To determine current patterns of care and disease characteristics for patients with
thyroid carcinoma, a Patient Care Evaluation Study was initiated in 1996 in the U.S. and Germany. This project addresses ongoing concerns with respect to the diagnostic evaluation and treatment of patients diagnosed with
thyroid carcinoma and raises questions concerning how physicians are interpreting current standards and acting on the basis of these recommendations.
METHODS: Patients with primary
thyroid carcinoma were entered into a prospective multicenter observational study with free choice of treatment (no control group) between January 1, 1996 and December 31, 1996 in Germany. This resulted in a total of 2537 cases under observation and analysis; 1685 patients had
papillary carcinoma (66.4%), 691 had follicular
carcinoma (27.2%), 70 had
medullary carcinoma (2.8%), and 91 had
anaplastic carcinoma (3.6%). The 2376 patients with
carcinoma of either papillary or follicular histology were included in the current analysis.
RESULTS: The major symptoms reported for patients with papillary and
follicular thyroid carcinoma was neck mass (reported in 76% and 79%, respectively) followed by
dysphagia (reported in 25% and 27%, respectively),
stridor (reported in 9% and 14%, respectively), and
neck pain (reported in 7% and 8%, respectively). Greater than 50% of the patients with
papillary thyroid carcinoma were reported to have American Joint Committee on
Cancer/International Union Against
Cancer Stage I disease. Between 37-39% of the follicular
carcinoma patients had Stage I and Stage II disease. Only slight differences in the diagnostic approach to patients with papillary or follicular
carcinoma were noted. The majority of patients underwent an ultrasound of the thyroid region (78.1%), which was suggestive of
carcinoma in only 39% of the cases. A thyroid scan was performed on 76.6% of patients, and the results were suggestive of
carcinoma in 44.8% of the individuals. In contrast, fine-needle aspiration biopsy of the thyroid is highly recommended in the current Clinical Practice Guidelines (CPG) but results were obtained in only 27.4% of the patients. Total
thyroidectomy without
lymph node dissection was the most commonly used
surgical procedure in the treatment of patients with papillary and
follicular thyroid carcinoma. Only approximately 2% of patients at low risk in the group with Stage I disease were treated with a lobectomy. In 80% of the patients with Stage I
papillary thyroid carcinoma and approximately 90% of those patients diagnosed with Stage II, III, and IV disease treating physicians chose to utilize radioiodine as adjuvant treatment after disease-directed surgery. External beam radiation was added to the treatment regimen for many patients diagnosed with Stage III and IV disease (30% in patients with
papillary thyroid carcinoma and 33% in patients with
follicular thyroid carcinoma).
CONCLUSIONS: To the authors' knowledge no single effective diagnostic test for
thyroid carcinoma currently is available and in the majority of cases a combination of ultrasound, thyroid scan, or fine-needle aspiration biopsy together with the clinical findings (e.g., thyroid mass) led to a diagnosis of
carcinoma. The authors suspect that the high prevalence of concomitant pathologic findings such as
goiter, even in the healthy population in Germany, reduces the accuracy of all diagnostic test methods and may account for the frequent use of imaging techniques. The majority of patients underwent a total or near-total
thyroidectomy. Total
thyroidectomy with radical
lymph node dissection was used very frequently in those patients with
papillary thyroid carcinoma (22%). German physicians tend to surgically treat early stage
thyroid carcinoma somewhat more radically than recommended in the CPG. With respect to other treatment options employed as part of the first course of treatment, radioiodine appears to play the most important role. [See commentary o