A Qualitative Study of Clinician Barriers and Facilitators to De-escalation of Thyroid Stimulating Hormone Suppression in Thyroid Cancer Survivors.

OBJECTIVE

Most patients with differentiated thyroid cancer have low-risk disease and excellent prognosis. Thyroid stimulating hormone (TSH) suppression therapy after initial treatment may be unnecessary and potentially harmful for survivors with recurrence-free, low- or intermediate-risk thyroid cancer. Little is known about clinician-reported barriers and facilitators to reducing thyroid cancer survivors' thyroid hormone dose with the goal of aiming for TSH in the normal reference range.

METHODS

Clinicians from the fields of endocrinology (n = 8) and primary care (n = 7) were recruited through convenience/snowball sampling to participate in semistructured focus groups. Data collection and analyses were informed by the Theoretical Domains Framework for behavior change, a valuable integrative framework which can facilitate comprehensive assessment of behavioral determinants in qualitative studies. Deductive coding and inductive thematic analysis were conducted.

RESULTS

Participants were majority female (73%) and averaged 14 years in clinical practice (range, 1-22). Barriers and facilitators emerged at the patient-level, clinician-level, and system-level. Key clinician-reported barriers included patient distress/anxiety and misinformation, unclear shared patient survivorship goals and plans between specialties, and clinic visit time constraints. Clinician-reported facilitators included building a trusting relationship, delivery of patient-centered education, and communication and collaboration between specialties to establish shared long-term survivorship plans.

CONCLUSIONS

We identified barriers and facilitators to de-escalating TSH suppression therapy in thyroid cancer survivors at multiple levels. Understanding these factors will enable clinicians to provide high-value, patient-centered care in order to reduce overtreatment, patient harm and improve quality of life in thyroid cancer survivors.