Delays to Low-Risk Thyroid Cancer Treatment During COVID-19—Refocusing From What Has Been Lost to What May Be Learned and Gained

“In recent years, a worldwide increase in the incidence of thyroid cancer has been acknowledged and has primarily been attributed to overdiagnosis of small, low-risk papillary thyroid cancers. Observational evidence suggests that active surveillance is a safe and effective management option for carefully selected patients with low-risk papillary thyroid cancers. In light of this contemporary data, guidelines now include more conservative treatment options for patients diagnosed with papillary thyroid cancer. Ultimately, these guidelines help to avoid potential overtreatment and improve quality-of-life outcomes. Yet despite all this, the willingness to accept less invasive management options, specifically the uptake and acceptability of active surveillance, seems to still be quite low and varied. Once a diagnosis of thyroid cancer is made, some patients and clinicians still seem to have strong beliefs that immediate surgery is required.

Take, for example, a hypothetical patient incidentally diagnosed with papillary microcarcinoma (<1 cm) immediately before or during the early stages of the COVID-19 pandemic. It is a completely unexpected diagnosis for the patient; the patient is scared, and her first thought is “I want it removed as soon as possible.” In a normal situation this preference would not be an issue. The thyroid surgeon would likely discuss the management options with the patient, which may or may not include active surveillance, and would be happy to perform surgery for this patient if that was her preference. The patient would be getting what she thought she wanted, and the surgeon would be performing their job and providing surgery to the patient. However, does the normal situation allow patients to take time to reflect on their diagnosis, gain a better understanding through discussions with their clinicians and further research about the low-risk nature of their diagnosis, and ultimately weigh the benefits and harms of each management option? Perhaps, but also, perhaps, the typical “act now” mentality that is ingrained in us and the societal fear of cancer is not conducive to in-depth patient and clinician discussions and data-driven decision-making.

During this COVID-19 pandemic, the patient is told by her surgeon that she will not be able to proceed with immediate surgery and will have to wait (for an unknown period perhaps). The surgeon takes more time to reassure her of the low-risk nature of the diagnosis and points her toward specific evidence from active-surveillance trials to show that “waiting” or not proceeding to immediate treatment is safe. Does this provide reassurance to the patient? Will she be more receptive to the idea of active surveillance? Or is the patient more worried than before, with an overwhelming thought that the cancer will progress during this time? Varied responses are a product of multiple factors, including previous experiences, personality, and confidence in the discussions and evidence provided by the surgeon.”

Full editorial, Nickel B, Glover A and Miller JA. JAMA Otolaryngology-Head & Neck Surgery, 2020.10.29