Thyroid Cancer Incidence During 2020 to 2021 COVID-19 Variant Waves.

Importance: How rates of thyroid cancer diagnosis were affected by the emergence of COVID-19 variants during the 2020 to 2021 era of the pandemic has not been described. Objective: To estimate the total number of undiagnosed cases of thyroid cancer, by histologic type, during the first 2 years of the COVID-19 pandemic (2020 and 2021) by comparing observed to expected incidence and to test for changes in size of cancer at incidence during the same period compared to prior years. Design, Setting, and Participants: This longitudinal study analyzed trends in thyroid cancer diagnoses from 2016 to 2021 among US adults using data from the Surveillance, Epidemiology, and End Results 22 (SEER-22) program database. Data analyses were performed in April to May 2024. Main Outcomes and Measures: Age-adjusted incidence rate per 100 000 US adults, changes in incidence, estimated number of undiagnosed cases, and mean cancer size. Results: Absolute rates of overall thyroid cancer incidence in the first quarter of 2016 and of 2019 were 21.0 and 18.8 per 100 000, respectively. From 2020 through 2021, the quarterly rates were 17.3, 11.1, 17.2, 17.9, 17.4, 19.0, 17.1, and 17.3 per 100 000, respectively. The observed incidence of thyroid cancers decreased by 11% for papillary cancers 2 cm or smaller (risk ratio [RR], 0.89; 95% CI, 0.83-0.95), 14% for papillary cancers larger than 2 cm (RR, 0.86; 95% CI, 0.79-0.93), 8% for follicular cancers (RR, 0.92; 95% CI, 0.82-0.92), 10% for medullary cancers (RR, 0.90; 95% CI, 0.78-1.04), and 15% for anaplastic cancers (RR, 0.85; 95% CI, 0.68-1.07) from March 2020 to December 2021. Oncocytic cancers declined in incidence early in the pandemic, but rates returned to baseline or above through 2021 (RR, 1.15; 95% CI, 0.97-1.37). Extrapolated to the general US population, the total estimated number of thyroid cancer cases not diagnosed (expected minus observed) from March 2020 to December 2021 was approximately 10 200: 5400 papillary cancers 2 cm or smaller (95% CI, 2380-8530), 3700 papillary cancers larger than 2 cm (95% CI, 1660-5810), 600 follicular cancers (95% CI, -260 to 1550), 300 medullary cancers (95% CI, -110 to 720), and 190 anaplastic cancers (95% CI, -75 to 530). Mean size at diagnosis did not change significantly between 2016 and 2021 for any histologic type. Conclusions and Relevance: This longitudinal study found that by the end of 2021, many thyroid cancers remained undiagnosed. These were predominantly small papillary cancers but also affected all histologic types except oncocytic. These deficits in diagnosis could produce a temporary increase in the rate of patients presenting with larger or more advanced stage cancers in the future, and consequently, temporary increases in population morbidity and mortality.

Temporal Trends in Thyroid Nodule Size on Ultrasonography: A Systematic Review and Meta-Analysis.

Importance: In recent years, concern has grown around the overdetection of thyroid cancer. Changes to thyroid nodule risk stratification systems and guidelines were made to improve diagnostic yield. It is not known how these advancements have affected the size of thyroid nodules reported on ultrasonography over time. Objective: To evaluate change in reported nodule size since 1990, particularly between studies of thyroid ultrasonography obtained for diagnostic vs screening purposes. Study Selection: The systematic review included original research studies that reported thyroid nodule size in adults undergoing their first thyroid ultrasonography. Excluded studies were those that included patients with known thyroid disease, prior thyroid ultrasonography, nodules identified through other imaging modalities, and/or that had constraints on nodule size and/or characteristics. Data Sources: PubMed, SCOPUS, CENTRAL, and CINAHL were reviewed from January 1990 to March 2021. Study characteristics, patient demographic characteristics, nodule size, and ultrasonography techniques were independently extracted by multiple observers. Main Outcomes and Measures: The size of thyroid nodules reported via ultrasonography over time. Mixed-effects meta-regression models were used to evaluate mean nodule size (1) overall, (2) in studies that used ultrasonography diagnostically, and (3) in studies that used ultrasonography for screening. Results: A total of 11 963 patients were included; the mean (SD) age was 47.6 (5.2) years. A total of 1097 studies were identified; of these, 395 full-text articles were assessed, and 18 studies met inclusion criteria. All were done at academic institutions. Altogether, these studies had 11 963 patients who underwent a first thyroid ultrasonography. Reported mean nodule size increased 0.52 mm each year from 1990 to 2021 (95% CI, 0.2-0.81). Diagnostic subgroup mean nodule size increased 0.57 mm each year from 1990 to 2021 (95% CI, 0.21-0.93). Screening subgroup mean nodule size decreased by 0.23 mm each year up to 2012 (95% CI, -0.40 to -0.07). Conclusions: The results of this systematic review and meta-analysis suggest that thyroid nodule size reported on diagnostic ultrasonography has increased over time in conjunction with changes in risk stratification systems, nodule guidelines, and radiology practice patterns. Conversely, a decrease in size reported in asymptomatic, ultrasonography-screened populations was observed. Findings from screening studies show that subcentimeter nodules are prevalent and easily identified with ultrasonography, but clinical relevance is questionable. Altogether, these results may provide insight into how ultrasonography guidelines and practice patterns have changed thyroid nodule reporting over time and can inform future guidelines and policies associated with thyroid nodule management.

