Impact of surgical treatment on outcomes for papillary thyroid cancer.

Based on data from SEER and the NCDB, the contemporary dominant practice pattern in the United States for patients with PTC > or =1.0 cm is a total or near-total thyroidectomy. Only approximately 10% of patients with such tumors currently undergo hemithyroidectomy. Patients from older age groups, minority ethnic groups, and the lower socioeconomic strata dominate the set of patients who undergo hemithyroidectomy. Moreover, patients at low-volume and community hospitals are less likely to undergo total thyroidectomy. These differences in practice patterns likely reflect disparities in access to health care, medication, and comprehensive cancer centers. Critics of total or near-total thyroidectomy for PTC have historically commented that "an operation not worth doing, is not worth doing well." Such comments are no longer appropriate now that compelling data exist that show an improvement in survival and recurrence after more extensive thyroid resection. If all patients with PTC > or =1.0 cm were to instead undergo total thyroidectomy, the estimated improvement in long-term survival would be approximately 2%. The differences in outcomes seem relatively small when expressed as a percentage; however, the number of patients affected would be relatively large. The incidence of these small (<2 cm, PTCs has been increasing, and now greater than 50% of the PTC in the NCDB fall into the less than 2-cm size category. There are several valid reasons why surgeons may not perform a total thyroidectomy. Hemithyroidectomy is the appropriate operation for patients with unilateral cancers who will not or cannot comply with lifelong thyroid hormone replacement. Surgical decision making may also be influenced by concerns about the risk of devastating complications such as bilateral recurrent laryngeal nerve injury or permanent hypocalcemia, neither of which are a concern with a lobectomy. Population-based volume-outcome studies have suggested that the risk of nerve injury and hypocalcemia is significantly greater at low-volume centers. Importantly, the majority of patients in the United States undergo thyroid surgery at low-volume centers. Unless the surgeon's complication rate for thyroidectomy is substantially lower than the 2% improvement in survival rate offered by the more extensive operation, total thyroidectomy should not be offered. Alternatively, patients could be referred, if possible, to high-volume surgeons to minimize the risk of complications while offering the operation that affords the best long-term outcomes. Total or near-total thyroidectomy for PTCs greater than 1 cm in size yields the best outcome in terms of risk of recurrence and death. The surgical treatment of PTC needs to be individualized, however. based on the patient, the tumor, and the experience of the surgeon to offer the best outcome.