Roughly 70 to 80 percent of the more than 100,000 adult thyroid operations that occur annually in the United States are performed by low-volume general surgeons or otolaryngology and head and neck surgeons in local communities. However, until recently, no resource had existed for nationally agreed-upon standards of care.
Kepal N. Patel, MD, director of the Division of Endocrine Surgery at NYU Langone Health, is the lead author of the first set of evidence-based guidelines to surgically manage adult thyroid disease, including thyroid nodules and cancers. By describing and evaluating the evidence and risk–benefit ratio of clinical recommendations, the guidelines are meant to enhance clinician decision-making. They were published in the Annals of Surgery in the March 2020 issue.
Collecting and Validating 30 Years of Evidence
The diagnosis and management of thyroid disease have advanced significantly in recent years, leading to a proliferation of differences in clinical interpretation and management. Surgical indications and treatment paradigms also have undergone extensive change, particularly with the addition of new cytologic and pathologic diagnostic criteria, molecular profiling tests, operative techniques, and adjuncts.
“Although the field of endocrine surgery is still relatively young, it has matured and accumulated the necessary data at this point in time to form best practices,” Dr. Patel says.
To address this variability and help advance safe, effective, and appropriate patient care, the American Association of Endocrine Surgeons (AAES) convened a group of distinguished physicians and surgeons from across the nation to develop multidisciplinary, evidence-based guidelines for surgical care of adult thyroid disease.
Developing the guidelines was a 2-year process, involving 19 experts from around the country with broad expertise in endocrinology, pathology, and surgery. The group reviewed all relevant literature from 1984 through 2018, analyzing and evaluating the evidence for each type of thyroid disease, and covering the entire spectrum of surgical management.
Providing Dozens of Recommendations to Enhance Clinician Decision-Making
The resulting guidelines include 66 recommendations for indicating and conducting adult thyroid surgery, guided by a comprehensive evidence-based review of the medical literature to support the best potential outcomes. The guidelines summarize the relevant aspects of the epidemiology and pathogenesis of thyroid disease, describing the succinct diagnosis, defining indications for surgical intervention, detailing methods for safe and effective perioperative management, and analyzing optimal management of thyroid cancer based on a personalized approach.
The recommendations are meant to enhance clinician decision-making by describing and evaluating the evidence and risk–benefit ratio of clinical recommendations. For each recommendation, the level of evidence is noted as high-quality, moderate-quality, low-quality, or insufficient evidence, as per the standard 2010 American College of Physicians grading system, which employs a validated scale to critically interpret and evaluate the strength and quality of the evidence.
For example, a recommendation rated with a high level of evidence might include prospective, randomized clinical trials. But if the recommendation is based on expert opinion in an area where a study cannot be done, it may be rated as having low-quality evidence. Proposed recommendations were discussed and debated until consensus was reached. Members of the AAES provided input on preliminary drafts of the content.
“Everyone on the committee is proud of the final product,” Dr. Patel says. “The paper we’ve published is a comprehensive resource, and it sets a precedent for surgical treatment of thyroid disease.”
Prominent Organizations Endorse the Guidelines
In addition to its origination and support from the AAES, the document is endorsed by the American Thyroid Association, the Society of Surgical Oncology, and the International Association of Endocrine Surgeons.
The guidelines are intended primarily for use in the United States and other medically advanced countries. In less-developed countries, on-the-ground conditions may indicate a need for different practices that have strong rationales in those geographies.
Dr. Patel and four of his co-authors presented the results of their review and analysis in a scientific session at the clinical congress of the American College of Surgeons in San Francisco in October 2019. A pocket guide to the AAES guidelines will be distributed at several relevant medical meetings throughout the year.