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Active surveillance for young patients with insular thyroid cancer: an initial and novel finding.

ABSTRACT: Insular thyroid cancer (ITC) is a relatively rare thyroid malignancy that has an unclear prognosis. Recent studies have indicated that watchful waiting is sufficient for younger patients with more differentiated thyroid lesions such as papillary thyroid microcarcinoma (PTMC). In this study, we investigated the prognosis of younger patients (< 45 and < 55 years old) with ITC and compared their outcomes to patients with PTMC and follicular thyroid microcarcinoma (FTMC). We hypothesized that ITC, like PTMC and FTMC, can be managed with active surveillance in younger patients with this disease. We investigated a large cohort of younger patients with ITC, PTMC, or FTMC who were listed in the Surveillance, Epidemiology, and End Results database between 2004 and 2013. Patient mortality was examined by Kaplan-Meier analyses with log-rank tests and Cox proportional hazards regression analyses. In the study cohort, the rate of cancer-specific mortality per 1000 person-years for younger ITC patients (< 45 and < 55 years) was lower than that for PTMC and FTMC. Kaplan-Meier analyses revealed that the cancer-specific and all-cause mortality rates in younger ITC patients were similar to those of PTMC and FTMC. Similar results were obtained when cases with tumor extension were excluded from the analysis. The unanticipated excellent prognosis of younger patients with ITC challenges the current clinical practice of automatically treating this disease, and offers new implications for management such as pursuing active surveillance instead.

SUBMITTER: Liu Z

PROVIDER: S-EPMC6357322 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Active surveillance for young patients with insular thyroid cancer: an initial and novel finding.

Liu Zeming Z Zeng Wen W Zhou Ling L Zhou Wei W Chen Danyang D Feng Haifeng H Wei Wei W Zhang Chao C Wang Min M Guo Liang L

American journal of translational research 20190115 1

Insular thyroid cancer (ITC) is a relatively rare thyroid malignancy that has an unclear prognosis. Recent studies have indicated that watchful waiting is sufficient for younger patients with more differentiated thyroid lesions such as papillary thyroid microcarcinoma (PTMC). In this study, we investigated the prognosis of younger patients (< 45 and < 55 years old) with ITC and compared their outcomes to patients with PTMC and follicular thyroid microcarcinoma (FTMC). We hypothesized that ITC, l ...[more]

PMID: 30787977

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Project description:ImportanceSmall papillary thyroid cancers are the most common type of thyroid cancer, with the incidence increasing across the world. Active surveillance of appropriate cancers has the potential to reduce harm from overtreatment but is a significant de-escalation from prior practice. Mechanisms that inform the rates of retention and adherence have not been described and need to be understood if broader uptake is to be considered.ObjectiveTo evaluate patient retention, adherence, and experience in the largest and most long-standing thyroid cancer active surveillance program, to our knowledge.Design, setting, and participantsA cohort study using convergent design mixed-methods analysis of attendance data, semistructured interviews, and field observation was conducted at Kuma Hospital, Kobe, Japan. Participants included 1179 patients who were enrolled in surveillance between February 1, 2005, and August 31, 2013, and followed up through December 31, 2017. Data analysis was performed from January 25, 2018, through September 30, 2020.Main outcomes and measuresPatients were considered adherent if they underwent ultrasonography within at least 13 months of the previous ultrasonographic examination. Patients were considered retained if they continued surveillance with an ultrasonographic examination at least every 2 years, without having had surgery for patient preference or clinical reasons.ResultsOf the 1179 patients included in the study, 1037 (88%) were women. The mean (SD) age was 56 (13.5) years (median, 57 years). Patients were followed up for up to 12.76 years (median, 5.97 years) and underwent a median of 9 ultrasonographic examinations (range, 2-50); 76 patients (6.4%) had surgery for clinical reasons. In analysis of retention, 53 of 1179 patients (4.5%) changed to surgery after a mean (SD) of 2.14 (1.53) years (median, 1.47; range, 0.14-7.17 years); at the study end point, 101 of 1179 patients (8.6%) had not been seen at Kuma Hospital in at least the past 2 years. Kaplan-Meier analysis to 10 years of follow-up time without structural progression estimated that 21.5% (95% CI, 17.0%-28.2%) of patients would not have had an ultrasonographic examination within at least the past 2 years. Mean adherence over a surveillance period of 10 follow-up ultrasonographic examinations (8878 person-examinations) was 91% (range, 85%-95%). Receipt of detailed test results, education regarding active surveillance, and supportive/collaborative style interactions with their physician were identified by patients as key factors for continuing surveillance.Conclusions and relevanceFor patients with low-risk papillary thyroid cancer participating in active surveillance, retention in the program and adherence to follow-up ultrasonographic examination do not appear to be barriers to broader implementation of surveillance. The program's success may benefit from an approach analogous to traveler (patient) and their guide (clinician): the clinician advising on options, advocating for the optimal path over time, and supportively reaffirming the care plan or recommending alternatives as conditions change.

