Data Show Potential Impact of Shared Decision Making With RAI Therapy in Thyroid Cancer

Lauren P. Wallner, PhD, MPH

Patients with differentiated thyroid cancer (DTC) who were felt to not have a choice in receiving radioactive iodine (RAI) treatment reportedly had lower satisfaction with the treatment decision, suggesting a need for increased shared decision making between physicians and patients, according to results of a study published in the Journal of Clinical Oncology.

“Taken together, these results suggest that shared decision making may provide an opportunity to not only reduce the overuse of RAI, but also improve decision-making outcomes for patients,” the study authors, led by Lauren P. Wallner, PhD, MPH, wrote in their report.

Although the benefit of RAI remains uncertain among the majority of patients with DTC, especially among those with more favorable risk, the treatment is still commonly used and the timing to use RAI among hospitals is varied. Clinical guidelines recommend selective use of RAI for most patients with thyroid cancer, however, as there are associated adverse effects and costs with the treatment.

In the study, patients with DTC were surveyed about their perceived choice in receiving RAI treatment. The investigators sought to characterize patient perspectives about RAI treatment and determine the current extent of shared decision making in the thyroid cancer setting. They conducted a population-based survey of a diverse group of patients with DTC who were reported in the SEER registries of Georgia and Los Angeles between January 2014 and December 2015. A total of 4185 eligible patients were identified who were sent surveys between 2017 and 2018 about their perspectives on RAI. The survey garnered a 63% response rate and a 77% cooperation rate.

In the survey, patients were asked questions about how much of a choice they felt they had in receiving RAI, how strongly their physician recommended it, whether they received it, and how satisfied they were with their decision.

The analysis included responses from 1319 patients who were recommended for selective RAI use and whose disease matched the 2009 American Thyroid Association recommendations for RAI treatment. Of these responders, 75.9% received RAI treatment. Physician recommendation strongly correlated with the receipt of RAI as almost all of the patients whose physician recommended RAI received it (94.9%); only 22.5% of patients received RAI even though their physician recommended against treatment and 39.9% of patients received RAI even though their physician was neither for or against the treatment (P <.01).

Among those who felt they did have a choice about receiving RAI, 68.3% did receive it versus 31.7% who did not, and conversely, among the patients who felt they did not have a choice, 84.9% received RAI and 15.1% did not (P <.01).

After adjusting for demographic covariates, patients whose physician recommended RAI were more likely to feel that they did not have a choice about their treatment (odds radio [OR], 1.56; 95% CI, 1.13-2.17). These patients who did not feel they had a choice about receiving RAI were also more likely to receive the treatment versus those who did feel they had a choice (OR, 2.50; 95% CI, 1.64-3.82). Overall, physician recommendation was the strongest factor associated with the receipt of RAI (OR, 36.32; 95% CI, 22.67-58.19). In accordance with guidelines, those with N1 disease were also more likely to receive RAI treatment than those with N0 disease (OR, 2.44; 95% CI, 1.42-4.17).

Patients who felt they did not have a choice about their RAI treatment were more likely to be less satisfied with their therapy decision than those who felt they did a choice (OR, 2.31; 95% CI, 1.67-3.20). Additionally, older age was also associated with less satisfaction with the patient’s decision on RAI treatment.

Moreover, patients who felt they did not have a choice about their treatment were more likely to believe that they did not receive enough information or have enough involvement in the decision than who did feel that they had a choice. The perceptions regarding not having enough information or involvement were also associated with less satisfaction in the RAI decision (P <.01).

Overall, the study authors suggested that physicians should discuss the risks and benefits of RAI with benefits and work with them to tailor the treatment to their specific disease to improve outcomes.

“In the context of differentiated thyroid cancer, engaging in shared decision making may be an important strategy to avoid overtreatment," the authors stated in the article. "To promote a high-quality decision that is both informed and preference sensitive, providers should engage in discussions with patients about the risk and benefits of treatments, while also ascertaining how the treatment options align with patients’ values and preferences.”

However, the authors did note that these conversations may be difficult as the information is complex and there is uncertainty surrounding the benefit of RAI in select patient subgroups. Additionally, as the patients were surveyed several years after their initial treatment, their answers may be subject to recall bias.

It was concluded that efforts are warranted to promote shared decision making and to support providers in their discussions with patients with DTC about the risks and benefits of RAI to potentially reduce overtreatment in thyroid cancer.

Wallner LP, Reyes-Gastelum D, Hamilton AS, Ward KC, Hawley ST, Haymart MR. Patient-perceived lack of choice in receipt of radioactive iodine for treatment of differentiated thyroid cancer. J Clin Oncol. 2019;37(24):2152-2161. doi: 10.1200/JCO.18.02228.