[Skip to Content]
[Skip to Content Landing]

Challenges of Shared Decision-making by Clinicians and Patients With Low-risk Differentiated Thyroid CancerA Systematic Review and Meta-Ethnography

To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What are the challenges of the current decision-making process for treatment of low-risk differentiated thyroid cancer (LRDTC)?

Findings  This systematic review and meta-ethnography of 12 qualitative and/or mixed-method studies on patient and clinician experiences with LRDTC treatment decision-making found a bimodal distribution divided by either a fear of disease progression or of adverse effects and decline in quality of life. In addition, clinicians struggled to identify and understand patient concerns, and recommendations were biased by the clinician’s perceptions of the patient’s risk tolerance and anxiety.

Meaning  The findings of the systematic review and meta-ethnography suggest that without exploring patient concerns and preferences, LRDTC treatment decisions may not reflect the patient’s values, goals, and long-term wishes, which may be a factor in the overtreatment of LRDTC.


Importance  Several international guidelines have endorsed more conservative treatment of low-risk differentiated thyroid cancer (LRDTC), yet patients are facing more treatment options with similar oncologic outcomes and are expressing feelings of confusion, dissatisfaction, and anxiety. Shared decision-making, which considers the patient’s values and preferences along with the most reliable medical evidence, has been proposed to optimize patient satisfaction in the context of the current clinical equipoise.

Objectives  To understand key individual and behavioral factors affecting the patient and clinician decision-making process in treatment decision for LRDTC.

Evidence Review  This systematic review and meta-ethnography involved a comprehensive literature search of MEDLINE, Embase, PubMed, and CINAHL databases for qualitative and mixed-method studies on patient and clinician experiences with the decision-making process for LRDTC treatment. The quality of the studies was assessed using the Mixed Methods Appraisal Tool; meta-ethnography was used for data analysis. Primary and secondary themes of the included studies were extracted, compared, and translated across articles to produce a lines-of-argument synthesis.

Findings  Of 1081 publications identified, 12 articles met the inclusion criteria. The qualitative synthesis produced 4 themes: (1) a bimodal distribution of patient preferences for treatment decisions; (2) clinician anxiety affected equipoise and biased their recommendations; (3) clinicians struggled to identify patient concerns and preferences; and (4) the clinician-patient relationship and psychosocial support were key to shared decision-making but were frequently overlooked.

Conclusions and Relevance  The findings of this systematic review and meta-ethnography emphasize the need for better patient-clinician communication, particularly with respect to eliciting patient concerns and preferences. With an ever-increasing pool of thyroid cancer survivors, future efforts should be directed at establishing and evaluating tools that will aid in shared decision-making for treatment of patients with LRDTC.

Trial Registration  PROSPERO Identifier: CRD42022286395

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: January 26, 2023.

Published Online: March 23, 2023. doi:10.1001/jamaoto.2023.0101

Corresponding Author: Wanding Yang, MBChB, Department of Head and Neck Surgery, Royal Marsden NHS Foundation Trust, 203 Fulham Rd, London SW3 6JJ, UK (wanding.yang@rmh.nhs.uk).

Author Contributions: Drs Yang and Rogers had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Yang, Lorgelly, Rogers, Kim.

Acquisition, analysis, or interpretation of data: Yang, Lee, Kim.

Drafting of the manuscript: Yang, Kim.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Yang.

Obtained funding: Kim.

Administrative, technical, or material support: Yang, Rogers, Kim.

Supervision: Lorgelly, Rogers, Kim.

Conflict of Interest Disclosures: Dr Yang reported academic support from The Royal Marsden Cancer Charity during the conduct of the study. No other disclosures were reported.