SQUIRE-SIM (Standards for Quality Improvement Reporting Excellence for SIMulation): Publication Guidelines for Simulation-Based Quality Improvement Projects.

INTRODUCTION: With increased incorporation of simulation-based methodologies into quality improvement activities, standards for reporting on simulation-specific elements in healthcare improvement research are needed. METHODS: We followed established consensus process methodology to iteratively create simulation-based extensions for SQUIRE 2.0 reporting guidelines. Initial steps involved forming a steering committee, defining the scope, and conducting premeeting activities with an expert panel of simulation and quality improvement researchers. Recommendations from the expert panel were brought to a consensus meeting where existing guidelines were reviewed and recommendations made. Steering Committee members reviewed all recommendations, reconciled differences, and made final recommendations, which were piloted by experienced simulation and quality improvement researchers. RESULTS: Fifteen Steering Committee members, 59 experts in simulation and quality improvement research, and 86 consensus meeting attendees reviewed SQUIRE 2.0 reporting guidelines and ultimately recommended simulation-based reporting guidelines for 22 of the 41 (54%) SQUIRE 2.0 guidelines. Those items for which simulation-based extensions were identified were: Notes to Authors, 1 (Title), 2a (Abstract), 2b (Abstract), 4 (Introduction: Available knowledge), 5 (Introduction: Rationale), 7 and 8a & b (Methods: Context and intervention), 9a (Methods - Study of the intervention), 9b (Methods - Study of the intervention), 10a (Methods - Measures), 10b (Methods-Measures), 10c (Methods-Measures), 11b (Methods- Analysis), 12 (Methods - Ethical considerations), 13a (Results), 13e (Results), 14b (Discussion - Summary), 15a-e (Discussion - Interpretation), 16a (Discussion - Limitations), 16b (Discussion - Limitations), 17c (Discussion - Conclusions), and 17d (Discussion - Conclusions). CONCLUSIONS: We created simulation-based extensions to SQUIRE 2.0 reporting guidelines to improve the quality and standardization of reporting on simulation-specific elements of healthcare improvement research.

The Sustained Impact of the COVID-19 Pandemic on Vascular Surgical Care Delivery.

BACKGROUND: The COVID-19 pandemic necessitated postponement of vascular surgery procedures nationally. Whether procedure volumes have since recovered remains undefined. Therefore, our objective was to quantify changes in procedure volumes and determine whether surgical volume has returned to its prepandemic baseline. METHODS: This study was a retrospective cross-sectional study between 2018 and 2023 using the US Fee-for-Service Medicare 5% National Sample as part of the VA Disrupted Care National Project. We studied patients who underwent 1 of 3 procedures: abdominal aortic aneurysm (AAA) repair for intact aneurysms, carotid endarterectomy (CEA), and major lower extremity amputation (LEA). The case volume of each quarter of 2020-2023 was compared to its corresponding prepandemic quarter in 2019. We then performed a subanalysis of these trends by sex, age, and race. RESULTS: We identified 21,031 procedures: 4,411 AAA repair, 8,361 CEA, and 8,259 LEA. The average percent change during the baseline prepandemic period from 2018 to 2019 was -4.3% for AAA repair, -8.5% for CEA, and -2.6% for LEA. Compared to Q2 of 2019, Q2 of 2020 demonstrated that AAA repair procedures decreased by 47%, CEA by 40%, and LEA by 14%. While procedures initially rebounded in Q3 of 2020, volumes did not return to their prepandemic baseline, demonstrating a persistent volume reduction (-16% AAA, -22% CEA, and -11% LEA). Thereafter, procedure counts again declined in Q1 of 2022 (-25% AAA, -34% CEA, and -25% LEA). CONCLUSIONS: Despite a perception that vascular surgical care was singularly disrupted at the outset of the pandemic, there has been a sustained reduction in vascular surgical volume since 2019. Not only have procedure volumes not returned to prepandemic baseline but it also appears that there has been a cumulative incremental impact on overall procedure volume. The impact of these findings on long-term population health remains uncertain and necessitates a better understanding of postpandemic care delivery.

