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Very few surgeons said they would take a wait-and-watch approach to papillary thyroid cancer, according to a survey-based study.

When 264 thyroid cancer surgeons were asked how they would treat a hypothetical patient with papillary thyroid cancer, about half said they would opt for a thyroid lobectomy while just 1.5% chose active surveillance, reported Megan Haymart, MD, of the University of Michigan in Ann Arbor, and colleagues in .

Treatment recommendations were based on a clinical vignette involving a 0.9-cm papillary thyroid tumor.

Total thyroidectomy was the second-most recommended treatment strategy chosen by respondents (41.6%), followed by thyroidectomy with lymph node resection (7.5%). A quarter said they opt for total thyroidectomy for all papillary thyroid tumors, most commonly those treating ten or fewer patients in the prior year, the authors stated.

Haymart's group pointed out that "thyroid surgery is not without its risks," and "limiting the extent of surgery without sacrificing oncologic outcomes is paramount. Understanding the factors involved in surgeon recommendations is important, especially with evolving evidence and guidelines."

The study was conducted from October 2018 to August 2019 and had a response rate of 69%. The responding surgeons were generally split between general surgeons and otolaryngologists, and most were in private practice. More than a quarter treated more than 20 patients with thyroid cancer in the past year.

They were presented with the following clinical vignette: "A 40-year-old female patient presents to your office after an FNA [fine-needle aspiration] of a 0.9-cm right thyroid nodule was consistent with papillary thyroid cancer. No suspicious lymph nodes were seen on ultrasound evaluation."

The respondents were given four possible treatment options that they would recommend to this patient:

• Thyroid lobectomy
• Total thyroidectomy
• Total thyroidectomy with lymph node resection
• Active surveillance

The researchers also asked the respondents why they would recommend a total thyroidectomy versus a lobectomy for a 1-cm papillary thyroid tumor, and the most commonly reported reason was if there were nodules present in the other lobe (87.4%).

"Despite previous work suggesting that observation of contralateral low-risk nodules is safe, most surgeons still report bilateral nodules as a reason to perform a total thyroidectomy," Haymart and colleagues pointed out.

The second most common reason for opting for a total thyroidectomy was presence of a suspicious lymph node on a preoperative ultrasonography (86.0%), followed by patient preference (70.3%), and desire to treat with radioactive iodine (58.8%).

Less common reasons included the ease of long-term follow-up (40.8%), concern about the anxiety level of the patient (36.7%), and if the surgeon simply always performs a total thyroidectomy (25.6%).

The researchers reported some trends based on duration of practice. For example, longer-practicing physicians (>20 years) were less likely to recommend a total thyroidectomy based on the ease of long-term follow-up (OR 0.53, 95% CI 0.31-0.91), patient preference (OR 0.21, 95% CI 0.11-0.43), or due to patient worry (OR 0.52, 95% CI 0.29-0.91). Instead, newer physicians were more likely to put more weight on patient preference and worry when it came to clinical decision-making, according to Haymart's group.

Study limitations included the risk of recall bias.

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