Pizzato  M , Li  M , Vignat  J ,  et al.  The epidemiological landscape of thyroid cancer worldwide: GLOBOCAN estimates for incidence and mortality rates in 2020.   Lancet Diabetes Endocrinol. 2022;10(4):264-272. doi:10.1016/S2213-8587(22)00035-3 PubMedGoogle ScholarCrossref
Haugen  BR , Alexander  EK , Bible  KC ,  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):1-133. doi:10.1089/thy.2015.0020 PubMedGoogle ScholarCrossref
Perros  P , Boelaert  K , Colley  S ,  et al; British Thyroid Association.  Guidelines for the management of thyroid cancer.   Clin Endocrinol (Oxf). 2014;81(suppl 1):1-122. doi:10.1111/cen.12515 PubMedGoogle ScholarCrossref
Pacini  F , Basolo  F , Bellantone  R ,  et al.  Italian consensus on diagnosis and treatment of differentiated thyroid cancer: joint statements of six Italian societies.   J Endocrinol Invest. 2018;41(7):849-876. doi:10.1007/s40618-018-0884-2 PubMedGoogle ScholarCrossref
Mitchell  AL , Gandhi  A , Scott-Coombes  D , Perros  P .  Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines.   J Laryngol Otol. 2016;130(S2):S150-S160. doi:10.1017/S0022215116000578 PubMedGoogle ScholarCrossref
Filetti  S , Durante  C , Hartl  D ,  et al; ESMO Guidelines Committee.  Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.   Ann Oncol. 2019;30(12):1856-1883. doi:10.1093/annonc/mdz400 PubMedGoogle ScholarCrossref
Haddad  RI , Bischoff  L , Ball  D ,  et al.  Thyroid carcinoma, version 2.2022, NCCN Clinical Practice Guidelines in Oncology.   J Natl Compr Canc Netw. 2022;20(8):925-951. doi:10.6004/jnccn.2022.0040 PubMedGoogle ScholarCrossref
Moumjid  N , Brémond  A , Mignotte  H , Faure  C , Meunier  A , Carrère  MO .  Shared decision-making in the physician-patient encounter in France: a general overview.   Z Arztl Fortbild Qualitatssich. 2007;101(4):223-228. doi:10.1016/j.zgesun.2007.02.042 PubMedGoogle ScholarCrossref
Walshaw  EG , Smith  M , Kim  D , Wadsley  J , Kanatas  A , Rogers  SN .  Systematic review of health-related quality of life following thyroid cancer.   Tumori. 2022;108(4):291-314. doi:10.1177/03008916211025098 Google ScholarCrossref
Dixon  PR , Tomlinson  G , Pasternak  JD ,  et al.  The role of disease label in patient perceptions and treatment decisions in the setting of low-risk malignant neoplasms.   JAMA Oncol. 2019;5(6):817-823. doi:10.1001/jamaoncol.2019.0054 PubMedGoogle ScholarCrossref
Nickel  B , Brito  JP , Barratt  A , Jordan  S , Moynihan  R , McCaffery  K .  Clinicians’ views on management and terminology for papillary thyroid microcarcinoma: a qualitative study.   Thyroid. 2017;27(5):661-671. doi:10.1089/thy.2016.0483 PubMedGoogle ScholarCrossref
Brito  JP , Moon  JH , Zeuren  R ,  et al.  Thyroid Cancer treatment choice: a pilot study of a tool to facilitate conversations with patients with papillary microcarcinomas considering treatment options.   Thyroid. 2018;28(10):1325-1331. doi:10.1089/thy.2018.0105 PubMedGoogle ScholarCrossref
Ahmadi  S , Gonzalez  JM , Talbott  M ,  et al.  Patient preferences around extent of surgery in low-risk thyroid cancer: a discrete choice experiment.   Thyroid. 2020;30(7):1044-1052. doi:10.1089/thy.2019.0590 PubMedGoogle ScholarCrossref
McDow  AD , Roman  BR , Saucke  MC ,  et al.  Factors associated with physicians’ recommendations for managing low-risk papillary thyroid cancer.   Am J Surg. 2021;222(1):111-118. doi:10.1016/j.amjsurg.2020.11.021 PubMedGoogle ScholarCrossref
Applewhite  MK , James  BC , Kaplan  SP ,  et al.  Quality of life in thyroid cancer is similar to that of other cancers with worse survival.   World J Surg. 2016;40(3):551-561. doi:10.1007/s00268-015-3300-5 PubMedGoogle ScholarCrossref
Husson  O , Haak  HR , Buffart  LM ,  et al.  Health-related quality of life and disease specific symptoms in long-term thyroid cancer survivors: a study from the population-based PROFILES registry.   Acta Oncol. 2013;52(2):249-258. doi:10.3109/0284186X.2012.741326 PubMedGoogle ScholarCrossref
Singer  S , Husson  O , Tomaszewska  IM ,  et al.  Quality-of-life priorities in patients with thyroid cancer: a multinational European organisation for research and treatment of cancer phase I study.   Thyroid. 2016;26(11):1605-1613. doi:10.1089/thy.2015.0640 PubMedGoogle ScholarCrossref
