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Reference: Saving Thyroids — Over-treatment of Small Papillary Cancers. H. Gilbert Welch, M.D., M.P.H., and Gerard M. Doherty, M.D.

This weeks paper of the week is brought to you by Professor Sir Muir Gray, 3V Executive Director.

Bottom line

Voice and endocrine function are important to patients. Over the past 25 years, some 150,000 women and 50,000 men in the United States have undergone total thyroidectomy for small papillary cancers; all of them require thyroid hormone replacement, and thousands of them have hypoparathyroidism or have faced unnecessary voice changes. These consequences are too important to be influenced by the vicissitudes of our management habits and anxiety about under-treatment. Active surveillance should be an option available for patients with small papillary cancers. And for those who prefer intervention, or whose disease warrants it, we should make it clear that lobectomy is often the best choice.

Implications for value improvement

Note how the shape of the total thyroidectomy curve matches the shape of the benefits curve of Donabedian curve of the law of diminishing returns

First we had the epidemic of ‘thyroid cancer’ detection in increased scanning of thyroid glands, now we have the epidemic of thyroidectomy, examples of what David Eddy called in his 1993 classic the relentless increase in the ‘volume and intensity of clinical practice’.

Source: Eddy, D. M. (1993) ‘Three Battles to Watch In The 1990s’, JAMA: 270: 520-6.