A “Special Article”, recently published in THYROID, tells the story of what happens when unsubstantiated clinical practice guidelines for thyroid cancer are promoted as optimal care. 

When the most recent revised thyroid nodule and thyroid cancer clinical practice guidelines were published by the ATA in 2015 (see: https://www.liebertpub.com/doi/pdf/10.1089/thy.2015.0020), the document remained at odds with the scientific consensus over the state of knowledge and previous standards of care. These guidelines made several sweeping recommendations without sufficient scientific or ethical justification (See: https://www.futuremedicine.com/doi/abs/10.2217/ije-2015-0010 and https://www.futuremedicine.com/doi/abs/10.2217/ije-2017-0008). The document also disclosed overt financial conflicts of interests by several of the authors, raising questions about whether some recommendations were influenced by authors’ industry ties. The fallout within the community of experts led to considerable moral distress amongst dissenting practitioners who felt they had beneficence-based duties to treat, but whose voices were marginalized. Indeed, thyroid cancer content presented at conferences in the post-2015 guideline years basically regurgitated the Haugen et al. (2015) recommendations as though they were partisan talking points. 

The most questionable departure from traditional thyroid oncology practice were recommendations against the diagnostic or therapeutic use of radioactive iodine, as well as recommendations against total thyroidectomy in patients whose tumors were as large as 4 cm – what some surgeons and thyroid oncologists would consider egregious. The guidelines also encouraged observation of “low risk” tumors (although I have argued elsewhere that such practice should be regarded as experimental, and violates the Belmont Report if it is not presented in a research context). No treatment, undertreatment and questionable disclosure to patients became the new paradigm in thyroid cancer care. Many of the recommendations were based on pet theories and biases of some of the authors, relying on highly flawed or ethically questionable studies to support them.  Of note, the nuclear medicine community refused to endorse the guidelines, which was unprecedented.

This month, in a stunning rebuke by Luster et al. entitled “European Perspective on 2015 ATA Management Guidelines for Adult patients with thyroid Nodules and DTC”, European experts called for revisions to approximately one-thirdof the ATA’s 101 recommendations in its 2015 document. (See: https://www.liebertpub.com/doi/abs/10.1089/thy.2017.0129.)

They stated the following in their abstract:

“Divergent viewpoints were the focus of an invited symposium organized by the European Association of Nuclear Medicine involving 17 European thyroidologists, four ATA Guidelines Taskforce members, and an audience of 200 international experts. The group discussed the preoperative assessment of thyroid nodules, surgery and the role of pathology, radioiodine (RAI) therapy (RAIT), the assessment of initial therapy and dynamic risk stratification, and the treatment of persistent disease, recurrences, and advanced thyroid cancer. The dialogue resulted in this position paper contrasting European and ATA 2015 perspectives on key issues. One difference pertains to the permissiveness of ATA 2015 regarding lobectomy for primary tumors ≤4 cm. European panelists cited preclusion of RAIT, potential need for completion thyroidectomy, frequent inability to avoid chronic thyroid hormone replacement, and limitations of supportive evidence as arguments against widely applying lobectomy. Significant divergence involved ATA 2015’s guidance regarding RAIT. European panelists favored wider use of postoperative RAIT than does ATA 2015. …European panelists suggested modifications to approximately one-third of ATA 2015 recommendations.” 

Facts can be a stubborn thing.