Patient-Perceived Lack of Choice in Receipt of Radioactive Iodine for Treatment of Differentiated Thyroid Cancer

Abstract

Purpose: For many patients with differentiated thyroid cancer, use of radioactive iodine (RAI) does not improve survival or reduce recurrence risk. Yet there is wide variation in RAI use, emphasizing the importance of understanding patient perspectives regarding RAI decision making.

Patients and methods: All eligible patients diagnosed with thyroid cancer from 2014 to 2015 from the Georgia and Los Angeles SEER registries were surveyed (N = 2,632; response rate, 63%). Patients in whom selective RAI use is recommended were included in this analysis (n = 1,319). Patients were asked whether they felt like they had a choice to receive RAI (yes or no), how strongly their physician recommended RAI (5-point Likert-type scale), whether they received RAI (yes or no), and how satisfied they were with their RAI decision (more [score of 4 or greater] v less). Multivariable, weighted logistic regression with multiple imputation was used to assess the associations between patient characteristics and perception of no RAI choice and between perception of no RAI choice with receipt of RAI and decision satisfaction.

Results: More than half of respondents (55.8%) perceived they did not have an RAI choice, and the majority of patients (75.9%) received RAI. The odds of perceiving no RAI choice was greater among those whose physician strongly recommended RAI (adjusted odds ratio [OR], 1.56; 95% CI, 1.13 to 2.17). Patients who perceived they did not have an RAI choice were more likely to receive RAI (adjusted OR, 2.50; 95% CI, 1.64 to 3.82) and report lower decision satisfaction (adjusted OR, 2.31; 95% CI, 1.67 to 3.20).

Conclusion: Many patients did not feel they had a choice about whether to receive RAI. Patients who perceived they did not have a choice were more likely to receive RAI and report lower decision satisfaction, suggesting a need for more shared decision making to reduce overtreatment.

FIG 1.

Sample selection (N = 1,319). Cooperation rate was 77%. RAI, radioactive iodine.

FIG 2.

Multivariable adjusted odds ratio (OR) and 95% CIs of the associations between patient perception of radioactive iodine (RAI) choice and receipt of RAI (N = 1,319). (*) OR estimates are based on 50 imputed data sets and are also adjusted for sex and insurance. (†) Physician recommendation for RAI is noted as a dagger because it was outside the range of the other associations on the scale. (OR, 36.32; 95% CI, 22.67 to 58.19). Ref, reference value.

FIG 3.

Multivariable adjusted odds ratio (OR) and 95% CIs of the associations between patient perception of radioactive iodine (RAI) choice and lower RAI decision satisfaction (n = 1,319). (*) OR estimates are based on 50 imputed data sets and are also adjusted for sex, insurance, and SEER tumor status. Ref, reference value.

FIG 4.

Distribution (weighted percentage) of patient perceptions about amount of information they had and their level of involvement in their radioactive iodine (RAI) treatment decision by levels of patient perception of RAI choice. Both Rao-Scott χ² P < .01.