A Retrospective Analysis of Surgical Acuity & Procedure Volume Before & During the COVID-19 Pandemic.

INTRODUCTION: In March 2020, the American College of Surgeons recommended postponing elective procedures amid the COVID-19 pandemic. We used Medicare claims to analyze changes in surgical and interventional procedure volumes from 2016 to 2021. METHODS: We studied 37 common surgical and interventional procedures using 5% Medicare claims files from January 1, 2016, through December 31, 2021. Procedures were classified according to American College of Surgeons guidelines as low, intermediate, or high acuity, and counts were analyzed per calendar year quarter (Q1-Q4), with stratification by sex and race/ethnicity. RESULTS: We observed 1,840,577 procedures and identified two periods of marked decline. In Q2 2020, overall procedure counts decreased by 32.2%, with larger declines in low (41.1%) and intermediate (30.8%) acuity procedures. High acuity procedures declined the least (18.2%). Overall volumes increased afterward but never returned to baseline. Another marked decline occurred in Q4 2021, with all acuity levels having declined to a similar extent (40.1%, 44.2%, and 46.9% for low, intermediate, and high acuity, respectively). High and intermediate acuity procedures declined more in Q4 2021 than Q2 2020 (P = 0.002). Similar patterns were observed across sex and race/ethnicity strata. CONCLUSIONS: Two major procedural volume declines occurred between 2020 and 2022 during the COVID-19 pandemic in the United States. High acuity (life or limb threatening) procedures were least affected in the first decline (Q2 2020) but not spared in second decline (Q4 2021). Future efforts should prioritize preserving high-acuity access during times of stress.

PREF-NET: a patient preference and experience study of lanreotide autogel administered in the home versus hospital setting among patients with gastroenteropancreatic neuroendocrine tumours in the UK.

PURPOSE: PREF-NET reported patients' experience of Somatuline® (lanreotide) Autogel® (LAN) administration at home and in hospital among patients with gastroenteropancreatic neuroendocrine tumours (GEP-NETs). METHODS: PREF-NET was a multicentre, cross-sectional study of UK adults (aged ≥ 18 years) with GEP-NETs receiving a stable dose of LAN, which comprised of (1) a quantitative online survey, and (2) qualitative semi-structured interviews conducted with a subgroup of survey respondents. The primary objective was the description of overall patient preference for home versus hospital administration of LAN. Secondary objectives included describing patient-reported opinions on the experience and associated preference for each administration setting, and the impact on healthcare utilisation, societal cost, activities of daily living and health-related quality of life (HRQoL). RESULTS: In the primary analysis (80 patients; mean age 63.9 years), 98.7% (95% confidence interval [CI]: 96.1-100.0) of patients preferred to receive LAN at home, compared with 1.3% (95% CI: 0.0-3.9) who preferred the hospital setting. Among participants, over half (60.3%) received their injection from a non-healthcare professional. Most patients (79.5% [95% CI: 70.5-88.4]) reported a positive effect on HRQoL after the switch from hospital to home administration. Qualitative interviews (20 patients; mean age 63.6 years) highlighted that patients preferred home administration because it improved overall convenience; saved time and costs; made them feel more comfortable and relaxed, and less stressed; and increased confidence in their ability to self-manage their treatment. CONCLUSION: Almost all patients preferred to receive LAN treatment at home rather than in hospital with increased convenience and psychological benefits reported as key reasons for this preference.

Hypertension Control During the Coronavirus Disease 2019 Pandemic: A Cohort Study Among US Veterans.

