A new interactive web-based tool — announced this week at the American Association of Clinical Endocrinology (AACE) Virtual Annual Meeting 2021 — offers a novel and comprehensive approach to improve on the clinical decision-making process for thyroid nodules, with the goal of preventing the far too common unnecessary testing and surgical overtreatment.
The Thyroid Nodule App (dubbed TNAPP) is a computer-interpretable guideline that incorporates data from the most recently updated 2016 AACE clinical practice guideline recommendations on thyroid nodule evaluation, but also allows for regular revisions based on evolving data and current clinical considerations.
“[TNAPP] is an electronic tool that is an easily revised ‘living document’,” said Jeffrey R. Garber, MD, chief of endocrinology at Atrius Health and associate professor of medicine at Harvard Medical School, in Boston, Massachusetts, during a presentation about the app.
A white paper detailing the development of the tool was published this week in Endocrine Practice as an in press article.
“The novel part of the tool is that it’s comprehensive,” Garber explained to Medscape Medical News. “The app includes the spectrum of all clinical factors, including ultrasound…and (an array) of other factors, whereas existing apps tend to be more like mortgage calculators, with limited input.”
“Once this is prospectively validated, we foresee employing this tool in a variety of settings,” he emphasized.
Victor Bernet, MD, moderator of the AACE session, agreed that the app could help fill a need for better thyroid assessment tools.
“While available…tools and clinical practice guidelines for thyroid nodules do assist practitioners with decision making in regards to managing patients with thyroid nodules, some grey areas and ambiguity exist in regards to the process when working with individual patients,” he told Medscape Medical News.
The new tool “appears to be a much more involved calculator that attempts to address several stages of decision making for thyroid nodule diagnosis and management, which will hopefully assist clinicians and patients in making more informed choices,” added Bernet, who is chair of the Division of Endocrinology at the Mayo Clinic, in Ponte Vedra Beach, Florida.
Improving Thyroid Nodule Evaluation
The new tool was developed by a multidisciplinary task force, including members of AACE, as well as the American College of Endocrinology and Italian Association of Medical Endocrinologists, which was charged with establishing an interactive algorithmic system to improve the process of thyroid nodule evaluation.
The need for better guidance is pressing. Although most thyroid nodules are benign and those that are malignant are low risk, with little effect on survival, more than 500,000 fine-needle aspirations of thyroid nodules are performed each year in the United States alone, and as many as 200,000 of those are unnecessary, the task force explains.
Among key reasons for the uncertainty is variations among recommendations in existing international guidelines on thyroid nodule evaluation, such as ultrasound risk classification and other factors.
The TNAPP tool reflects recommendations using clinical, imaging, cytologic, and molecular marker data that can be updated as needed.
The result is a computer-interpretable guideline that “facilitates testing and validating recommendations prospectively and retrospectively,” the task force notes.
Cross-Checking With TI-RADS
In a preliminary test to cross-check the TNAPP with the American College of Radiology (ACR) Thyroid Imaging, Reporting, and Data System (TI-RADS), the task force members submitted cases of thyroid nodules that had histology-proven diagnoses available.
Additional data that were available for the cases included surgical outcomes, personal or familial history of thyroid cancer, serum thyrotropin level, diagnostic ultrasound, indication for fine needle aspiration, and cytologic report.
Six task force members from three US thyroid referral centers and two European centers submitted 108 cases, of which 13 were excluded because of elevated calcitonin levels, familial thyroid cancer syndromes, or other factors.
Although 95 cases met TNAPP criteria, only 78 (82%) of those cases had sufficient data to make a TI-RADS determination with guidance.
Comparing the two methods, there was a 79% rate of concordance between the TNAPP and TI-RADS on recommendations of whether to perform fine-needle aspirations of the nodule.
Garber noted that the task force is currently embarking on a more formal prospective multicenter validation trial for the TNAPP tool.
Meanwhile, important potential uses of the tool are for medical education for trainees and integration of its data into electronic health records and registries.
“Registries are very important for studying diseases and interventions, and this can be a great springboard for doing that,” Garber explained.
He noted that the computer-interpretable guideline approach has shown benefits in other clinical areas, including diabetes, hypertension, stroke, cancer, HIV, and genetic counseling.
“We trust that it will facilitate the care of patients with clinically significant thyroid nodules while reducing the substantial burden incurred by those who would not benefit from further evaluation and treatment,” Garber concluded.
Garber and Bernet have reported no relevant financial relationships.
Endocr Pract. 2021;27. In Press
For more diabetes and endocrinology news, follow us on Twitter and Facebook.
Source: Read Full Article