scholarly journals Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi-institutional Study

OTO Open ◽  
2021 ◽  
Vol 5 (2) ◽  
pp. 2473974X2110159
Author(s):  
Victoria Kuta ◽  
David Forner ◽  
Jason Azzi ◽  
Dennis Curry ◽  
Christopher W. Noel ◽  
...  
Keyword(s):  
Decision Making ◽  
Thyroid Nodules ◽  
Management Decision ◽  
Molecular Testing ◽  
Fee For Service ◽  
Hospital Type ◽  
Patient Centered ◽  
Cross Sectional ◽  
Payment Model ◽  
Nodule Size

Objective Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population. Study Design This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules. Setting Multi-institutional. Methods Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients. Results A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery. Conclusion While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

scholarly journals Clinicopathologic Characteristics of Thyroid Nodules Positive for PTEN Mutations on Preoperative Molecular Testing

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A1013-A1014
Author(s):  
Jacob Quaytman ◽  
Yuri E Nikiforov ◽  
Marina Nikiforova ◽  
Elena Morariu
Keyword(s):  
Thyroid Nodules ◽  
Follicular Carcinoma ◽  
Retrospective Chart Review ◽  
Needle Aspiration ◽  
Follicular Neoplasm ◽  
Molecular Testing ◽  
Nras Mutation ◽  
Clinicopathologic Characteristics ◽  
Nodule Size

Abstract Somatic and germline mutations of PTEN tumor suppressor gene are associated with follicular-pattern thyroid tumors and PTEN Hamartoma Tumor Syndrome (PHTS). The incidence of cancer in thyroid nodules positive for PTEN mutations on fine-needle aspiration (FNA) is not well defined. The aim of this study was to characterize diagnostic and phenotypic features of thyroid nodules with preoperatively detected PTEN mutations and their impact on management. Thyroid nodules with PTEN mutations on ThyroSeq v3 GC testing of FNA and core needle biopsy specimens from November 2017 to July 2020 were identified from the ThyroSeq Molecular Database. Demographic and clinicopathologic data were obtained through retrospective chart review. We identified 49 PTEN mutation-positive nodules from 48 patients. Patients were 57 years old on average (range 14-88) and 80% female. Cytology was predominantly indeterminate (73% atypia of undermined significance, 18% follicular neoplasm). There were 18 (29%) frameshift, 6 (10%) splice site, and 39 (62%) single nucleotide variant PTEN mutations. Fourteen (29%) nodules had two PTEN mutations, 5 (10%) had copy number alterations, and single cases had concurrent BRAF K601N, EZH1, and NRAS mutations. Surveillance was pursued for 27 (56%) and surgery for 21 (44%) patients (16 lobectomies, 5 total thyroidectomies). There were 14 follicular adenomas (FA), 4 oncocytic FA’s, 1 oncocytic hyperplastic nodule, and 1 encapsulated follicular variant papillary thyroid carcinoma (EFVPTC). The EFVPTC had two low-frequency PTEN mutations, PTEN locus loss, an NRAS mutation, and was a low-risk tumor with capsular but no angiolymphatic invasion. Four (8.3%) patients had confirmed or suspected PHTS, all with multiple nodules. Two had surgery finding no malignancies (2 FA). One PHTS patient had a prior thyroidectomy for a MET mutation-positive nodule that was follicular carcinoma. On US, the mean nodule size of patients who had surgery was larger than the surveillance group (3.2 cm vs. 2.3 cm, p=0.02) but there was no difference in TI-RADS level (p=0.54). There was no difference in mean nodule size (3.5 cm vs. 2.6 cm, p=0.35) or TI-RADS level (p=0.81) between PHTS and non-PHTS patients. Among surveillance patients, follow-up US was done at 1 year in 13/19 (68%) and 2 years in 3/6 (50%) of eligible cases. Only 1/19 (5%) underwent repeat FNA for increased nodule size. No thyroid malignancy was found with a mean of 1.75 years of follow-up (range 1.00-2.78). The EFVPTC patient had no recurrence after 1.05 years of follow-up. In summary, thyroid nodules with isolated somatic PTEN mutations are primarily benign and can be safely followed with serial imaging. Nodules with multiple PTEN mutations were only associated with malignancy when accompanied by an additional NRAS mutation. About 8% of patients with PTEN mutations may be PHTS patients who may be at greater risk for malignancy.