DESIGN: Retrospective cohort study. OBJECTIVE: We sought to examine whether disruptions in follow-up intervals contributed to hypertension control. BACKGROUND: Disruptions in health care were widespread during the coronavirus disease 2019 pandemic. PATIENTS AND METHODS: We identified a cohort of individuals with hypertension in both prepandemic (March 2019-February 2020) and pandemic periods (March 2020-February 2022) in the Veterans Health Administration. First, we calculated follow-up intervals between the last prepandemic and first pandemic blood pressure measurement during a primary care clinic visit, and between measurements in the prepandemic period. Next, we estimated the association between the maintenance of (or achieving) hypertension control and the period using generalized estimating equations. We assessed associations between follow-up interval and control separately for periods. Finally, we evaluated the interaction between period and follow-up length. RESULTS: A total of 1,648,424 individuals met the study inclusion criteria. Among individuals with controlled hypertension, the likelihood of maintaining control was lower during the pandemic versus the prepandemic (relative risk: 0.93; 95% CI: 0.93, 0.93). Longer follow-up intervals were associated with a decreasing likelihood of maintaining controlled hypertension in both periods. Accounting for follow-up intervals, the likelihood of maintaining control was 2% lower during the pandemic versus the prepandemic. For uncontrolled hypertension, the likelihood of gaining control was modestly higher during the pandemic versus the prepandemic (relative risk: 1.01; 95% CI: 1.01, 1.01). The likelihood of gaining control decreased with follow-up length during the prepandemic but not pandemic. CONCLUSIONS: During the pandemic, longer follow-up between measurements contributed to the lower likelihood of maintaining control. Those with uncontrolled hypertension were modestly more likely to gain control in the pandemic.

Modeling Thyroid Cancer Epidemiology in the United States Using Papillary Thyroid Carcinoma Microsimulation Model.

OBJECTIVES: Thyroid cancer incidence increased over 200% from 1992 to 2018, whereas mortality rates had not increased proportionately. The increased incidence has been attributed primarily to the detection of subclinical disease, raising important questions related to thyroid cancer control. We developed the Papillary Thyroid Carcinoma Microsimulation model (PATCAM) to answer them, including the impact of overdiagnosis on thyroid cancer incidence. METHODS: PATCAM simulates individuals from age 15 until death in birth cohorts starting from 1975 using 4 inter-related components, including natural history, detection, post-diagnosis, and other-cause mortality. PATCAM was built using high-quality data and calibrated against observed age-, sex-, and stage-specific incidence in the United States as reported by the Surveillance, Epidemiology, and End Results database. PATCAM was validated against US thyroid cancer mortality and 3 active surveillance studies, including the largest and longest running thyroid cancer active surveillance cohort in the world (from Japan) and 2 from the United States. RESULTS: PATCAM successfully replicated age- and stage-specific papillary thyroid cancers (PTC) incidence and mean tumor size at diagnosis and PTC mortality in the United States between 1975 and 2015. PATCAM accurately predicted the proportion of tumors that grew more than 3 mm and 5 mm in 5 years and 10 years, aligning with the 95% confidence intervals of the reported rates from active surveillance studies in most cases. CONCLUSIONS: PATCAM successfully reproduced observed US thyroid cancer incidence and mortality over time and was externally validated. PATCAM can be used to identify factors that influence the detection of subclinical PTCs.

Excess mortality in US Veterans during the COVID-19 pandemic: an individual-level cohort study.

BACKGROUND: Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. METHODS: We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e. excess mortality rates, number of excess deaths) and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. RESULTS: Of 5 905 747 patients, the median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103 164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). CONCLUSIONS: Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasizing the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.

Key Points for Clinicians About the SEER Oral Cancer Survival Calculator.

Importance: In the setting of a new cancer diagnosis, the focus is usually on the cancer as the main threat to survival, but people may have other conditions that pose an equal or greater threat to their life than their cancer: a competing risk of death. This is especially true for patients who have cancer of the oral cavity, because prolonged exposure to alcohol and tobacco are risk factors for cancer in this location but also can result in medical conditions with the potential to shorten life expectancy, competing as a cause of death that may intervene in conjunction with or before the cancer. Observations: A calculator designed for public use has been released that allows patients age 20 to 86 years who have a newly diagnosed oral cancer to obtain estimates of their health status-adjusted age, life expectancy in the absence of the cancer, and probability of surviving, dying of the cancer, or dying of other causes within 1 to 10 years after diagnosis. The models in the calculator showed that patients with oral cavity cancer had a higher than average risk of death from other causes than the matched US population, and this risk increases by stage. Conclusions and Relevance: The Surveillance, Epidemiology and End Results Program Oral Cancer Survival Calculator supports a holistic approach to the life of the patient, and the risk of death of other causes is treated equally to consideration of the probability of death of the cancer. This tool may be usefully paired with the other available prognostic calculators for oral cancer and is an example of the possibilities now available with registry linkages to partially overlapping or independent data sets and statistical techniques that allow the use of 2 time scales in 1 analysis.

