James Z. Zhang1, Grace S. Li2, Wen Tian3
1Southern Medical University, Guangzhou, China; 2AOT Editorial Office, AME Publishing Company; 3Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, China.
Editor's Note: On the weekend of 19–20 March 2018, the 7th Chinese Research Hospital Association Thyroid Disease Summit and the 3rd Symposium on Endoscopic Thyroid Surgery of Shangdu Medical Forum of Henan Provincial Health Science and Technology Society were successfully held online. The summit not only allowed greater insights into the standardized treatment of thyroid cancer but also provided an opportunity for sharing new concepts and new technology in this field. Prof. Tian Wen, director of Division of Thyroid Hernia Srugery, Department of General Surgery, Chinese People's Liberation Army General Hospital and editor-in-chief of Annals of Thyroid, gave a keynote speech titled "Interpretation of Chinese Expert Consensus on Postoperative Management of Differentiated Thyroid Cancer (2020 Edition)" and was interviewed by the editorial office of Annals of Thyroid, AME Publishing Company, after the meeting.
AOT: What were the priorities and highlights of this meeting?
Prof. Tian: This conference focused on the interpretation and further promotion of the expert consensus guidelines series on the diagnosis and treatment of thyroid diseases, especially the management of difficult and complex thyroid diseases. A series of consensuses and guidelines on the diagnosis and treatment of thyroid cancer have been developed in the past few years, which are helpful to improve the quality of life of thyroid cancer patients and increase their survival rates. In our current meeting, we used different modes such as academic lectures and surgical videos to explain these consensuses and guidelines, with an attempt to further boost and optimize these theories and practice. Another priority of our meeting was to call for attention to difficult and complex thyroid diseases, for which new treatment methods and theoretical systems may be explored and some neglected aspects may be further investigated. Based on the conventional studies, the past decades have seen some new breakthroughs in minimally invasive techniques and in the treatment of advanced tumors, including genetic testing. In general, the first highlight was the inheritance and promotion of the expert consensus guidelines series. The second highlight was the academic exchanges on new research hotspots and clinical challenges. The meeting offered a good platform for sharing experiences and promoting the standardized diagnosis and treatment of thyroid cancer.
AOT: Could you tell us the incidence and mortality of thyroid cancer as well as the treatment of this malignancy in China?
Prof. Tian: First, thyroid cancer is the seventh most common cancer in China, after lung cancer, gastrointestinal tumors, liver cancer, esophageal cancer, and breast cancer. Interestingly, there is a long-existing myth that thyroid cancer occurs in the youngest population and has the highest incidence. Second, women are more susceptible to this disease. Third, thyroid cancer can be fatal in some cases. Many people think that thyroid cancer is an indolent tumor that needs no treatment. Actually, it's not. Therefore, it’s important to standardize the diagnosis and treatment of thyroid cancer. In China, the overall five-year survival rate of thyroid cancer was only 67.5% in 2003 and 2005. In 2015, the five-year survival rate rose to 84.3% and even reached 90% in metropolises such as Shanghai and Beijing, showing a tremendous progress. However, there is still a gap compared to foreign countries. For example, this figure reached 98.3% in the United States. In general, China has made great progress in thyroid cancer diagnosis and treatment and is approaching the level of developed countries; however, gaps are still open and will require further efforts.
AOT: You specifically interpreted the "Chinese Expert Consensus on Postoperative Management of Differentiated Thyroid Cancer” in this meeting. Why should we pay special attention to the postoperative management of differentiated thyroid cancer?
Prof. Tian: This is a very important question. First, with the wide adoption of the Consensus, the diagnostic capability of thyroid cancer been greatly improved, and many techniques such as puncture biopsy are now also available in Chinese hospitals. Secondly, the thyroid cancer can be removed in a more complete and safe manner. As a result, the five-year survival rate has increased, as we have mentioned above. However, improvements in diagnosis and surgery are not enough for thyroid cancer; post-surgical management and services are also very important because there is a risk of recurrence and metastasis after thyroid surgery. Timely detection and treatment of postoperative recurrence and metastasis relies on postoperative management, which is also helpful for optimizing the above links. For example, what causes recurrence? How to deal with recurrence timely? All these questions need to be answered by postoperative management, which may last a long period of time, at least ten years. Unfortunately, the role of postoperative management has not been recognized by clinicians, researchers, and patients and their families. Therefore, we developed this Consensus to promote the implementation of standardized postoperative management, and hopefully it will increase the awareness of more clinicians and benefit more patients. At present, postoperative management is a very critical link, and I believe that the optimized postoperative management will further increase the five-year survival rate and improve the quality of life.
