Low-risk Thyroid Cancer, Surgical Training, and Radioactive Iodine

Abstract

Schuessler1 and her colleagues from the University of Michigan have undertaken an interesting and complex study of surgeon training and use of radioactive iodine for low risk thyroid cancer patients. This study is based on several hypotheses, a questionnaire to the surgeons and correlating their training to radioactive iodine use. Clearly, management of thyroid cancer starting from extent of thyroidectomy, radioactive iodine use and extent of suppressive therapy continue to be a controversial subject and depends on experience and judgment of the treating physician. Even though there are no firm standards of practice, the general tendency in the United States appears to be total thyroidectomy followed by radioactive iodine ablation. Some of these decisions are made definitely by surgeons who have performed the surgical procedure; however, there is an enormous impact of endocrinologists, and the patient themselves having read extensively on Google. Clearly, trying to correlate these issues of treatment, referring specifically to the surgeon training, parent specialty, and attending the professional meeting may be difficult. In any case, the authors have made a genuine effort to correlate these issues and concluded that training with a thyroid surgeon and attending one or more professional society meeting a year was associated with lower rate of hospital based RAI use. Clearly, these conclusions may be difficult to digest because decision making regarding RAI is generally not one individual decision. The manuscript mentions Stage I thyroid cancer patients while a majority of the manuscript discusses the low risk thyroid cancer patients. Clearly, Stage I thyroid cancer patients, especially below the age of 45 with lymph node metastasis, definitely will require radioactive iodine and is quite rational approach, while in the truly low risk thyroid cancer patient, where the tumor appears to be intrathyroidal, the role of radioactive iodine is always questioned and similar opinion is reflected in the ATA guidelines. The basic conclusion that can be made out of this manuscript is the surgeon training, and the experience of the surgeon is more important in treatment policies.Having read this manuscript several times, certain important points need to be highlighted. The collection of the data and its relation to NCDB is quite complex. It should be mentioned that the average surgeon age was 51 years and the surgeon's average years in practice was 19. This reflects the seniority of the surgeons and their training several years before the ATA guidelines and our recent multidisciplinary management of thyroid cancer.The practice distribution of thyroidectomy is also quite interesting that the general surgeons comprised of 39 % while the otolaryngologists comprised of 44 % a reflection of current shifting practice pattern in the United States. There are very few individuals who are members of the American Association of Endocrine Surgeons with high level training background of the endocrine surgery. The authors have mentioned ab...