A New Personalized Oral Cancer Survival Calculator to Estimate Risk of Death From Both Oral Cancer and Other Causes.

Importance: Standard cancer prognosis models typically do not include much specificity in characterizing competing illnesses or general health status when providing prognosis estimates, limiting their utility for individuals, who must consider their cancer in the context of their overall health. This is especially true for patients with oral cancer, who frequently have competing illnesses. Objective: To describe a statistical framework and accompanying new publicly available calculator that provides personalized estimates of the probability of a patient surviving or dying from cancer or other causes, using oral cancer as the first data set. Design, Setting, and Participants: The models used data from the Surveillance, Epidemiology, and End Results (SEER) 18 registry (2000 to 2011), SEER-Medicare linked files, and the National Health Interview Survey (NHIS) (1986 to 2009). Statistical methods developed to calculate natural life expectancy in the absence of the cancer, cancer-specific survival, and other-cause survival were applied to oral cancer data and internally validated with 10-fold cross-validation. Eligible participants were aged between 20 and 94 years with oral squamous cell carcinoma. Exposures: Histologically confirmed oral cancer, general health status, smoking, and selected serious comorbid conditions. Main Outcomes and Measures: Probabilities of surviving or dying from the cancer or from other causes, and life expectancy in the absence of the cancer. Results: A total of 22 392 patients with oral squamous cell carcinoma (13 544 male [60.5%]; 1476 Asian and Pacific Islander [6.7%]; 1792 Black [8.0%], 1589 Hispanic [7.2%], 17 300 White [78.1%]) and 402 626 NHIS interviewees were included in this calculator designed for public use for patients ages 20 to 86 years with newly diagnosed oral cancer to obtain estimates of health status-adjusted age, life expectancy in the absence of the cancer, and the probability of surviving, dying from the cancer, or dying from other causes within 1 to 10 years after diagnosis. The models in the calculator estimated that patients with oral cancer have a higher risk of death from other causes than their matched US population, and that this risk increases by stage. Conclusions and relevance: The models developed for the calculator demonstrate that survival estimates that exclude the effects of coexisting conditions can lead to underestimates or overestimates of survival. This new calculator approach will be broadly applicable for developing future prognostic models of cancer and noncancer aspects of a person's health in other cancers; as registries develop more linkages, available covariates will become broader, strengthening future tools.

Absolute and relative excess mortality across demographic and clinical subgroups during the COVID-19 pandemic: an individual-level cohort study from a nationwide healthcare system of US Veterans.

Background: Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. Methods: We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e., excess mortality rates, number of excess deaths), and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall, and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. Results: Of 5,905,747 patients, median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103,164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). Conclusions: Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasising the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.

Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic.

Importance: During the first year of the COVID-19 pandemic, there was a substantial increase in the rate of death in the United States. It is unclear whether those who had access to comprehensive medical care through the Department of Veterans Affairs (VA) health care system had different death rates compared with the overall US population. Objective: To quantify and compare the increase in death rates during the first year of the COVID-19 pandemic between individuals who received comprehensive medical care through the VA health care system and those in the general US population. Design, Setting, and Participants: This cohort study compared 10.9 million enrollees in the VA, including 6.8 million active users of VA health care (those with a visit in the last 2 years), with the general population of the US, with deaths occurring from January 1, 2014, to December 31, 2020. Statistical analysis was conducted from May 17, 2021, to March 15, 2023. Main Outcomes and Measures: Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared with previous years. Changes in all-cause death rates by quarter were stratified by age, sex, race and ethnicity, and region, based on individual-level data. Multilevel regression models were fit in a bayesian setting. Standardized rates were used for comparison between populations. Results: There were 10.9 million enrollees in the VA health care system and 6.8 million active users. The demographic characteristics of the VA populations were predominantly male (>85% in the VA health care system vs 49% in the general US population), older (mean [SD], 61.0 [18.2] years in the VA health care system vs 39.0 [23.1] years in the US population), and had a larger proportion of patients who were White (73% in the VA health care system vs 61% in the US population) or Black (17% in the VA health care system vs 13% in the US population). Increases in death rates were apparent across all of the adult age groups (≥25 years) in both the VA populations and the general US population. Across all of 2020, the relative increase in death rates compared with expected values was similar for VA enrollees (risk ratio [RR], 1.20 [95% CI, 1.14-1.29]), VA active users (RR, 1.19 [95% CI, 1.14-1.26]), and the general US population (RR, 1.20 [95% CI, 1.17-1.22]). Because the prepandemic standardized mortality rates were higher in the VA populations prior to the pandemic, the absolute rates of excess mortality were higher in the VA populations. Conclusions and Relevance: In this cohort study, a comparison of excess deaths between populations suggests that active users of the VA health system had similar relative increases in mortality compared with the general US population during the first 10 months of the COVID-19 pandemic.