scholarly journals Evaluation of the Effect of Diagnostic Molecular Testing on the Surgical Decision-Making Process for Patients With Thyroid Nodules

2016 ◽  
Vol 142 (7) ◽  
pp. 676 ◽  
Author(s):  
Salem I. Noureldine ◽  
Alireza Najafian ◽  
Patricia Aragon Han ◽  
Matthew T. Olson ◽  
Dane J. Genther ◽  
...  
Keyword(s):  
Decision Making ◽  
Thyroid Nodules ◽  
Decision Making Process ◽  
Molecular Testing ◽  
Surgical Decision ◽  
Surgical Decision Making

scholarly journals Impact of molecular testing on thyroid nodule neoplastic diagnosis, stratified by 4-cm size, in a surgical series

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Rupendra T. Shrestha ◽  
Muhammed Kizilgul ◽  
Maryam Shahi ◽  
Khalid Amin ◽  
Maria R. Evasovich ◽  
...  
Keyword(s):  
Thyroid Nodule ◽  
Thyroid Nodules ◽  
Follicular Adenoma ◽  
Diagnostic Value ◽  
Mutation Testing ◽  
Molecular Testing ◽  
Nodule Size ◽  
Histopathologic Diagnosis ◽  
The Impact

AbstractWhether molecular testing adds diagnostic value to the evaluation of thyroid nodules 4-cm or larger is unknown. The impact of molecular testing on cytopathologic-histopathologic diagnosis of neoplasm (adenoma or malignant), stratified by nodule size <or≥ 4-cm, was analyzed from a surgical series. Of 490 index nodules, molecular testing was performed on 18% of 353 nodules <4-cm and 8.8% of 137 nodules ≥4-cm (p = 0.0118). Adenoma was higher (30% vs 14%) and malignancy lower in nodules ≥4-cm vs <4-cm (p < 0.0001). Molecular testing impacted the finding of malignancy in the <4-cm group. Molecular testing of the ≥4-cm AUS and FN cytology subcategory impacted neoplasm discovery (combining adenoma and malignancy), with mutation positive 100% (3/3), mutation negative 38% (3/8), no mutation testing 88% (21/24), p = 0.0122. In conclusion, more adenoma was found in nodules ≥4-cm, including those with benign cytology, which was not explained by available molecular testing results. Molecular testing impacted the finding of malignancy in thyroid nodules <4-cm. The overall number of ≥4-cm nodules with molecular testing in this study was too low to exclude its diagnostic value in this setting. Further study is recommended to include molecular testing in nodules ≥4-cm, including those with benign cytology, to identify follicular adenoma.

scholarly journals Designing a portal to patient-centered care? Let�s start with the patient. A cross-sectional survey. (Preprint)

2017 ◽  
Author(s):  
Steve Alfons Van den Bulck ◽  
Rosella Hermens ◽  
Karin Slegers ◽  
Bert Vandenberghe ◽  
Geert Goderis ◽  
...  
Keyword(s):  
Decision Making ◽  
Health Information ◽  
Shared Decision Making ◽  
Information Needs ◽  
Patient Portal ◽  
Shared Decision ◽  
Cross Sectional Survey ◽  
Patient Centered ◽  
Cross Sectional ◽  
Centered Care

