Challenges of Shared Decision-making by Clinicians and Patients With Low-risk Differentiated Thyroid Cancer

Abstract

ImportanceSeveral international guidelines have endorsed more conservative treatment of low-risk differentiated thyroid cancer (LRDTC), yet patients are facing more treatment options with similar oncologic outcomes and are expressing feelings of confusion, dissatisfaction, and anxiety. Shared decision-making, which considers the patient’s values and preferences along with the most reliable medical evidence, has been proposed to optimize patient satisfaction in the context of the current clinical equipoise.ObjectivesTo understand key individual and behavioral factors affecting the patient and clinician decision-making process in treatment decision for LRDTC.Evidence ReviewThis systematic review and meta-ethnography involved a comprehensive literature search of MEDLINE, Embase, PubMed, and CINAHL databases for qualitative and mixed-method studies on patient and clinician experiences with the decision-making process for LRDTC treatment. The quality of the studies was assessed using the Mixed Methods Appraisal Tool; meta-ethnography was used for data analysis. Primary and secondary themes of the included studies were extracted, compared, and translated across articles to produce a lines-of-argument synthesis.FindingsOf 1081 publications identified, 12 articles met the inclusion criteria. The qualitative synthesis produced 4 themes: (1) a bimodal distribution of patient preferences for treatment decisions; (2) clinician anxiety affected equipoise and biased their recommendations; (3) clinicians struggled to identify patient concerns and preferences; and (4) the clinician-patient relationship and psychosocial support were key to shared decision-making but were frequently overlooked.Conclusions and RelevanceThe findings of this systematic review and meta-ethnography emphasize the need for better patient-clinician communication, particularly with respect to eliciting patient concerns and preferences. With an ever-increasing pool of thyroid cancer survivors, future efforts should be directed at establishing and evaluating tools that will aid in shared decision-making for treatment of patients with LRDTC.Trial RegistrationPROSPERO Identifier: CRD42022286395

Shared Decision-making Among Clinicians and Patients With Low-risk Differentiated Thyroid Cancer

“…To the Editor Yang et al have extolled the virtues of shared decision-making due to the high number of treatment options for low-risk differentiated thyroid cancer and recommend the establishment and evaluation of decision-making tools for clinicians and patients. This is an important contribution to the debate on morbidity of total thyroidectomy for thyroid carcinoma.…”

“…In the systematic review by Yang et al, all studies in the final synthesis were anglophone and from high-resource settings in North America, Australia, and the Netherlands. Although this may represent a dearth of qualitative enquiry on this topic from other regions, the true breadth of the treatment options and decision-making complexity can only be appreciated by also considering the views of patients and clinicians in low-resource settings.…”

“…One of the themes identified in the review was clinician anxiety regarding patient concerns around consent. The review cites multiple international guidelines to suggest deescalation in treatment strategies, but all the cited guidelines are from North America or Europe.…”

Shared Decision-making Among Clinicians and Patients With Low-risk Differentiated Thyroid Cancer—Reply

“…Our systematic review was conducted with strict adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines . The literature search was performed independently by 2 of the authors using 4 recognized databases at 2 different time points and with additional articles sought by reviewing reference lists of identified key articles.…”

“…In our systematic review, we highlighted several international thyroid cancer treatment guidelines that have specifically endorsed individualized decision-making in the presence of clinical equipoise. Our aim was to demonstrate that despite these well-established guidelines, the evidence suggests that many clinicians are reluctant to discuss all available treatment options with patients, and they also fail to identify the concerns and preferences of patients.…”