AOT: What are the highlights in the Consensus? How about further additions and updates?
Prof. Tian: The 2020 edition of the Consensus proposes a series of presentations and guidance based on measures and norms for thyroid cancer diagnosis and treatment prior to 2020. As time goes by, new ideas, new theories, and new practice will emerge, and we will continue to update the Consensus accordingly. There might be a 2022 or 2023 edition of the Consensus in coming years, which is an evolutionary process. The Consensus is focused on the diagnosis and treatment of differentiated thyroid cancer because this condition accounts for vast majority of all thyroid malignancies. Of course, the Consensus will also shed light on the management of other cancers. One of the major highlights of the Consensus is the dynamic assessment of patients after surgery, i.e., the dynamic assessment of the classification of disease conditions before and after surgery. Different preoperative conditions will result in different surgical outcomes, and further disease classification after surgery is feasible. This concept of dynamic assessment is important. For instance, a patient who has undergone proper early treatment after early detection and has been found to be safe on follow-up examinations is considered to be at low risk from the beginning of diagnosis to the long-term follow-up period. In another patient, however, a metastasis on the opposite side or in a distant area occurs within five years after surgery despite early detection and timely treatment; under such condition, the risk is preoperatively low but postoperatively high. Serial, multidisciplinary therapies will be required in such cases. Dynamic assessment is important for both clinicians and patients. A mild disease does not mean that it will remain mild in future. In contrast, for patients with severe thyroid cancer, active surgery may achieve good effectiveness, and the risk may change from high to low. Therefore, it is important to dynamically assess the postoperative condition and offer appropriate treatments accordingly. This is one of the most important highlights of postoperative management.
AOT: Which factors will affect the recurrence of thyroid cancer after surgery?
Prof. Tian: There are several factors. First, the pathological type of thyroid cancer. A “good” type (e.g. papillary thyroid cancer) is often associated with a good prognosis. In contrast, treatment for a “bad” pathological type (e.g. undifferentiated carcinoma, which is highly malignant) is difficult to achieve satisfactory results. The general public typically has a misunderstanding of thyroid cancer, thinking that all thyroid cancers are very curable, but in fact, the treatment outcome depends largely on the pathological type. The second influencing factor is whether a thyroid cancer is detected timely or too late. Treatments for a “good” pathological type can be less effective if the disease is found too late. For example, papillary thyroid cancer, which typically has a good prognosis, can invade its surrounding organs and tissues if detected too late and/or not treated in time, leading to more serious conditions and even death. Therefore, thyroid cancer also needs to be diagnosed and treated early. The third factor is whether standardized treatment is available. Early detection without standardized treatment may still lead to recurrence of thyroid cancer after surgery. For example, if a patient does not actively seek treatment after a thyroid cancer is detected, does not take the prescribed drugs timely, and/or does not receive scheduled follow-up visits, the disease with a good prognosis may end up with a poor treatment result.
AOT: How to increase the early diagnosis rate of thyroid cancer?
Prof. Tian: It remains a controversial issue. Some people argue that there is over-diagnosis and over-treatment of thyroid cancer nowadays, but this is not true. There is only right or wrong diagnosis for thyroid cancer, and there is no question of over-diagnosis. Therefore, early screening can be a priority when calling for early detection and early treatment. First of all, we should pay special attention to thyroid cancer screening and then implement the principle of early detection and early treatment. Standardized diagnosis and treatment of thyroid cancer should be offered at an early stage, followed enhanced examination and evaluation to guide subsequent treatments. In addition, new management strategies and techniques (e.g.) genetic testing have been available to help clinicians to distinguish between benign and malignant lesions, which can also increase the early diagnosis rate of thyroid cancer. However, these are only improvements at the technical level; scientific guidance at the theoretical level should be further developed and applied to enable early detection and early diagnosis.
AOT: Do you have any suggestion for patients with thyroid cancer?
