Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi‐institutional Study

Abstract

Objective Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population. Study Design This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules. Setting Multi-institutional. Methods Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients. Results A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery. Conclusion While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

Experiences of older people, healthcare providers and caregivers on implementing person-centered care for community-dwelling older people: a systematic review and qualitative meta-synthesis

“…Most participants emphasized the significance of person-centered communication skills and shared decision-making capabilities for implementing effective PCC interventions in the community. Through shared decision-making, older people's values and preferences are combined with the expertise and knowledge of their caring teams [ 43 ]. Older people should express their needs and preferences clearly to translate them into professional actions that result in person-centered outcomes [ 44 ].…”

Perspectives of older people and healthcare providers on implementing person-centred care for community-dwelling older people: a systematic review and qualitative meta-synthesis

“…Enhancing the person-centred communication skill of HCPs and decision-making capabilities among older people were cornerstones for implementing PCC in community. Older values and preferences are incorporated with the expertise and knowledge of their treating teams through shared decision-making [30]. This PCC intervention will require older people to clearly express their needs and preferences in order to be translated into professional expectations and actions as person-centred outcomes [31].…”

Comment on: "Evaluating treatment options in managing thyroid nodules with indeterminate cytology of TBSRTC in thyroidology: addendum aut non?"

“…Management of thyroid nodules with indeterminate cytology remains a major challenge for thyroidology. We read with a great deal and respect the article by Kuta and colleagues 1 entitled, “Treatment choices in managing Bethesda III and IV thyroid nodules: a Canadian multi-institutional study.” The authors reported their objective as identifying the factors associated with decision-making in that population and concluded that the larger nodules, younger age, and higher category of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) 2 were associated with decision for surgery. However, they stated that they considered 3 cm as the cutoff point for the determination of nodule size 1 .…”

“…We read with a great deal and respect the article by Kuta and colleagues 1 entitled, “Treatment choices in managing Bethesda III and IV thyroid nodules: a Canadian multi-institutional study.” The authors reported their objective as identifying the factors associated with decision-making in that population and concluded that the larger nodules, younger age, and higher category of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) 2 were associated with decision for surgery. However, they stated that they considered 3 cm as the cutoff point for the determination of nodule size 1 . Nevertheless, the 8th edition of The American Joint Committee on Cancer/Tumor, Node, and Metastasis (AJCC/TNM) Staging System reported the size cutoff points of 2 and 4 cm for T2 and T3 tumors, respectively.…”