756 (1.7%) patients and was always preceded by raised thyroglobulin/ thyroglobulin antibody levels. In all 13 patients elevation of thyroglobulin occurred within 5 years of diagnosis. Two additional patients were found to have rising thyroglobulin at almost 9 and 10.5 years from diagnosis, although to date radiological recurrence has not been detected. Assuming these two patients developed recurrence with longer duration of follow-up, then 0.26% (2/756) of patients would not have their recurrence discovered within 5 years of diagnosis. To detect 100% of patients with a putative recurrence in our cohort would require 10.5 years of follow-up. Four patients had transiently raised thyroglobulin, which became undetectable within 2 years (in three patients), without any treatment and radiological recurrence was not discovered. Conclusion: Discharge of DRS low-risk DTC patients to primary care after 5 years of secondary care follow-up is reasonable, accepting that late recurrence may occur in a very small minority of individuals (0.26%, w1:400). A more cautious approach would be to continue monitoring for 10 years, although the frequency of assessments could be reduced with increasing duration of follow-up.

Outcomes of 756 patients with differentiated thyroid cancer and excellent response to treatment: An evidence‐based paradigm for long‐term surveillance strategies

“…Our findings confirm a remarkable prognosis after an excellent response to treatment upon DRS comparable to previous studies that have shown a risk of 1%–4% tumour recurrence over 5–10 years 8–11 . Importantly, biochemical recurrence became evident in all patients before detection of the structural disease on imaging, although unfortunately, only four patients had ‘curable’ recurrence.…”

Outcomes of Patients With Metastatic Differentiated Thyroid Cancer After Excellent Response to Treatment

“…These findings suggest that long-term follow-up of Tg in patients with excellent response is needed. A similar study reveals 1.1% of DTC patients with excellent response to initial therapy developed metastatic disease during a median follow-up of 10 years (9). The most common metastatic site was lung in our (71.4%) and that (75.0%) studies.…”

“…Patients with excellent response have a low recurrence rate (1-4%) and low mortality rate (<1%) ( 8 ). Therefore, a decrease in the intensity and frequency of follow-up is recommended for patients who have excellent response to initial therapy ( 9 ).…”

Unexplained Hyperthyroglobulinemia in Differentiated Thyroid Cancer Patients as an Indication for Radioiodine Adjuvant Therapy: A Prospective Multicenter Study

“…It has been acknowledged that patients with S/FIR require a more intensive follow-up than those with non-S/FIR (1,17,18). Conversely, a non-S/FIR means a < 1% rate of disease-specific death (1,19). The current study revealed no significant difference in response to RAT among the three risk groups, manifesting that RAT using a high activity of 5.55 GBq can yield similar short-term efficacies among the three-tiered risk groups.…”