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Original Research Thyroid Disorders Pilot Study of a Web-based Decision Tool on Post-operative Use of Radioactive Iodine Shrujal S Baxi, 1,2 Rachel Kurtzman, 1 Anne Eaton, 3 Eliza Dewey, 4 Craig Bickford, 4 Stephanie Fish, 5 Leonard Wartofsky 6 and R Michael Tuttle 5 1. Head and Neck Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, US; 2. Department of Medicine, Weill Medical College of Cornell University, New York, New York, US; 3. Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, US; 4. The THANC Foundation, PO Box 1021, New York, New York, US; 5. Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, US; 6. Division of Endocrinology, Department of Medicine, MedStar Washington Hospital Center, Washington, DC, US B ackground: The Thyroid Cancer Care Collaborative developed a web-based clinical decision-making module (CDMM) to inform risk- adjusted decisions on post-thyroidectomy radioactive iodine (RAI) use in papillary thyroid cancer (PTC). Methods: In a pilot study, we evaluated the CDMM in 19 PTC cases representing low- (five), intermediate- (seven) and high-risk (seven) disease. Two PTC experts and 10 PTC physicians reviewed cases and assigned risk level and RAI recommendation. The experts used a standard approach while the others used the CDMM. We assessed agreement between responses using a weighted Kappa. Results: Between experts, risk-assignment was concordant in 100%, 57% and 86% of low-, intermediate- and high-risk cases, respectively. Between CDMM users, risk-assignment was concordant in 100%, 29% and 14% in low-, intermediate- and high-risk cases, respectively (p=0.01). CDMM-assigned risk agreed with the expert-assigned risk in 100%, 25% and 0% of low-, intermediate- and high-risk cases, respectively (Kappa=0.69). For RAI use, the experts agreed in 15 cases while CDMM users agreed in eight. On further analysis, interpretation of extrathyroidal extension and lymph node staging led to discrepancies with the CDMM. Conclusions: For a web-based CDMM to accurately inform appropriate use of RAI in PTC, standard pathological and surgical reports are necessary. Keywords Thyroid cancer, radioactive iodine, thyroidectomy, decision-making, web-based Disclosure: Shrujal S Baxi has a consulting role with BMS and serves on an advisory board for AstraZeneca. Leonard Wartofsky has been a consultant for Asuragen, Eisei, IBSA and Interpace Diagnostics. He has received speaker honoraria from Genzyme. R Michael Tuttle is a consultant for AstraZeneca, Bayer/Onyx, Genzyme, Novo Nordisk and Veracyte. Rachel Kurtzman, Anne Eaton, Eliza Dewey, Craig Bickford and Stephanie Fish have nothing to disclose in relation to this paper. Acknowledgements: This work was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center award number P30 CA008748. Compliance with Ethics: This case study was performed in accordance with the responsible committee on human experimentation and with the Helsinki Declaration of 1975. Institutional Review Board approval was obtained. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 23 January 2017 Accepted: 9 March 2017 Citation: European Endocrinology, 2017;13(1):26–9 Corresponding Author: Shrujal S Baxi, Head and Neck Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, 1459, New York, NY 10065, US. E: baxis@mskcc.org 26 The incidence of thyroid cancer is increasing at a rate of 7% a year; there were an estimated 62,450 cases diagnosed in the US in 2015 alone. The majority of this rise in incidence is explained by the growing number of incidentally detected well-differentiated, early-stage or ‘low-risk’ papillary thyroid cancers (PTCs). 3 There is a growing awareness that many thyroid cancers may indeed be relatively benign in their behaviour and can be followed without any intervention. 4 As a result, the management of differentiated thyroid cancer has undergone a major paradigm shift over the last two decades from a ‘one size fits all’ to a ‘risk-adapted’ approach. The American Thyroid Association (ATA) has led this effort by developing and publishing evidence-based guidelines on thyroid cancer management. The ATA guidelines incorporate tumour and patient characteristics to estimate the initial risk of recurrence (prognostication) and then use this information to inform recommendations on the use of adjuvant radioactive iodine (RAI) or remnant ablation therapy and the intensity and method of surveillance. 5 One major goal of the ATA guidelines is to minimise potential harm from overtreatment for low-risk patients, while appropriately treating high-risk patients. In well-differentiated thyroid cancer, adjuvant RAI is an effective method of attempting to address microscopic disease both in the thyroid bed (remnant thyroid) and distant metastatic sites. The phrases remnant ablation and adjuvant therapy are often used interchangeably, but there are distinct differences. A lower dose of RAI, 30 to 50 mCi (or 1,110 to 1,850 MBq) is used for remnant ablation while a higher dose, 100 to 150 mCi (3,700 to 5,550 MBq) is reserved for adjuvant therapy in patients deemed at high risk of micrometastatic disease. 6 The use of RAI improves survival and decreases recurrence rates for high-risk patients with extensive disease, but does not change the already excellent prognosis of patients with low-risk disease. 7–9 The use of post-thyroidectomy RAI has dramatically risen over the last three decades as part of the first course of therapy for thyroid cancer from 6.1% of cases treated in 1973 to 48.7% of cases treated in 2006. 10 During the same time frame, an increasing proportion of patients have been diagnosed with low-risk thyroid cancer raising the question of benefit of added RAI therapy. 3 Early recommendations on RAI use were shaped by retrospective studies completed in the 1970- 80’s that reported decreased risk of recurrence in patients who received RAI therapy compared with those treated with surgery and thyroid suppression alone. 11,12 In 2009, the ATA released their first guidelines with the definitive recommendation against RAI use in low-risk populations. A 2014 study showed that these 2009 guidelines only modestly reduced the use of RAI for the very-low- TOU C H ME D ICA L ME D IA