Moher  D , Shamseer  L , Clarke  M ,  et al; PRISMA-P Group.  Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.   Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1 PubMedGoogle ScholarCrossref
Graziosi  SJ , Brunton  J , Thomas  J . EPPI-Reviewer 4.0: software for research synthesis. Accessed February 20, 2023. https://eppi.ioe.ac.uk/CMS/Default.aspx?alias=eppi.ioe.ac.uk/cms/er4&
Hong  QN , Gonzalez-Reyes  A , Pluye  P .  Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT).   J Eval Clin Pract. 2018;24(3):459-467. doi:10.1111/jep.12884 PubMedGoogle ScholarCrossref
Hong  QN , Pluye  P , Fàbregues  S ,  et al.  Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study.   J Clin Epidemiol. 2019;111:49-59.e1. doi:10.1016/j.jclinepi.2019.03.008 PubMedGoogle ScholarCrossref
Noblit  GW , Hare  RD .  Meta-Ethnography: Synthesizing Qualitative Studies. Vol 44. Peter Lang AG; 1999:93-123. http://Www.Jstor.Org/Stable/42975557
Campbell  R , Pound  P , Morgan  M ,  et al.  Evaluating meta-ethnography: systematic analysis and synthesis of qualitative research.   Health Technol Assess. 2011;15(43):1-164. doi:10.3310/hta15430 PubMedGoogle ScholarCrossref
Munro  SA , Lewin  SA , Smith  HJ , Engel  ME , Fretheim  A , Volmink  J .  Patient adherence to tuberculosis treatment: a systematic review of qualitative research.   PLoS Med. 2007;4(7):e238. doi:10.1371/journal.pmed.0040238 PubMedGoogle ScholarCrossref
Koot  A , Netea-Maier  R , Ottevanger  P , Hermens  R , Stalmeier  P .  Needs, preferences, and values during different treatment decisions of patients with differentiated thyroid cancer.   J Pers Med. 2021;11(7):682. doi:10.3390/jpm11070682 PubMedGoogle ScholarCrossref
Pitt  SC , Saucke  MC , Roman  BR , Alexander  SC , Voils  CI .  The influence of emotions on treatment decisions about low-risk thyroid cancer: a qualitative study.   Thyroid. 2021;31(12):1800-1807. doi:10.1089/thy.2021.0323 PubMedGoogle ScholarCrossref
Jensen  CB , Saucke  MC , Francis  DO , Voils  CI , Pitt  SC .  From overdiagnosis to overtreatment of low-risk thyroid cancer: a thematic analysis of attitudes and beliefs of endocrinologists, surgeons, and patients.   Thyroid. 2020;30(5):696-703. doi:10.1089/thy.2019.0587 PubMedGoogle ScholarCrossref
Doubleday  A , Saucke  MC , Bates  MF , Pitt  SC .  Patient-surgeon decision-making about treatment for very low-risk thyroid cancer.   Trends Cancer Res. 2019;14:79-89.Google Scholar
Lubitz  CC , Kiernan  CM , Toumi  A ,  et al.  Patient perspectives on the extent of surgery and radioactive iodine treatment for low-risk differentiated thyroid cancer.   Endocr Pract. 2021;27(5):383-389. doi:10.1016/j.eprac.2021.01.005 PubMedGoogle ScholarCrossref
Sawka  AM , Ghai  S , Yoannidis  T ,  et al.  A prospective mixed-methods study of decision-making on surgery or active surveillance for low-risk papillary thyroid cancer.   Thyroid. 2020;30(7):999-1007. doi:10.1089/thy.2019.0592 PubMedGoogle ScholarCrossref
D’Agostino  TA , Shuk  E , Maloney  EK , Zeuren  R , Tuttle  RM , Bylund  CL .  Treatment decision-making in early-stage papillary thyroid cancer.   Psychooncology. 2018;27(1):61-68. doi:10.1002/pon.4383 PubMedGoogle ScholarCrossref
Nickel  B , Brito  JP , Moynihan  R , Barratt  A , Jordan  S , McCaffery  K .  Patients’ experiences of diagnosis and management of papillary thyroid microcarcinoma: a qualitative study.   BMC Cancer. 2018;18(1):242. doi:10.1186/s12885-018-4152-9 PubMedGoogle ScholarCrossref
Sawka  AM , Straus  S , Rodin  G ,  et al.  Thyroid cancer patient perceptions of radioactive iodine treatment choice: Follow-up from a decision-aid randomized trial.   Cancer. 2015;121(20):3717-3726. doi:10.1002/cncr.29548 PubMedGoogle ScholarCrossref
Sawka  AM , Goldstein  DP , Brierley  JD ,  et al.  The impact of thyroid cancer and post-surgical radioactive iodine treatment on the lives of thyroid cancer survivors: a qualitative study.   PLoS One. 2009;4(1):e4191. doi:10.1371/journal.pone.0004191 PubMedGoogle ScholarCrossref