Response to Toshihide Tsuda, Yumiko Miyano and Eiji Yamamoto [1].

BACKGROUND: Using a toolkit approach, Tsuda et al. critiqued work carried out by or in collaboration with the International Agency for Research on Cancer (IARC/WHO), including the IARC technical publication No. 46 on "Thyroid health monitoring after nuclear accidents" (TM-NUC), the project on nuclear emergency situations and improvement on medical and health surveillance (SHAMISEN), and the IARC-led work on global thyroid cancer incidence patterns as per IARC core mandate. MAIN BODY: We respond on the criticism of the recommendations of the IARC technical publication No. 46, and of global thyroid cancer incidence evaluation. CONCLUSION: After nuclear accidents, overdiagnosis can still happen and must be included in informed decision making when providing a system of optimal help for cases of radiation-induced thyroid cancer, to minimize harm to people by helping them avoid diagnostics and treatment they may not need.

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section.

Importance: Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation: This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance: Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

Analysis of Unmet Information Needs Among Patients With Thyroid Cancer.

Importance: Counseling prior to thyroid cancer (TC) treatment is an essential component of informed consent. An informed patient affects treatment-related expectations and patient engagement, factors that contribute significantly to patient-reported quality-of-life outcomes. Objective: To describe experiences with pretreatment counseling among survivors of TC and to test factors associated with self-reported treatment meeting expectations. Design, Setting, and Participants: A cross-sectional survey was administered between October 18, 2019, and February 8, 2020, to members of ThyCa: Thyroid Cancer Survivors' Association Inc, and to individuals accessing the public-facing ThyCa website. Survey respondents were asked 55 questions, including 4 free-text questions and 2 multiple-choice questions about pretreatment counseling. Main Outcomes and Measures: Respondents self-reported (1) their unmet information needs, (2) rates of treatment meeting expectations, and (3) rates of treatment understanding. A mixed-methods analysis was performed, including qualitative content analysis of free-text responses and multivariable logistic regression of factors associated with self-reported levels of treatment meeting expectations. Results: Of the 1412 survey respondents, 1249 were women (88.4%). The median age at diagnosis was 48 years (range, 18-85 years), and the median age at the time of survey completion was 60 years (range, 18-87 years). A total of 1259 respondents (89.2%) provided free-text responses to the question, "What would you tell someone newly diagnosed with your same condition?" Of these individuals, 526 (37.2%) reported inadequate pretreatment plan understanding and 578 (40.9%) reported that their treatment experience did not meet their expectations. Treatment met expectations for only 95 respondents (18.1%) reporting an inadequate pretreatment plan understanding. Of the 526 survivors of TC reporting a lack of understanding, 473 (90.0%) provided additional textual comments, most commonly in the categories of postoperative treatment, surveillance, and treatment effects. On multivariable logistic regression, self-reported failure to have an understanding of TC treatment was independently associated with failure of treatment to meet expectations (odds ratio, 5.1 [95% CI, 3.7-6.9]). Patients reporting a full understanding of their treatment plan were 5-fold more likely to indicate that their initial treatment experience was on par with expectations, independent of reported postoperative complications, age, sex, and other potential confounders. Conclusions and Relevance: In this survey study, a substantial proportion of survivors of TC reported inadequate pretreatment understanding. This gap in understanding was associated with high levels of self-reported failure of treatment to meet expectations, which in turn is associated in other studies with poorer patient-reported quality-of-life outcomes. These outcomes may be improved by addressing gaps in patient understanding so expectations more closely match TC diagnosis and treatment pathways.