INTRODUCTION
We are quite familiar with the COVID-19 epidemic and its unprecedented implications. It has clearly changed our lives, healthcare, clinical practice, urgency of the health problems, financial implications and mental health. The issues of mental health are applicable both to the patients and healthcare providers. Obviously, we need to pay special attention to the patients suffering from COVID-19 especially those who are symptomatic or having major health crisis such as pulmonary issues and multiorgan failure.
As of the 8th of April, globally there have been approximately 1.52 million confirmed cases of COVID-19 of whom 90,000 are dead. In the United States, the confirmed COVID-19 cases are reported to be 435,564 while the reported deaths are 14,829. New York State has faced the major brunt of this pandemic with confirmed cases of 147,037 and death number of 6,220.
In spite of this major health crisis patients are always concerned about their own problems in relation to other health issues especially with fear of proven or suspicious cancers. Clearly, some of the cancers are life-threatening and will require urgent attention while other tumors may be monitored or treated at a later date when the COVID-19 issues are relatively settled. In a referral center or a tertiary care cancer center it is fairly common to receive consultations regarding thyroid problems or thyroid tumors.
Even though, there are no set guidelines in the management of patients asking for thyroid surgery it would be appropriate to manage these patients based on the risk group analysis and the overall risks of progression to life-threatening issues. We need to explain every patient that thyroid tumors grow slowly and there is no need for active and emergent intervention. It is quite appropriate to wait for 4-6 months.
If the patient is extremely anxious a follow up ultrasound may be performed in 3-4 months to document the stability of thyroid tumor. We have divided thyroid cancer patients for almost 50 years into low, intermediate and high-risk groups based on their prognostic features1. We popularly described this as good, bad and ugly tumors. The prognostic factors were described as age, grade of the tumor, size of the tumor, extrathyroidal extension, distant metastases, etc. Other prognostic factors such as multiple lymph node metastases and the molecular analysis should go into the equation of management of these patients. Needless to say, patients are extremely concerned for the fear of any cancer whether it is thyroid or pancreatic cancer. It is our responsibility to explain to the patients the concern about these cancers on their overall prognosis and the best timeline definition for active intervention. The new American Thyroid Association guidelines published in 2015 have done a fantastic job in line with the biology of these tumors and appropriate management 2. As a matter of fact, the ATA endorsed observation as a definitive approach in proven microcarcinomas. This clearly reflects the management of these tumors in relation to their biology and avoiding over treatment. Let the punishment fit the crime or let the treatment not be worse than the disease is quite appropriately applied to thyroid cancer. However, it would be important to define certain indications and road map of active management of some these thyroid cancers. If we use the analogy of management of thyroid cancer during pregnancy and delaying the treatment by 9-10 months, it would be the same philosophy of managing these patients during the COVID-19 pandemic. Clearly, some patients will require urgent or active intervention in a timely fashion. The following summary will describe some of the decision-making issues.
We don’t have the answers to these questions, however, I would like to salute the frontline healthcare workers who have been actively involved in offering the best medical care to the patients suffering from COVID-19 and offering them and the society a Glimpse of Hope. These are the true Noble Laureates.
References:
  1. Shaha, AR. Implications of prognostic factors and risk groups in the management of differentiated thyroid cancer. Laryngoscope. 2004, 114; 393-402.
  2. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association – Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer; the American Thyroid Association Guidelines Task Force on Thyroid nodules and differentiated thyroid cancer. Thyroid. 2016, 26; 1-133.
  3. Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Berman KD et al, American Thyroid Association Guidelines for Management of patients with anaplastic thyroid cancer. Thyroid. 2012, 22; 1104-39.
  4. Miyauchi, A. Clinical trials of active surveillance of papillary microcarcinoma of the thyroid. World J Surg. 2016, 40; 516-22.
  5. Tuttle, RM, Fagin JA, Minkowitz G, Wong RJ, Roman B, Patel S et al, Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol Head Neck Surg. 2017, 143; 1015-1020.