Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey

Abstract

Context: Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States.

Objective: This work aimed to understand factors associated with the adoption of AS.

Methods: We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases).

Results: The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS.

Conclusion: Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

Keywords: active surveillance; microcarcinoma; surveillance; survey; thyroid cancer.

Figure 1.

Summary of survey response. Overall response rate was 33.3%, calculated as (surveys returned ÷ eligible providers).

Figure 2.

Histograms show respondents’ awareness, knowledge, and discussion of active surveillance (AS) in their clinical practice (unweighted %). For symbols, “*” indicates P less than .05 for nonadopters compared to adopters (both partial and full adopters) and “**” indicates P less than .05 for partial vs full adopters.

Figure 3.

The histograms illustrate respondents’ beliefs about the use of active surveillance (AS) in the United States and factors impacting their motivation to increase use of AS (unweighted %). For symbols, “*” indicates P less than .05 for nonadopters vs adopters (both partial and full adopters).

Figure 4.

Histograms depicting respondents’ attitudes and beliefs about active surveillance (AS) (unweighted %). For symbols, “*” indicates P less than .05 for nonadopters vs adopters (both partial and full); “**” indicates P less than .05 for partial vs full adopters.