Incidental thyroid nodules and thyroid cancer: considerations before determining management.
The worldwide incidence of thyroid cancer is increasing substantially, almost exclusively attributable to small papillary thyroid cancers. Increased use of diagnostic imaging is considered the most likely explanation for this reported rise, but other factors may also be contributing. The increase in health care expenditures related to managing these presumably low-risk cancers, without a clear patient benefit, has resulted in a backlash against the early detection of thyroid cancer. Currently, there is no way to confidently predict which incidentally detected thyroid nodule may be the precursor to a more aggressive process. Predictions such as these would require more accurate characterization of the biology of individual thyroid cancers than is currently possible. With time, we might prove our ability to confidently differentiate low-risk from high-risk thyroid cancers, but until that happens, routine screening for thyroid cancer by imaging billed as a "health checkup" should not be performed. However, incidentally detected thyroid nodules should be reported, and a clear medical team management plan should be developed. Our ethical responsibility is to provide patients with objective, evidence-based information about their disease status, not to assume that we know what is best for them by selectively withholding information. In addition, providing patients with psychosocial assistance will help them process the information necessary to make informed decisions that will provide them with the most value when a small thyroid nodule or cancer is incidentally identified. Herein, we summarize the epidemiological data for disease incidence, discuss some controversies in disease management, and outline the key elements and ethical considerations of informed decision making as they apply to managing incidentally detected thyroid nodules and thyroid cancer.
Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Ralph P
RP
Tufano
Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Salem I
SI
Noureldine
Department of Surgery, Pritzker School of Medicine, The University of Chicago, Chicago, Illinois.
Peter
P
Angelos
D018263:Adenocarcinoma, Follicular / Q000175:diagnosis / Q000453:epidemiology / Q000473:pathology / Q000628:therapy; D044963:Biopsy, Fine-Needle; D002291:Carcinoma, Papillary / Q000175:diagnosis / Q000453:epidemiology / Q000473:pathology / Q000628:therapy; D002423:Cause of Death; D003937:Diagnosis, Differential; D019468:Disease Management; D055088:Early Detection of Cancer / Q000009:adverse effects / Q000706:statistics & numerical data; D014943:Global Health; D006801:Humans; D015994:Incidence; D033162:Incidental Findings; D010353:Patient Education as Topic; D010817:Physician-Patient Relations; D056910:Republic of Korea / Q000453:epidemiology; D012307:Risk Factors; D015996:Survival Rate; D013961:Thyroid Gland / Q000473:pathology; D013964:Thyroid Neoplasms / Q000175:diagnosis* / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy; D016606:Thyroid Nodule / Q000175:diagnosis / Q000453:epidemiology / Q000473:pathology / Q000628:therapy; D013965:Thyroidectomy / Q000191:economics; D019564:Unnecessary Procedures / Q000191:economics; D057832:Watchful Waiting / Q000706:statistics & numerical data