BACKGROUND In recent literature, patient portals are considered as important tools for the delivery of patient-centered care. Yet, it is not clear how patients would conceptualize a patient portal and which health information needs they have when doing so. OBJECTIVE 1) To investigate health information needs, expectations and attitudes towards a patient portal. 2) To assess if determinants such as patient characteristics, health literacy and empowerment status can predict two different variables, namely the importance people attribute to obtaining health information when using a patient portal and the expectations concerning personal healthcare when using a patient portal. METHODS A cross-sectional survey was performed in the Flemish population on what patients prefer to know about their digital health data and on their expectations and attitudes towards using a patient portal to access their Electronic Health Record. People were invited to participate in the survey through newsletters, social media and magazines. We used a questionnaire including demographics, health characteristics, health literacy, patient empowerment and patient portal characteristics. RESULTS We received 433 completed surveys. The health information needs included features such as being notified when one’s health changes (93.7%, 371/396), being notified when physical parameters rise to dangerous levels (93.7%, 370/395), to see connections between one’s symptoms/diseases/biological parameters (85.2%, 339/398), to view the evolution of one’s health in function of time (84.5%, 333/394) and to view information about the expected effect of treatment (88.4%, 349/395). Almost 90% (369/412) of respondents were interested in using a patient portal. Determinants of patients’ attachment to obtaining health information on a patient portal were 1) age between 45 and 54 years (P = .047); 2) neutral (P = .030) or interested attitude (P = .008) towards shared decision-making; 3) commitment to question the physicians’ decisions (P = .030). (R2 = .122) Determinants of patients’ expectations on improved healthcare by accessing a patient portal were 1) lower education level (P = .040); 2) neutral (P = .030) or interested attitude (P = .008) towards shared decision-making; 3) problems in understanding health information (P = .037). (R2 = .106) CONCLUSIONS The interest in using a patient portal is considerable in Flanders. People report they would like to receive alerts or some form of communication from a patient portal in case they need to take action to manage their health. Determinants such as education, attached importance to shared decision-making, difficulties in finding relevant health information and the attached importance to questioning the decisions of physicians need to be taken into account in the design of a patient portal.

scholarly journals Patient Navigation in Cancer: The Business Case to Support Clinical Needs

2019 ◽  
Vol 15 (11) ◽  
pp. 585-590 ◽  
Author(s):  
Ronald M. Kline ◽  
Gabrielle B. Rocque ◽  
Elizabeth A. Rohan ◽  
Kris A. Blackley ◽  
Cynthia A. Cantril ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Patient Navigation ◽  
Business Case ◽  
Emergency Department Visits ◽  
Fee For Service ◽  
Patient Centered ◽  
Payment Model ◽  
Financial Benefits ◽  
Oncology Providers ◽  
Patient Retention

PURPOSE: Patient navigation (PN) is an increasingly recognized element of high-quality, patient-centered cancer care, yet PN in many cancer programs is absent or limited, often because of concerns of extra cost without tangible financial benefits. METHODS: Five real-world examples of PN programs are used to demonstrate that in the pure fee-for-service and the alternative payment model worlds of reimbursement, strong cases can be made to support the benefits of PN. RESULTS: In three large programs, PN resulted in increased patient retention and increased physician loyalty within the cancer programs, leading to increased revenue. In addition, in two programs, PN was associated with a reduction in unnecessary resource utilization, such as emergency department visits and hospitalizations. PN also reduces burdens on oncology providers, potentially reducing burnout, errors, and costly staff turnover. CONCLUSION: PN has resulted in improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and the alternative payment model worlds, lending support for more robust staffing of PN programs.

Community Oncology in an Era of Payment Reform

2014 ◽  
pp. e447-e452 ◽  
Author(s):  
John V. Cox ◽  
Jeffery C. Ward ◽  
John C. Hornberger ◽  
Jennifer S. Temel ◽  
Barbara L. McAneny
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
The United States ◽  
Fee For Service ◽  
Shared Decision ◽  
Payment Reform ◽  
Patient Centered ◽  
Payment Schemes ◽  
Oncology Practice ◽  
Personalized Cancer

