Have you been diagnosed with a small papillary thyroid cancer (PTC)?
Canadian research study examining patients’ choice between the options of surgery or close follow-up for the management of very low risk PTC.

About PTC

Papillary thyroid cancer (PTC) and its traditional treatment

In recent decades, the number of individuals diagnosed with thyroid cancer has rapidly increased throughout the world. The most common type of thyroid cancer is papillary thyroid cancer (PTC), and most patients diagnosed with this disease, particularly if diagnosed at an early stage, do not die of thyroid cancer.

Patients with PTC are generally offered surgery to remove all or part of the thyroid containing the cancer (thyroidectomy), and this is often followed by lifelong thyroid hormone treatment (a daily oral pill). Some patients also receive radioactive iodine treatment (oral radiation) after their thyroid is completely removed.

Are there other options for treating early stage papillary thyroid cancer?

Currently surgery is the standard treatment for all stages of thyroid cancers but scientists are studying another management option called “active surveillance” for very low risk papillary thyroid cancer.  Active surveillance is when the healthcare team closely monitors the cancer over time and advises treatment if it becomes necessary.

  • Active surveillance is already used to care for patients with early stage prostate cancer.

Active surveillance for early stage papillary thyroid cancer means that the healthcare team regularly checks on the patient’s cancer and track its measurements on neck ultrasounds over time.  The lymph nodes in the neck are also tracked on neck ultrasounds. The patient will be advised to have surgery when the cancer grows by a certain amount or if the thyroid cancer is detected in the lymph nodes.

  • Patients on active surveillance can choose to stop active surveillance and have thyroid surgery at any time, even if the cancer has not grown and the thyroid cancer has not spread outside the thyroid gland.

What studies have been done on using active surveillance for early stage papillary thyroid cancer?

Scientists in many countries including Canada are studying active surveillance as a management option for early stage papillary thyroid cancer.

The first study on using active surveillance to care for papillary thyroid cancer patients started in 1993 in Japan. Active surveillance was offered to patients with cancer tumours smaller than 1 cm in size. So far:

  • In published reports from Japan on long-term outcomes of patients who underwent active surveillance of early stage papillary thyroid cancer, none of the patients who chose active surveillance have died from thyroid cancer or had their cancer spread to a distant organ.
  • In published reports from Japan, most patients who chose active surveillance have avoided thyroid surgery.
  • One of the aims of our study is to confirm the clinical outcomes reported in the the published reports from Japan.

About the Study

We are doing an observational study on active surveillance for very low-risk papillary thyroid cancer at University Health Network (UHN) in Toronto, Canada.

  • An observational study is a scientific study that tries to understand cause-and-effect relationships. Scientists give study participants different disease management options and the study participant decides what treatment they want to have.

The study is referred to as “A Novel Active Surveillance Approach to the Primary Management of Low Risk Papillary Thyroid Cancer”. We are interested in how often patients choose surgery or active surveillance and the reasons for their choice. We are also interested in patients’ feelings about their initial decision on managing their thyroid cancer. Our study is considered “novel” in Canada, where surgery has been the standard of care for management of all thyroid cancers.

This study is being led by Drs. Anna Sawka (Endocrinologist, a specialist in the thyroid and thyroid hormone) and David Goldstein (a Head and Neck Cancer Surgeon).

What is very low-risk papillary thyroid cancer?

The definition of very low-risk papillary thyroid cancer used in our study is as follows:

  • the primary cancer is smaller than 2 cm in size
  • thyroid cancer has not spread from the thyroid to other areas of the body (such as lymph nodes or distant sites)
  • the thyroid cancer is not too close to important body parts (critical structures) such as the breathing tube (trachea or windpipe) or the nerves attached to your voicebox (recurrent laryngeal nerve)

What does participation involve?

There are two phases in this study. You can choose to participate in both phases or only Phase 1.

