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Management of recurrent and persistent metastatic lymph nodes in well-differentiated thyroid cancer: a multifactorial decision-making guide for the Thyroid Cancer Care Collaborative

Urken, Mark L; Milas, Mira; Randolph, Gregory W; Tufano, Ralph; Bergman, Donald; Bernet, Victor; Brett, Elise M; Brierley, James D; Cobin, Rhoda; Doherty, Gerard; Klopper, Joshua; Lee, Stephanie; Machac, Josef; Mechanick, Jeffrey I; Orloff, Lisa A; Ross, Douglas; Smallridge, Robert C; Terris, David J; Clain, Jason B; Tuttle, Michael
BACKGROUND:Well-differentiated thyroid cancer (WDTC) recurs in up to 30% of patients. Guidelines from the American Thyroid Association (ATA) and the National Comprehensive Cancer Network (NCCN) provide valuable parameters for the management of recurrent disease, but fail to guide the clinician as to the multitude of factors that should be taken into account. The Thyroid Cancer Care Collaborative (TCCC) is a web-based repository of a patient's clinical information. Ten clinical decision-making modules (CDMMs) process this information and display individualized treatment recommendations. METHODS:We conducted a review of the literature and analysis of the management of patients with recurrent/persistent WDTC. RESULTS:Surgery remains the most common treatment in recurrent/persistent WDTC and can be performed with limited morbidity in experienced hands. However, careful observation may be the recommended course in select patients. Reoperation yields biochemical remission rates between 21% and 66%. There is a reported 1.2% incidence of permanent unexpected nerve paralysis and a 3.5% incidence of permanent hypoparathyroidism. External beam radiotherapy and percutaneous ethanol ablation have been reported as therapeutic alternatives. Radioactive iodine as a primary therapy has been reported previously for metastatic lymph nodes, but is currently advocated by the ATA as an adjuvant to surgery. CONCLUSION/CONCLUSIONS:The management of recurrent lymph nodes is a multifactorial decision and is best determined by a multidisciplinary team. The CDMMs allow for easy adoption of contemporary knowledge, making this information accessible to both patient and clinician.
PMID: 24436291
ISSN: 1097-0347
CID: 5523242

Database and registry research in thyroid cancer: striving for a new and improved national thyroid cancer database

Mehra, Saral; Tuttle, R Michael; Milas, Mira; Orloff, Lisa; Bergman, Donald; Bernet, Victor; Brett, Elise; Cobin, Rhoda; Doherty, Gerard; Judson, Benjamin L; Klopper, Joshua; Lee, Stephanie; Lupo, Mark; Machac, Josef; Mechanick, Jeffrey I; Randolph, Gregory; Ross, Douglas S; Smallridge, Robert; Terris, David; Tufano, Ralph; Alon, Eran; Clain, Jason; DosReis, Laura; Scherl, Sophie; Urken, Mark L
BACKGROUND:Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations. SUMMARY/CONCLUSIONS:In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries. CONCLUSION/CONCLUSIONS:A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.
PMID: 25517683
ISSN: 1557-9077
CID: 5523322

Improving the quality of thyroid cancer care: how does the Thyroid Cancer Care Collaborative cross the Institute of Medicine's Quality Chasm?

Mehra, Saral; Tuttle, R Michael; Bergman, Donald; Bernet, Victor; Brett, Elise; Cobin, Rhoda; Doherty, Gerard; Klopper, Joshua; Lee, Stephanie; Machac, Josef; Milas, Mira; Mechanick, Jeffrey I; Orloff, Lisa; Randolph, Gregory; Ross, Douglas S; Smallridge, Robert; Terris, David; Tufano, Ralph; Alon, Eran; Clain, Jason; Dos Reis, Laura; Scherl, Sophie; Urken, Mark L
BACKGROUND:The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled "Crossing the Quality Chasm," the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery. SUMMARY/CONCLUSIONS:The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, "ask the expert," and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management. CONCLUSION/CONCLUSIONS:The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.
PMID: 24512449
ISSN: 1557-9077
CID: 5523262