Patients and payers (government and private) are frustrated with the fee-for-service system (FFS) of payment for outpatient health services. FFS rewards volume and highly valued services, including expensive diagnostics and therapeutics, over lesser valued cognitive services. Proposed payment schemes would incent collaboration and coordination of care among providers and reward quality. In oncology, new payment schemes must address the high costs of all services, particularly drugs, while preserving the robust distribution of sites of service available to patients in the United States. Information technology and personalized cancer care are changing the practice of oncology. Twenty-first century oncology will require increasing cognitive work and shared decision making, both of which are not well regarded in the FFS model. A high proportion of health care dollars are consumed in the final months of life. Effective delivery of palliative and end-of-life care must be addressed by practice and by new models of payment. Value-based reimbursement schemes will require oncology practices to change how they are structured. Lessons drawn from the principles of primary care's Patient Centered Medical Home (PCMH) will help oncology practice to prepare for new schemes. PCMH principles place a premium on proactively addressing toxicities of therapies, coordinating care with other providers, and engaging patients in shared decision making, supporting the ideal of value defined in the triple aim—to measurably improve patient experience and quality of care at less cost. Payment reform will be disruptive to all. Oncology must be engaged in policy discussions and guide rational shifts in priorities defined by new payment models.

scholarly journals Development and Pilot Testing of the Transgender and Gender Diverse Fertility Preservation Knowledge Scale

2021 ◽  
Author(s):  
Denise Rivera ◽  
Angela Jukkala ◽  
Katherine Mistretta ◽  
Willa Starke
Keyword(s):  
Decision Making ◽  
Fertility Preservation ◽  
Treatment Decision ◽  
Patient Centered ◽  
Cross Sectional ◽  
Decision Regret ◽  
Gender Diverse ◽  
Healthcare Decision Making ◽  
And Gender ◽  
Knowledge Scale

Little is known about fertility preservation within the TGD community. Few receive adequate counseling placing them at risk for decision regret. The goal of this project was to develop, and pilot test the Transgender Fertility Preservation Knowledge Scale (TFPKS) to support the development and evaluation of health education resources. A community engaged; cross sectional retrospective design was used. Participants (n=189) provided information describing demographics, healthcare decision-making preferences, experiences/knowledge of fertility preservation, and treatment decision regret. The sample included 189 TGD adults. Most were white and aged 26-35 (33.3%) and not offered a consultation (73.0%). Many (41.2%) report they would have participated if offered. Knowledge regarding fertility preservation to support this desire was low. Most participants identified a patient-centered (69.4%) decision making preference. Much remains to address the healthcare inequities within the TGD population regarding fertility preservation. Overall participants had low levels of knowledge to support decision making. Further, healthcare system and individual barriers to fertility preservation remain prevalent. A foundational step towards addressing these disparities, is the identification of a valid and reliable instrument to measure TGD knowledge of fertility preservation.

scholarly journals Barriers to Evidence-Based Treatment Decision-Making in Acute Myeloid Leukemia: A Quality Improvement Initiative Across Community Oncology Practices

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3016-3016
Author(s):  
Joshua F. Zeidner ◽  
William Blum ◽  
Amir T. Fathi ◽  
Daniel A. Pollyea ◽  
Megan M. Stephan ◽  
...  
Keyword(s):  
Decision Making ◽  
Treatment Planning ◽  
Shared Decision Making ◽  
Research Funding ◽  
Patient Centered Care ◽  
Molecular Testing ◽  
Shared Decision ◽  
Patient Centered ◽  
Community Oncology ◽  
Centered Care