Study Phase 1: Understanding how patients decide on their treatment options

Phase 1 is about:

  • seeing how often participants choose active surveillance rather than surgery
  • understanding how participants made their choice

As a participant during Phase 1 you will:

  1. be interviewed about what you think of your treatment options
  2. go to an information session, where you will speak to a doctor to learn about the long-term outcomes of having surgery and what it means to be on active surveillance. You will also be provided written information that you may take home to review on your own or with any healthcare providers, family, or friends, if you so choose.
  3. be interviewed by telephone about your disease management choice (specifically surgery or active surveillance and the reasons for the decision)

Study Phase 2: Patient follow-up

Phase 2 of the study is about:

  • carefully monitoring participants’ very low risk papillary thyroid cancer (including review of thyroid cancer-related medical records)
  • following up with participants to see how they feel about their treatment decision and examining their wellbeing a year later

You must participate in Phase 1 of this study to be eligible to participate in Phase 2 (so that you have received information about the treatment choices).

Eligibility

Are you eligible to participate?

You may be eligible for this study if you:

    • are 18 years old or older
    • have never had thyroid surgery
    • had a thyroid biopsy (tissue taken from your thyroid for testing) that shows papillary thyroid cancer or is suspicious for papillary thyroid cancer, and the cancer:
      • is smaller than 2 cm in size
      • has not spread from the thyroid to other parts of the body (such as lymph nodes or distant sites)
    • have not been diagnosed with another cancer in the past 3 years
    • have no medical reasons that make surgery necessary
    • are able to provide informed consent

Research Team

Primary Investigators (Study Leaders)

Dr David Goldstein

Dr. David P. Goldstein

Dr Goldstein is a Head and Neck Surgical Oncologist, Clinical and Health Services Researcher, and Associate Professor in the Departments of Otolaryngology- Head and Neck Surgery and Surgical Oncology at the University Health Network (Toronto General Hospital and Princess Margaret Cancer Center) and the University of Toronto. He is currently the Site Leader for Endocrine Oncology at the Princess Margaret Cancer Center.

Dr Anna Sawka

Dr. Anna Sawka

Dr. Sawka is an Endocrinologist Clinical and Health Services Researcher, and Associate Professor in the Division of Endocrinology, Department of Medicine of University Health Network and University of Toronto. Dr. Sawka was co-author on the 2015 American Thyroid Association clinical practice guidelines on management of thyroid nodules and Differentiated Thyroid Cancer in adults.

Co-Investigators/ Collaborators

University Health Network

  • Dr. Sangeet Ghai (Study Lead- Radiology)
  • Dr. Lorne Rotstein
  • Dr. Dale Brown
  • Dr. John de Almeida
  • Dr. Patrick Gullane
  • Dr. Doug Chepeha
  • Dr. Jon Irish
  • Dr. Jesse Pasternak
  • Dr. Shereen Ezzat
  • Dr. Jim Brierley
  • Dr. Richard Tsang

Mount Sinai Hospital

  • Dr Eric Monteiro
  • Dr. Jacqueline James
  • Dr. Afshan Zahedi
  • Dr. Karen Gomez

Sunnybrook Health Science Center / Odette Cancer Center

  • Dr. Antoine Eskander
  • Dr. Danny Enepekides
  • Dr. Kevin Higgins

St. Michael’s Hospital

  • Dr. Jennifer Anderson

Women’s College Hospital

  • Dr. Afshan Zahedi
  • Dr. Karen Devon

North York General Hospital

  • Dr. Everton Gooden
  • Dr. Manish Shah

William Osler Health System

  • Dr. Mark Korman

Mackenzie Health System

  • Dr. Phil Solomon

Trillium Health Partner

  • Dr. Janet Chung
  • Dr. Kareem Nazarali

Lakeridge Health

  • Dr. Eric Arruda
  • Dr. Artur Gevorgyan

Rouge Valley (Centenary Site)

  • Dr. Michael Chang

Scarborough Hospital (Grace Site)

  • Dr. Sumeet Anand

Scarborough Hospital (General Site)

  • Dr. Vinay Fernandes

Guelph General Hospital

  • Dr. Denny Lin

Grand River Hospital Kitchener

  • Dr. Avik Banerjee
  • Dr. Vinita Bindlish
  • Dr. Vinod Bharadwaj

Humber Hospital

  • Dr. Raewyn Seaburg
  • Dr. Laura Whiteacre

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