Dataset Information

Thyroid Cancer Active Surveillance Program Retention and Adherence in Japan.

ABSTRACT:

Importance

Small 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.

Objective

To evaluate patient retention, adherence, and experience in the largest and most long-standing thyroid cancer active surveillance program, to our knowledge.

Design, setting, and participants

A 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 measures

Patients 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.

Results

Of 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 relevance

For 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.

SUBMITTER: Davies L

PROVIDER: S-EPMC7689571 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundActive surveillance (AS) is recommended by most national medical organizations as the preferred treatment option for men with low-risk prostate cancer (PCa). However, studies report that up to one third of men on AS dropout within 5 years, without evidence of disease progression. Despite high dropout rates, few studies have purposively explored the opinions and experiences of men who discontinued AS. The aim of this study was to gain insight into the reasons why some men on AS for PCa discontinue active treatment without evidence of disease progression.MethodsSemi-structured interviews were undertaken with 14 men from diverse socio-cultural backgrounds who had been on AS for PCa but dropped out of surveillance to undergo active treatment without signs of disease progression. Purposive sampling to reach data saturation was used to select participants based on their experience of AS and willingness to share their experiences. Interviews were transcribed and analysis undertaken in an inductive thematic manner.ResultsThe following themes arose from interviews as factors that potentially influence adherence to AS: men's experience at diagnosis and follow-up consultations, involvement in shared decision-making, the extent of supportive care and information, administrative procedures and support from partner and peers. A poor experience during diagnosis could adversely influence long-term adherence to AS, given the same diagnostic tests are frequently repeated. The provision of consistent information and support while on AS, similar to that offered to men undergoing radical treatment, was also highlighted as being important to increase confidence in the process.ConclusionsEffective communications skills among health professionals, aimed at building trust in patient-clinician relationships, providing opportunities for shared decision-making and developing self-efficacy, along with structured information and support, are key to enhancing long-term adherence to AS.

Project description:Many men diagnosed with localized prostate cancer can postpone definitive treatment without raising their risk of metastasis or death from disease. Active surveillance (AS) is a method of monitoring select men, with the option of switching to active treatment upon signs of progression, thereby avoiding the well-known side-effects of surgery and radiotherapy. This review analyzes the data from long-running AS cohorts to determine the safety and efficacy of AS. We conducted a narrative review of recently published data, including 14 articles from 13 AS cohorts. The cohorts used varying inclusion criteria, with reported differences in clinical T stage and Gleason Score (Grade Group), among other features. Some studies (n=5) limited their cohorts to low-risk patients, while others (n=8) also included intermediate-risk patients. The heterogeneity of the cohorts produced mixed results, with the risk of prostate cancer metastasis ranging from 0.1-1.0% at 10 years and the risk of prostate cancer mortality ranging from 0-1.9% at 10 years. However, the majority of studies reported risks of less than 0.5% at 10 years for both metastasis and death. For most cohorts, half of men remained untreated for 5-10 years, with estimates ranging from 37% receiving active treatment in the Toronto cohort to 73% in the Prostate Cancer Research International AS (PRIAS) study. Current data do not support the use of negative magnetic resonance imaging (MRI) to avoid scheduled biopsy. Taken together, the data collected from these AS cohorts suggests that AS is a safe approach for men with low-grade prostate cancer and some men with intermediate risk disease. AS should be more broadly implemented for eligible patients to avoid the decreases in quality of life from undergoing active treatment. Studies expanding the inclusion criteria and further defining a subset of men with favorable intermediate-risk prostate cancer who might safely benefit from AS are needed to assess the long-term outcomes of using AS in intermediate-risk groups.

Project description:Background: Active surveillance is established as an alternative to surgery for papillary thyroid microcarcinomas, but inclusion criteria and mortality risk for pursuing a nonsurgical approach have not been clearly defined. To gauge the feasibility of expanding active surveillance thresholds, we investigated the effects of increasing size and age on disease-specific survival (DSS) in a large nonoperative thyroid cancer cohort, compared against a matched group of surgical patients. Methods: Papillary thyroid carcinoma patients staged T1-4N0M0 were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 1975 and 2015, stratified by nonsurgical and surgical management. Propensity score matching was performed to adjust for imbalances in covariates. Multivariable models were constructed using restricted cubic splines to model nonlinear relationships of age and tumor size with DSS. Results: Overall, 1453 nonoperative patients and 54,718 surgical patients met the inclusion criteria. Collectively, increasing age and size after certain thresholds independently led to greater differences in DSS between nonsurgical and surgical patients. For younger ages (14-55 years), surgical approach compared with nonsurgical approach was not associated with any difference in the 10-year DSS among 0-4 cm cancers (99.8% vs. 100%, p = 0.470), 4.1-6 cm cancers (98.8% vs. 100%, p = 0.599), or >6 cm cancers (97.3% vs. 100%, p = 0.718). Older patients with larger tumors (>75 years, >6 cm) demonstrated the greatest difference in DSS (48.1% vs. 91.3%, p < 0.001). Similar results were found when applying propensity score matching. For age, restricted cubic spline plots showed minimal relative survival hazard in nonoperative cases beginning after age 60 years, with a change point illustrating acceleration in relative hazard beyond age 72 years. For size, relative survival hazard was observed after 2.0 cm and increased slowly with nodule growth up to an inflection point of 4.5 cm. Beyond this, mortality risk escalated with each additional year without plateau. Conclusions: Increasing age and size lead to progressively greater mortality risk without surgery, but only beyond certain thresholds. We define escalating gradients at which a nonsurgical approach may be deemed appropriate, and beyond which survival benefits from surgery become apparent. Such findings reconcile controversial observations regarding age and size in active surveillance and further reshape evolving treatment paradigms in thyroid cancer.