Drs Goldstein, Sawka, Ghai
(L to R): Dr. David Goldstein, surgical oncologist, Dr. Anna Sawka, endocrinologist, and Dr. Sangeet Ghai, radiologist, are the team examining how many patients with Stage 1 low-risk papillary thyroid cancer choose active surveillance over surgery and why. (Photo: UHN)

Thyroid cancer physicians at UHN are enrolling approximately 200 patients with early-stage disease in the first Canadian observational study examining whether patients would choose active surveillance instead of surgery.

Drs. David Goldstein and Anna Sawka, co-principal investigators, will look at how many patients with Stage 1 low-risk papillary thyroid cancer choose active surveillance over surgery and why.

Active surveillance involves closely monitoring small, slow-growing thyroid cancer through ultrasound, blood work, and clinical exam.

If there is evidence of the thyroid cancer progressing, then it will be treated with surgery and other treatments if needed. Patients who choose active surveillance may change their mind at any time, even if their cancer has not progressed, and elect to have surgery.

A second part of the study will track patients' health outcomes, such as regretting the original treatment decision, cancer progression or recurrence, quality of life, fear and body image.

Thyroid cancer

The thyroid is a butterfly-shaped gland at the front of the neck, just below the larynx (voice box) and on top of the trachea. It makes hormones that regulate the way the body uses energy and help it work normally.

The thyroid gland tends to develop small lumps, known as nodules, and sometimes these nodules are cancerous.

Thyroid cancer has the most rapidly increasing incidence rate among all major cancers, not only in Canada but worldwide, according to the 2017 Cancer Statistics Report [Editor's Note: Link is no longer available]. It is now the number one cancer among young Canadians, aged 15 – 29 years.

Dr. Goldstein, surgical oncologist at UHN, says the increase can be attributed to improved imaging technology and over-screening related to a variety of reasons patients might undergo diagnostic imaging that will also detect thyroid abnormalities; for example, an ultrasound for a sore throat, or CT scan for breast cancer diagnostics.

"Most of these are what we call very low-risk thyroid cancers, they have a very low rate of spreading elsewhere in the body, low rate of causing death, or even coming back after treatment," he says.

"Typically, thyroid cancer is treated with surgery to remove half or all of the thyroid gland, and sometimes with radioactive iodine – a form of orally administered radiation treatment. So patients have to deal with subsequent implications, such as lifelong thyroid hormone treatment dependence, having a scar on the neck, and potentially, other surgical and medical complications."

Trying to reduce the risk of over treating

Dr. Sawka, an endocrinologist at UHN, says the purpose of the study is to try to reduce the risk of over treating low-risk thyroid cancer that may not necessarily be life-limiting to patients, as well as minimize morbidity for patients who are comfortable with not having curative surgery.

"There's never been any option to avoid surgery because the standard of care has been to operate on everybody," says Dr. Sawka. "This study opens up an opportunity for some patients to avoid surgery and use it only if needed."

Dr. Sangeet Ghai, radiologist at UHN, is leading the team with the interpretation of neck ultrasound images for the study.

There are a number of critical structures around the thyroid, so ultrasound imaging helps the team determine where nodules have formed and if a patient is an optimal candidate for active surveillance, Dr. Ghai says.

In the future, the team will look at whether active surveillance also provides healthcare cost savings.

Drs. Goldstein and Sawka say they believe the main impact on the system could be potentially reducing the number of thyroidectomies for people with low-risk disease that are unlikely to die from it, and reducing the potential side effects of surgery and going on thyroid medicine.

This research is funded by the Ontario Ministry of Health and Long-Term Care's Alternative Funding Plan, and the Canadian Cancer Society.

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