Prof. Tian: First of all, you should visit a doctor if a thyroid nodule is found. The second step is to receive an examination, and a puncture test is a very good choice. A benign lesion will not be troublesome and can be treated appropriately. If it is unfortunately malignant, you should receive timely surgical treatment according to the pathological results; dynamic assessment will be helpful. For a tumor with unclear malignant potential, genetic testing or other precise tests may be performed to make a definite diagnosis. Second, many people are reluctant to undergo surgery because they worry about the side effects of large amounts of medications they have to take after thyroid cancer surgery. In fact, this is a misconception. Taking medication after surgery is a supplement to the normal needs of human body. The side effects are mild if the drugs are rationally used. For example, some people may worry that taking drugs after surgery will affect fertility; in fact, rational drug use allows normal fertility, whereas patients who do not take medication are unsuitable for childbirth. Therefore, thyroid cancer patients should overcome the fear of taking medication. Third, surgical procedures are constantly improving. With the use of a series of methods, the nerves, parathyroid glands, and other important parts can be effectively protected during the surgery. Accurate diagnosis, rational drug use, and active cooperation with the treatment protocol will ensure a normal life.
AOT: What are your prospects for the thyroid surgery?
Prof. Tian: No matter how surgery develops, the safety and completeness of a surgery should always be the principle and basis, with the goal of prolonging survival and improving quality of life. Thyroid operations currently have two modalities: the conventional open surgery and the minimally invasive endoscopic surgery. Both of them have their own indications. The endoscopic surgery adds good cosmetic results to the completeness of treatment. However, the endoscopic technique cannot be applied to all procedures; rather, it needs to be performed appropriately (e.g., in patients with mild lesions). Therefore, on the basis of standardized surgical treatment, open surgery and minimally invasive surgery are compatible, and minimally invasive surgery cannot replace open surgery.
Expert introduction
Figure 1 Photo of Prof/Dr. Wen Tian.
Dr. Wen Tian (Figure 1) is a Chief Physician & Professor and tutor of master candidates at the Department of General Surgery, Chinese People's Liberation Army General Hospital. As an academic leader in thyroid surgery and hernia and abdominal wall surgery in China, he currently serves as the chairman of the Chinese Research Hospital Association Thyroid Disease Committee, chairman of the Chinese Thyroid Association, and board member of the Asian Association of Endocrine Surgeons. He is the member of the editorial boards of 8 core Chinese journals including Chinese Journal of Surgery, Chinese Journal of Digestive Surgery, Chinese Journal of Practical Journal, Chinese Journal of Minimally Invasive Surgery, Journal of Laparoscopic Surgery, and Chinese Journal of Hernia and Abdominal Wall Surgery.
He was the main contributor of the Clinical Guidelines on the Electrophy siological Monitoring during Thyroid and Parathyroid Surgery (Chinese edition), Expert Concensus on Parathyroid Protection during Thyroid Surgery, Expert Concensus on Surgical Management of Chronic Renal Failure Secondary to Hyperparathyroidism, and Expert Concensus on Robotic Surgical System-assisted Thyroid and Parathyroid Surgery. He participated in the development of two national health industry standards, i.e. Diagnostic Criteria of Thyroid Cancer and Quality Control Standards of Thyroid Cancer Treatment. He was the translator-in-chief of two top monographs - Surgery of the Thyroid and Parathyoid Glands and Thyroid Surgery - Preventing and Managing Complications. He was the editor-in-chief of the book Thyroid Surgery (Chinese edition and English edition). He was the contributor of six monographs including Endoscopic Surgery for Thyroid and Parathyroid Diseases, Surgery, General Surgery, and Colorectal Tumors. He contributed the development of Thyroid Teaching Video Series sponsored by the National Health and Family Planning Commission: a) Radical Operation of Thyroid Carcinoma (Central Lymph Node Dissection); b) Complete Endoscopic Resection of Thyroid (Periareolar Approach); and c) Nerve Monitoring Technology and Its Application in Thyroid Surgery. He also authored a book for the general public: Thyroid Diseases - How to See a Doctor.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Thyroid for the series “Meet the Professor”. The article did not undergo external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form. The series “Meet the Professor” was commissioned by the editorial office without any funding or sponsorship. JZZ reports that he was an intern editor of AME Publishing Company from February 17, 2022 to April 17, 2022. GL reports that she is a full employee of AME Publishing Company. HT declares no conflicts of interest.
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