Jensen  CB , Saucke  MC , Pitt  SC .  Active surveillance for thyroid cancer: a qualitative study of barriers and facilitators to implementation.   BMC Cancer. 2021;21(1):471. doi:10.1186/s12885-021-08230-8 PubMedGoogle ScholarCrossref
Groopman  J , Hartzband  P .  Your Medical Mind. How to Decide What Is Right for You. Penguin; 2011.
Scherer  LD , Caverly  TJ , Burke  J ,  et al.  Development of the medical maximizer-minimizer scale.   Health Psychol. 2016;35(11):1276-1287. doi:10.1037/hea0000417 PubMedGoogle ScholarCrossref
Tuttle  RM , Zhang  L , Shaha  A .  A clinical framework to facilitate selection of patients with differentiated thyroid cancer for active surveillance or less aggressive initial surgical management.   Expert Rev Endocrinol Metab. 2018;13(2):77-85. doi:10.1080/17446651.2018.1449641 PubMedGoogle ScholarCrossref
Charles  C , Gafni  A , Whelan  T .  Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango).   Soc Sci Med. 1997;44(5):681-692. doi:10.1016/S0277-9536(96)00221-3 PubMedGoogle ScholarCrossref
Stiggelbout  AM , Pieterse  AH , De Haes  JCJM .  Shared decision-making: concepts, evidence, and practice.   Patient Educ Couns. 2015;98(10):1172-1179. doi:10.1016/j.pec.2015.06.022 PubMedGoogle ScholarCrossref
Barry  MJ , Edgman-Levitan  S .  Shared decision-making–pinnacle of patient-centered care.   N Engl J Med. 2012;366(9):780-781. doi:10.1056/NEJMp1109283 PubMedGoogle ScholarCrossref
Stacey  D , Samant  R , Bennett  C .  Decision-making in oncology: a review of patient decision aids to support patient participation.   CA Cancer J Clin. 2008;58(5):293-304. doi:10.3322/CA.2008.0006 PubMedGoogle ScholarCrossref
Ghazali  N , Roe  B , Lowe  D , Rogers  SN .  Patients concerns inventory highlights perceived needs and concerns in head and neck cancer survivors and its impact on health-related quality of life.   Br J Oral Maxillofac Surg. 2015;53(4):371-379. doi:10.1016/j.bjoms.2015.01.022 PubMedGoogle ScholarCrossref
Rogers  SN , El-Sheikha  J , Lowe  D .  The development of a Patients Concerns Inventory (PCI) to help reveal patients concerns in the head and neck clinic.   Oral Oncol. 2009;45(7):555-561. doi:10.1016/j.oraloncology.2008.09.004 PubMedGoogle ScholarCrossref
Rogers  SN , Allmark  C , Bekiroglu  F ,  et al.  Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: main results of a cluster preference randomised controlled trial.   Eur Arch Otorhinolaryngol. 2021;278(9):3435-3449. doi:10.1007/s00405-020-06533-3 PubMedGoogle ScholarCrossref
Wei  J , Thwin  M , Nickel  B , Glover  A .  Factors that inform individual decision-making between active surveillance, hemithyroidectomy and total thyroidectomy for low-risk thyroid cancer: a scoping review.   Thyroid. 2022;32(7):807-818. doi:10.1089/thy.2021.0646 PubMedGoogle ScholarCrossref
Butler  A , Hall  H , Copnell  B .  A guide to writing a qualitative systematic review protocol to enhance evidence-based practice in nursing and health care.   Worldviews Evid Based Nurs. 2016;13(3):241-249. doi:10.1111/wvn.12134 PubMedGoogle ScholarCrossref
Seers  K .  Qualitative systematic reviews: their importance for our understanding of research relevant to pain.   Br J Pain. 2015;9(1):36-40. doi:10.1177/2049463714549777 PubMedGoogle ScholarCrossref
Aromataris  E , Pearson  A .  The systematic review: an overview.   Am J Nurs. 2014;114(3):53-58. doi:10.1097/01.NAJ.0000444496.24228.2c PubMedGoogle ScholarCrossref
Riesenberg  LA , Justice  EM .  Conducting a successful systematic review of the literature, part 1.   Nursing. 2014;44(4):13-17. doi:10.1097/01.NURSE.0000444728.68018.ac PubMedGoogle ScholarCrossref
Atkins  S , Lewin  S , Smith  H , Engel  M , Fretheim  A , Volmink  J .  Conducting a meta-ethnography of qualitative literature: lessons learnt.   BMC Med Res Methodol. 2008;8(1):21. doi:10.1186/1471-2288-8-21 PubMedGoogle ScholarCrossref
Britten  N , Campbell  R , Pope  C , Donovan  J , Morgan  M , Pill  R .  Using meta ethnography to synthesise qualitative research: a worked example.   J Health Serv Res Policy. 2002;7(4):209-215. doi:10.1258/135581902320432732 PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.