Project description:BackgroundThe inclusion criterion for active surveillance (AS) is low- or intermediate-risk prostate cancer. The predictive value of the presence of a suspicious lesion at magnetic resonance imaging (MRI) at the time of inclusion is insufficiently known.ObjectiveTo evaluate the percentage of patients needing active treatment stratified by the presence or absence of a suspicious lesion at baseline MRI.Design setting and participantsA retrospective analysis of the data from the multicentric AS GAP3 Consortium database was conducted. The inclusion criteria were men with grade group (GG) 1 or GG 2 prostate cancer combined with prostate-specific antigen <20 ng/ml. We selected a subgroup of patients who had MRI at baseline and for whom MRI results and targeted biopsies were used for AS eligibility. Suspicious MRI was defined as an MRI lesion with Prostate Imaging Reporting and Data System (PI-RADS)/Likert ≥3 and for which targeted biopsies did not exclude the patient for AS.Outcome measurements and statistical analysisThe primary outcome was treatment free survival (FS). The secondary outcomes were histological GG progression FS and continuation of AS (discontinuation FS).Results and limitationsThe study cohort included 2119 patients (1035 men with nonsuspicious MRI and 1084 with suspicious MRI) with a median follow-up of 23 (12-43) mo. For the whole cohort, 3-yr treatment FS was 71% (95% confidence interval [CI]: 69-74). For nonsuspicious MRI and suspicious MRI groups, 3-yr treatment FS rates were, respectively, 80% (95% CI: 77-83) and 63% (95% CI: 59-66). Active treatment (hazard ratio [HR] = 2.0, p < 0.001), grade progression (HR = 1.9, p < 0.001), and discontinuation of AS (HR = 1.7, p < 0.001) were significantly higher in the suspicious MRI group than in the nonsuspicious MRI group.ConclusionsThe risks of switching to treatment, histological progression, and AS discontinuation are higher in cases of suspicious MRI at inclusion.Patient summaryAmong men with low- or intermediate-risk prostate cancer who choose active surveillance, those with suspicious magnetic resonance imaging (MRI) at the time of inclusion in active surveillance are more likely to show switch to treatment than men with nonsuspicious MRI.

Project description:In the United States, 192,000 men were diagnosed as having prostate cancer in 2009, the majority with low-risk, clinically localized disease. Treatment of these cancers is associated with substantial morbidity. Active surveillance is an alternative to initial treatment, but long-term outcomes and effect on quality of life have not been well characterized.To examine the quality-of-life benefits and risks of active surveillance compared with initial treatment for men with low-risk, clinically localized prostate cancer.Decision analysis using a simulation model was performed: men were treated at diagnosis with brachytherapy, intensity-modulated radiation therapy (IMRT), or radical prostatectomy or followed up by active surveillance (a strategy of close monitoring of newly diagnosed patients with serial prostate-specific antigen measurements, digital rectal examinations, and biopsies, with treatment at disease progression or patient choice). Probabilities and utilities were derived from previous studies and literature review. In the base case, the relative risk of prostate cancer-specific death for initial treatment vs active surveillance was assumed to be 0.83. Men incurred short- and long-term adverse effects of treatment.Hypothetical cohorts of 65-year-old men newly diagnosed as having clinically localized, low-risk prostate cancer (prostate-specific antigen level <10 ng/mL, stage ?T2a disease, and Gleason score ?6).Quality-adjusted life expectancy (QALE).Active surveillance was associated with the greatest QALE (11.07 quality-adjusted life-years [QALYs]), followed by brachytherapy (10.57 QALYs), IMRT (10.51 QALYs), and radical prostatectomy (10.23 QALYs). Active surveillance remained associated with the highest QALE even if the relative risk of prostate cancer-specific death for initial treatment vs active surveillance was as low as 0.6. However, the QALE gains and the optimal strategy were highly dependent on individual preferences for living under active surveillance and for having been treated.Under a wide range of assumptions, for a 65-year-old man, active surveillance is a reasonable approach to low-risk prostate cancer based on QALE compared with initial treatment. However, individual preferences play a central role in the decision whether to treat or to pursue active surveillance.

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Active surveillance for young patients with insular thyroid cancer: an initial and novel finding.

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Active surveillance for young patients with insular thyroid cancer: an initial and novel finding.

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