Abstract Background Availability of molecularly targeted therapies has rapidly changed the treatment landscape for acute myeloid leukemia (AML). With these newer treatment choices, healthcare professionals (HCPs) must consider appropriate uses of molecular testing, treatment selection based on testing results, new sets of adverse events (AEs), and an increased need for patient education and shared decision-making (SDM). In this quality improvement (QI) initiative, we assessed barriers to evidence-based treatment planning for patients with AML in 4 community oncology systems and conducted team-based audit-feedback (AF) sessions within each system to facilitate HCP goal setting to mitigate identified barriers. Methods The QI initiative was conducted between Dec. 7, 2020 and Feb. 10, 2021. Initially, 14 hematology/oncology HCPs completed baseline team-based surveys to assess barriers in 4 community oncology systems (Table 1). To address identified gaps, 43 HCPs in the 4 systems participated in AF sessions. Action plans were developed by the clinical teams based on survey results (Table 1). Additional pre- and post-surveys completed before and after the AF sessions measured changes in participants' confidence and competence. Results On the pre-activity surveys, the most common challenges in AML management were: 1) identifying which treatment options are most appropriate (30%), 2) coordinating with other members of the care team (24%), 3) gaining/maintaining access to new therapies (15%), and 4) integrating molecular testing information into treatment decisions (15%) (Figure 1). After the 4 AF sessions, HCPs prioritized addressing these 4 challenges. In the baseline surveys, HCPs identified additional staff/resources (64%) and additional staff training/education as top resources needed to overcome these challenges. HCPs identified additional challenges in the areas of AE management and patient centered care in the baseline surveys. Identified barriers in patient centered care, specifically, shared decision making (SDM), included not enough time to engage in SDM (57%) and patients' low health literacy (57%). After the 4 AF sessions, HCPs prioritized addressing tailoring treatment decisions to achieve patient goals (42%), coordinating follow-up visits with other care team members (32%), and engaging patients in shared decision-making (21%) as goals for improving patient-centered care. Molecular testing emerged as a key challenge in AML treatment planning over the course of the QI initiative. Pre-activity, only 36% of HCPs expressed high confidence (4/5 Likert scale) in identifying which molecular tests should be ordered to guide treatment planning, and similarly only 36% were highly confident in selecting targeted therapies based on actionable mutations. HCPs also expressed dissatisfaction with ordering and timely receipt of molecular testing results in their systems. In post-activity surveys, over twice as many HCPs selected molecular testing as a challenge they were planning to address within their team (37% compared with 15% pre-activity), suggesting increased awareness of this barrier (Figure 1). Pre- to post-activity, HCPs who self-reported use of targetable mutations as an important factor in planning treatment for patients who are not candidates for induction therapy increased from 27% to 63%. Participation in the QI initiative led to improvements in clinician confidence and competence in molecular testing, treatment selection based on molecular results, AE management, and use of SDM (Figure 2). Conclusions HCPs participating in this QI initiative identified barriers and potential areas for improvement in AML treatment planning, including barriers related to molecular testing, treatment selection and access, AE management, and patient-centered care. Participation in the AF sessions led to measurable improvements in HCP confidence and competence in key areas of AML management which may ultimately improve the quality of AML care in the community. Study Sponsor Statement The study reported in this abstract was funded by an independent educational grant from Genentech. The grantor had no role in the study design, execution, analysis, or reporting. Figure 1 Figure 1. Disclosures Blum: Abbvie: Honoraria; AmerisourceBergen: Honoraria; Forma Therapeutics: Research Funding; Leukemia and Lymphoma Society: Research Funding; Celyad Oncology: Research Funding; Nkarta: Research Funding; Xencor: Research Funding; Syndax: Honoraria. Fathi: Seattle Genetics: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria; Blueprint: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Celgene/BMS: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria; Agios: Consultancy, Honoraria, Research Funding; Servier: Research Funding; AbbVie: Consultancy, Honoraria, Research Funding; Genentech: Consultancy, Honoraria; Trillium: Consultancy, Honoraria; Kura: Consultancy, Honoraria; Foghorn: Consultancy, Honoraria; Kite: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria; Ipsen: Consultancy, Honoraria. Pollyea: Takeda: Honoraria; Syros: Consultancy, Honoraria; Syndax: Honoraria; Novartis: Consultancy, Honoraria; Kiadis: Honoraria; Aprea: Honoraria; Astellas: Honoraria; Bristol Myers Squibb: Honoraria; Celgene: Honoraria; Foghorn: Honoraria; Genentech: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Jazz: Honoraria; Karyopharm: Consultancy, Honoraria; Amgen: Honoraria; AbbVie: Consultancy, Honoraria, Research Funding; Teva: Research Funding.

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