| Step 1. Control of anxiety and psychological stress |
Choose correct and precise words |
Use "nodule with intermediate or high suspicion of carcinoma" or "low-risk carcinoma" |
| Explain how the tumor was found and how it relates to the symptoms |
Incidental finding or incidentaloma = asymptomatic Clinical finding = symptomatic Meaning of overdiagnosis, overtreatment, and "retrospective" active surveillance |
| Explain if ultrasound and biopsy are not needed |
Ultrasound is not required to investigate pharyngeal globus, hypothyroidism, or overweight Biopsy is not required for nodules smaller than 1 cm |
| Ensure clarity |
Describe the TI-RADS method and the likelihood of cancer (Table 2) |
| Describe the Bethesda classification system and the likelihood of cancer (Table 3) |
| Show the natural history of thyroid tumors considered to have a mild or high risk of malignancy |
5%-11% of individuals who die of causes other than thyroid disease have undetected, asymptomatic thyroid cancer |
| Explain alternatives options |
Present alternative options fairly, considering how well they work, risks or side effects, and need for thyroid hormone therapy (Table 4) Begin with active surveillance |
Use whole numbers instead of percentages to convey the information, for example: "After 30 years of follow-up, 93 out of 100 patients will still have a stable nodule. There are three reasons why 7 out of the 100 patients will require surgery: (11 Davies L, Chang CH, Sirovich B, Tuttle RM, Fukushima M, Ito Y, et al. Thyroid Cancer Active Surveillance Program Retention and Adherence in Japan. JAMA Otolaryngol Head Neck Surg. 2021;147(1):77-84. doi: 10.1001/jamaoto.2020.4200
https://doi.org/10.1001/jamaoto.2020.420...
) lymph nodes will grow or produce suspicious nodes in 3 cases; (22 de Morais Fernandes FCG, de Souza DLB, Curado MP, de Souza TA, de Almeida Medeiros A, Barbosa IR. Incidence and mortality from thyroid cancer in Latin America. Trop Med Int Health. 2021;26(7):800-9. doi: 10.1111/tmi.13585
https://doi.org/10.1111/tmi.13585...
) the patient will change their mind in one case; and (33 Sierra MS, Soerjomataram I, Forman D. Thyroid cancer burden in Central and South America. Cancer Epidemiol. 2016;44 Suppl 1:S150-7. doi: 10.1016/j.canep.2016.07.017
https://doi.org/10.1016/j.canep.2016.07....
) the physician will change their opinion in 3 cases." |
| Explain why the patient would benefit from active surveillance |
Identify the patient's profile (i.e., ideal, appropriate, or inappropriate) (Table 5) |
| Talk about things that could change treatment choices |
Invite family or caretakers to take part in the decision-making process and talk about their concerns |
| Recommend to the patient to avoid talking to others about treatment choices |
| Make it clear that physicians have different points of view Establish follow-up at the same center and with the same group of professionals who made the initial recommendations |
| Follow-up assessments must be done with discipline and be available to everyone |
| Inform patients that they may change their minds at any time |
| Step 2: Explanation of how active surveillance works |
Explain how often surveillance will occur |
Clinical and ultrasound assessments should be performed every 6-12 months; it is currently unclear when these assessments should be interrupted |
| Explain how tumors grow |
Not all tumors behave the same way (Figure 1) |
| Identify the reasons why surgery should be done |
Nodule increases in size by more than 3 mm Smaller changes are considered variations by the examiner or the ultrasonography team Changes in how the tumor looks (e.g., it expands outside the gland or becomes close to the trachea) Presence of suspicious lymph nodes Patient's decision |
| Patients should be informed that they may change their minds at any time |
| Identify the most likely type of surgery |
Explain when lobectomy or total thyroidectomy is needed, and when neck dissection must be performed |
| Step 3: Maintenance of active surveillance |
Explain in detail the terms used in ultrasound reports and what they mean for experts |
How the growth of the nodule is estimated Reason for so many differences in measurements Most suspicious ultrasound findings Types of symptoms that the nodule could cause |
| Show individual experiences of different patients |
Display the tumor growth chart |
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