The guidelines had a profound impact on clinical practice that spanned the entire breadth of how we assess and manage patients with thyroid nodules and thyroid cancer. —David Terris, MD
Explore This IssueFebruary 2020
“These specific recommendations linked to voice and larynx are very important to otolaryngologists because we are the specialty that are able to examine the larynx, assess voice, and know about the larynx and its innervation,” he said. “Inclusion of these recommendations that focus on the larynx and voice indicates the importance of the otolaryngologist in the evaluation and management of these patients.”
Along with these changes in surgery, other changes to treatment include the use of radioactive iodine. Rather than using it in everyone who undergoes a total thyroidectomy, as has been the standard approach for many years, the 2015 guidelines recommend increasing the threshold for delivering radioactive iodine for thyroid cancer. “If a thyroid cancer has been judged to be low risk, we don’t feel as obligated to obsess over the thyroglobulin anymore and therefore don’t need to give all these patients radioactive iodine,” said Dr. Terris. “This reduces side effects, as well as cancer itself, from the radiation, so we’re doing patients a favor by avoiding treatment with radioactive iodine.”
One other change to practice suggested in the 2015 guideline is the potential for patients with small thyroid cancers that have not spread outside the gland, especially older patients, to undergo active surveillance. “The recognition that these older patients with small cancers may not need any treatment as long as they are getting active surveillance is new,” said Dr. Steward, citing evidence emerging from Japan over the past 10 years.
“This is not widely accepted in the 2015 guidelines, but will be more highlighted in the upcoming guideline,” he said.
Upcoming Updated Guideline
The ATA is working on its next iteration of the guidelines. According to Lisa Orloff, MD, director of endocrine head and neck surgery at Stanford University School of Medicine, director of the Stanford Thyroid Tumor Program at the Stanford Cancer Center in Stanford, Calif., and co-chair of the guideline, the upcoming updated guideline will be split into two separate documents: one focusing on the management of benign thyroid nodules and the other focusing on the management of differentiated thyroid cancer. “Both documents will have new information on diagnostic categories such as noninvasive follicular thyroid neoplasm with papillary-like nuclear features, nonsurgical alternatives to management, and new evidence on outcomes,” she said. “The discussion of molecular testing of thyroid nodules will be much more detailed as genetic tests and information have evolved, and recommendations for surgical decision-making and variations [on] and alternatives to surgery will also be expanded.”
The estimated target date for completion is December 2020.