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Special Communication |

Incidental Thyroid Nodules and Thyroid Cancer Considerations Before Determining Management

Ralph P. Tufano, MD, MBA1; Salem I. Noureldine, MD1; Peter Angelos, MD, PhD2
[+] Author Affiliations
1Division of Head and Neck Endocrine Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Department of Surgery, Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
JAMA Otolaryngol Head Neck Surg. 2015;141(6):566-572. doi:10.1001/jamaoto.2015.0647.
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The worldwide incidence of thyroid cancer is increasing substantially, almost exclusively attributable to small papillary thyroid cancers. Increased use of diagnostic imaging is considered the most likely explanation for this reported rise, but other factors may also be contributing. The increase in health care expenditures related to managing these presumably low-risk cancers, without a clear patient benefit, has resulted in a backlash against the early detection of thyroid cancer. Currently, there is no way to confidently predict which incidentally detected thyroid nodule may be the precursor to a more aggressive process. Predictions such as these would require more accurate characterization of the biology of individual thyroid cancers than is currently possible. With time, we might prove our ability to confidently differentiate low-risk from high-risk thyroid cancers, but until that happens, routine screening for thyroid cancer by imaging billed as a “health checkup” should not be performed. However, incidentally detected thyroid nodules should be reported, and a clear medical team management plan should be developed. Our ethical responsibility is to provide patients with objective, evidence-based information about their disease status, not to assume that we know what is best for them by selectively withholding information. In addition, providing patients with psychosocial assistance will help them process the information necessary to make informed decisions that will provide them with the most value when a small thyroid nodule or cancer is incidentally identified. Herein, we summarize the epidemiological data for disease incidence, discuss some controversies in disease management, and outline the key elements and ethical considerations of informed decision making as they apply to managing incidentally detected thyroid nodules and thyroid cancer.

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Figure.
Different Behaviors and Rates of Growth of Thyroid Cancers That Determine Their Potential to Be Detected by Screening

Tumor A grows rapidly and therefore is not usually detected by screening. This tumor is diagnosed clinically in the interval between screening examinations and has a poor prognosis. Tumor B is capable of metastasizing and progressing into advanced disease, but it grows slowly enough to be detected by screening (*). In most cases, early detection and treatment will result in disease-free survival. Tumor C eventually becomes detectable by screening (*), but it is so indolent that it will never progress to affect the quality of life of the patient. Its detection will result in overdiagnosis and potentially overtreatment. Molecular markers and other objective predictors of an individual patient's tumor behavior might be identified that will allow us to confidently differentiate low-risk (tumor C) from high-risk (tumor A and tumor B) thyroid cancer, but those predictors have not been elucidated yet.

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