- American Thyroid Association Thyroid Cancer Management 2025 Guidelines
- Recommendation 6:
- Due to lower complication rates and improved outcomes on average associated with high volume thyroid surgeons (> 25 to 50 thyroidectomies / year):
- Patients with thyroid cancer should be offered referral to a high-volume surgeon;
- Particularly for tumors requiring more extensive surgery:
- Strong recommendation, Moderate certainty evidence
- Particularly for tumors requiring more extensive surgery:
- Patients with thyroid cancer should be offered referral to a high-volume surgeon;
- Physician experience and expertise have long been revered in patient care:
- But quantifying the benefits can be challenging, particularly at an individual provider level
- There are many aspects of care where physician expertise is important in the diagnosis, staging, and management of patients with
thyroid cancer, including sonography, pathology, surgery, endocrinology, nuclear medicine, oncology, and radiation
therapy - Ultrasound of the neck is a prime example, due to its well-documented dependence on the skill and experience of the sonographer coupled with its importance for preoperative diagnosis, staging, and surveillance
- The experience of the cytopathologist also has been demonstrated to improve the accuracy of ultrasound-guided FNA biopsy diagnosis
- The evidence supporting improved outcomes at the hands of experienced surgeons is most compelling
- The relationship between thyroid surgery case volume and patient outcomes has been studied extensively during the past 20 years:
- In one of the recent studies examining the relationship between surgeon volume and thyroidectomy outcomes:
- Sosa et al. found a strong association between higher surgeon volume and favorable patient outcomes:
- Especially with respect to recurrent laryngeal nerve injury and wound complications
- This was most pronounced for patients undergoing total thyroidectomy for thyroid cancer
- Sosa et al. found a strong association between higher surgeon volume and favorable patient outcomes:
- Others have made similar observations on a larger scale:
- In a study of the Health Care Utilization Project Nationwide Inpatient Sample (HCUP-NIS);
- Over 80% of thyroidectomies were performed by low- and intermediate-volume surgeons (< 29 thyroidectomies /year)
- On average, high-volume surgeons (> 30 thyroidectomies / year) had the lowest
complication rates for patients who underwent total thyroidectomy for cancer (high 7.5% vs. intermediate 13.4% vs. low 18.9%; p < 0.001)
- In a study of the Health Care Utilization Project Nationwide Inpatient Sample (HCUP-NIS);
- A recent meta-analysis including 22 studies found unanimity in the association of lower complication rates with higher thyroid surgery volume
- In one of the recent studies examining the relationship between surgeon volume and thyroidectomy outcomes:
- When hospital volume and surgeon volume are both considered:
- On average, high-volume surgeons are associated with lower complication rates, lower hospital mortality, and lower cost:
- Whereas high-volume centers are associated primarily with lower cost and shorter lengths of stay
- On average, high-volume surgeons are associated with lower complication rates, lower hospital mortality, and lower cost:
- Estimates of the annual thyroid surgical volume necessary to achieve lower complication rates range from 25 to 50:
- With one series suggesting > 50 cases for more advanced thyroid
cancer
- With one series suggesting > 50 cases for more advanced thyroid
- Due to lower complication rates and improved outcomes on average associated with high volume thyroid surgeons (> 25 to 50 thyroidectomies / year):
- A study specically designed to address this number concluded that annual total thyroidectomy case volume > 25 / year was associated with improved outcomes
- Patients have an 87% increase in the odds of having a complication if the surgeon performed just 1 case / year:
- 68% for 2 to 5 cases / year
- 42% for 6 to 10 cases / year
- 22% for 11 to 15 cases / year
- 10% for 16 to 20 cases / year
- 3% for 21 to 25 cases / year
- Patients undergoing total thyroidectomy for cancer at the hands of high-volume surgeons also are reported to have signicantly less thyroid remnant tissue after resection:
- Resulting in a reduced radioiodine dose requirement for remnant ablation (if indicated)
- Finally, patients having thyroid cancer surgery at low-volume centers were signicantly more
likely to have an involved tumor margin compared to those treated at high-volume centers. - An overwhelming body of evidence demonstrates improved outcomes for patients undergoing thyroid cancer surgery with higher-volume surgeons
- Referral of patients to high-volume thyroid surgeons is associated with, on average, superior outcomes:
- However, referral is not always possible, in view of the relative scarcity of high-volume surgeons and their geographic concentration in larger urban areas
- Conclusions at an overall population level cannot
always be applied to individual surgeons and patient circumstances:- It seems reasonable to encourage referral of patients with grossly invasive and/or extensive disease to a high-volume surgeon experienced in the management of advanced thyroid cancer, and perhaps even to refer those patients undergoing
total thyroidectomy for low- to intermediate-risk cancers
- It seems reasonable to encourage referral of patients with grossly invasive and/or extensive disease to a high-volume surgeon experienced in the management of advanced thyroid cancer, and perhaps even to refer those patients undergoing
Rodrigo Arrangoiz MS, MD, FACS, FSSO 