Likhterov Ilya, Osorio Marcela, Moubayed Sami P, Hernandez-Prera Juan C, Rhodes Rosamond, Urken Mark L
1 Department of Otolaryngology - Head and Neck Surgery, Mount Sinai Beth Israel , New York, New York.
2 Thyroid, Head and Neck Cancer (THANC) Foundation , New York, New York.
Thyroid. 2016 Sep;26(9):1167-72. doi: 10.1089/thy.2016.0212.
Several studies have highlighted the lack of consensus in the diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC). An international multidisciplinary panel to address the controversy was assembled at the annual meeting of the Endocrine Pathology Society in March of 2015, leading to the recent publication reclassifying encapsulated (or noninvasive) FVPTC (EFVPTC) as a benign neoplasm. Does this change in histologic taxonomy warrant a change in clinical practice, and how should it affect those who have been given this diagnosis in the past? We consider the financial and psychological impact of this reclassification and discuss the ethical, legal, and practical issues involved with sharing this information with the patients who are affected.
The total direct and indirect cost of thyroid cancer surveillance in patients is significant. High levels of clinically relevant distress affect up to 43% of patients with papillary thyroid carcinoma, as estimated by the Distress Thermometer developed by the National Comprehensive Cancer Network for detecting distress in cancer patients. Although there are currently no legal opinions that establish a precedent for recontacting patients whose clinical status is altered by a change in nomenclature, the prudent course would be to attend to the requirements of medical ethics.
Informing patients with a previous diagnosis of EFVPTC that the disease has been reclassified as benign is expected to have a dramatic effect on their surveillance needs and to alleviate the psychological impact of living with a diagnosis of cancer. It is important to re-evaluate the pathologic slides of those patients at risk to ensure that the invasive nature of the tumor is comprehensively evaluated before notifying a patient of a change in diagnosis. The availability of the entire tumor for evaluation of the capsule may prove to be a challenge for a portion of the population at risk. We believe that it is the clinician's professional duty to make a sincere and reasonable effort to convey the information to the affected patients. We also believe that the cost savings with respect to the need for additional surgery, radioactive iodine, and rigorous surveillance associated with a misinterpretation of the biology of the diagnosis of EFVPTC in less experienced hands will likely more than offset the cost incurred in histologic review and patient notification.
多项研究强调了在甲状腺乳头状癌滤泡变体（FVPTC）诊断方面缺乏共识。2015年3月，一个国际多学科小组在内分泌病理学会年会上聚集，以解决这一争议，这导致了最近将包膜型（或非侵袭性）FVPTC（EFVPTC）重新分类为良性肿瘤的出版物。这种组织学分类的变化是否需要改变临床实践，以及它应该如何影响那些过去被给予这种诊断的人？我们考虑了这种重新分类的财务和心理影响，并讨论了与受影响患者分享此信息所涉及的伦理、法律和实际问题。
患者甲状腺癌监测的直接和间接总成本是巨大的。根据美国国立综合癌症网络开发的用于检测癌症患者痛苦的痛苦温度计估计，高达43%的甲状腺乳头状癌患者存在高水平的临床相关痛苦。尽管目前没有法律意见为重新联系临床状况因命名变化而改变的患者确立先例，但谨慎的做法是遵循医学伦理要求。
告知先前被诊断为EFVPTC的患者该疾病已被重新分类为良性，预计将对他们的监测需求产生巨大影响，并减轻患有癌症诊断的心理影响。在通知患者诊断变化之前，重新评估有风险患者的病理切片以确保全面评估肿瘤的侵袭性很重要。对于一部分有风险的人群来说，获得整个肿瘤以评估包膜可能是一个挑战。我们认为，真诚且合理地努力向受影响患者传达信息是临床医生的职业责任。我们还认为，与经验不足的医生对EFVPTC诊断生物学的错误解读相关的额外手术、放射性碘和严格监测需求方面节省的成本，可能会超过组织学审查和患者通知所产生的成本。
