An International Survey of Thyroid Nodule Risk Stratification System Use and Preferences: Are We Moving Towards a Universal System?

Clin Thyroidol 2022;34:246–249.

• Background:
  • Multiple ultrasound-based risk stratification systems (RSSs) have been developed to assist clinicians in the evaluation and management of thyroid nodules
  • Currently available systems differ in their approach to nodule categorization and suggest different fine-needle aspiration (FNA) size thresholds
  • Head-to-head comparisons of the performance of widely available RSS have yielded inconsistent results, making it difficult for individual practitioners to choose and implement an appropriate system
  • An International Thyroid Nodule Ultrasound Working Group (ITNUWG):
    • Is currently working on an international RSS to harmonize current systems
  • The present study is an international survey conducted by members of the ITNUWG to assess RSS use patterns and practitioner preferences
• Methods:
  • A 22-question online international survey was developed by four members of the ITNUWG steering committee and administered via Survey-Monkey.com
  • The focus of the survey was on choice and usage of RSS, practitioner and practice type and demographics, geographic region, specialty, level of training, experience, and volume of thyroid nodule ultrasound and fine-needle aspiration
  • Invitations to complete the survey were disseminated by email by professional organizations including the American Thyroid Association (ATA), Associazione Medici Endocrinologi (AME), European Thyroid Association, Korean Society of Thyroid Radiology, and the Society of Radiologists in Ultrasound
  • The survey focused on five widely available RSSs including the:
    • American Association for Clinical Endocrinology (AACE), American College of Endocrinology (ACE) and AME unified guidelines, ACR TI-RADS, the ATA guidelines, EU-TIRADS, and K-TIRADS
  • It was designed to be completed in less than 15 minutes and participation was voluntary without reward; respondents did not have to answer all questions
• Results:
  • A total of 875 respondents from 52 countries participated in the survey
  • 724 respondents answered questions about RSS awareness, value, and use
  • The response rate could not be calculated due to overlapping membership across the 5 disseminating societies
  • The majority of respondents were attending physicians in academic practice
  • There were 54% of respondents from Europe and 28.3% from North America; 61.5% were endocrinologists, 20.6% were radiologists, and 11.4% were surgeons
  • A reported 94.6% of respondents were at least somewhat familiar with an RSS, and a 91% found value in RSS usage
  • There were 95.6% of respondents who stated that an RSS was used in their practice, and 30.8% used more than one
  • Alone or in combination, RSS usage was as follows:
    • ATA guidelines (34%)
    • ACR TI-RADS (33.7%)
    • EU-TIRADS (29.6%)
    • AACE/ACE/AME guidelines 20.5%
    • K-TIRADS (14.6%)
    • Other (4.6%)
    • None (5%)
  • Geography and clinician specialty were major determinates of which RSS was used:
    • Surgeons and “others” were most likely to use multiple RSSs (40%)
  • A total of 271 respondents stated they did not personally use an RSS, most who favored narrative descriptions, and cited lack of institutional requirement (19.6%), multiplicity of options (18.1%), preference for using suspicious features (14.8%), contention that expertise is as or more effective (12.9%)
  • There were 62% of the 724 respondents who felt a universal lexicon with illustrative images would improve inter-observer variability
  • 54% supported a comprehensive online atlas
  • 44.9% supported a universal lexicon endorsed by societies
  • 95.2% preferred no more than 5 risk categories
• Conclusions:
  • An international survey of RSS use patterns and practitioner characteristics and preferences was performed to inform development of a unifying international RSS
  • The survey demonstrated wide variability in practice patterns across geography and specialty, with majority support for a comprehensive atlas and unified lexicon with no more than 5 risk categories
• Summary:
  • Ultrasound-based RSSs have attempted to codify and standardize the evaluation of thyroid nodules and have largely succeeded in articulating a shared lexicon of sonographic features that have predictive value
  • While RSSs differ in their specific format (e.g. pattern recognition versus point systems), definitions and weight of each sonographic criterion, risk categories, FNA size thresholds, and the presence and specifics of recommended surveillance intervals, most systems have more similarities than differences, and perform well with robust negative predictive value
  • The present study is one of the largest and most inclusive efforts to date to understand who uses which systems, and to seek to understand determinants of use, as well as clinician preferences
  • While the study’s methods traded some statistical rigor (no calculable response rate, high risk of sampling and non-response biases, etc.) for ease of execution (SurveyMonkey.com) and wide breadth and exposure (use of professional organizations to elicit international respondents, high respondent heterogeneity), it confirms the intuitive observation that clinicians choose systems informed by their geography and specialty, both of which select for involvement with particular professional societies, many of which have their own validated systems
  • the multiplicity of systems is particularly bewildering for primary care providers and patients (especially in the era of “open” notes), especially when radiologists and/or clinicians are using multiple RSSs with differing management recommendations
  • This confusion had led to widespread efforts to compare the performance of RSSs
  • While many comparative analyses have attempted to identify the “best” system, they employ heterogenous methods and outcomes, often looking at biopsy rates, and diagnostic accuracy
  • To date, there has not been a clear winner, and most of the discrepancies across systems are in lower risk strata
  • However, recommendations for lower risk categories are important, especially given that most thyroid cancers are small indolent papillary thyroid cancers and up to 11% to 14% of adults, perhaps more, have incidental papillary thyroid cancer found on biopsy
  • Overdiagnosis, and attendant overtreatment, are a source of cost and morbidity, although headway is being made
  • An ideal RSS would catch all clinically significant thyroid cancers through an up-front FNA biopsy or follow up sonographic surveillance, and minimize the cost and inconvenience of long-term follow up for innocent nodules and cancers
  • It is interesting that the survey did not query why some practitioners use more than one RSS
  • While most of physicians have settled on one particular system for day-to-day use, most of us would admit to selective application of one of several RSSs to justify a specific recommendation or express evidence-based support for patient preferences voiced in shared decision-making:
    • For instance, in older adults with multiple comorbidities and a conservative approach to healthcare, the 2015 ATA guidelines option to survey rather than biopsy spongiform nodules larger than 2 cm, and / or use ACR TI-RADS for more conservative FNA size thresholds, at least in part because of mindfulness around overdiagnosis and increasing data on the safety of an active surveillance strategy for the right patient and low-risk tumor characteristics
  • In the end, most clinically meaningful feature of this survey study is the effort that bore it
  • The results are clear that a majority of clinicians would welcome a universal lexicon and risk stratification system, and it is exciting to see an international effort underway to elicit clinician practice patterns and preferences as part of a larger collaboration to reconcile, improve, and unify current RSSs in the context of the unique biology and epidemiology of thyroid cancer
• References:
  • Hoang JK, Asadollahi S, Durante C, Hegedus L, Papini E, Tessler FN 2022 An International Survey on Utilization of Five Thyroid Nodule Risk Stratification Systems: A Needs Assessment with Future Implications. Thyroid. ePub 2022 Mar 1.
  • Grani G, Sponziello M, Pecce V, Ramundo V, Durante C 2020 Contemporary Thyroid Nodule Evaluation and Management. J Clin Endocrinol Metab 105.

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