Managing thyroid abnormalities in adults exposed to upper body irradiation in childhood: a decision analysis. Should patients without palpable nodules be scanned and those with scan defects be subjected to subtotal thyroidectomy?

This decision analysis compares two currently recommended management strategies for adults at increased risk for thyroid carcinoma due to childhood upper body irradiation who present without palpable thyroid nodularity: 1) scan-surgery: initially thyroid scan every patient, then perform subtotal thyroidectomy for each patient with single or multiple scan defects; and 2) no scan reexamine: do not scan initially, but reexamine at least every 2 yr, reserving surgery for those in whom palpable nodularity later develops. When surgical morbidity and mortality are taken into account, the expected utility of the no scan reexamine strategy slightly outweighs that of scan-surgery; this preference is maintained in several sensitivity analyses, unless more than 80% of occult cancers progress to palpable size. Moreover, the financial costs of universal scanning coupled with surgery are considerably greater. The no scan-reexamine approach, therefore, deserves serious consideration as the preferred strategy. Since the expected utilities of the two strategies are nearly equal, however, patient attitudes toward risk should be given particular weight in choosing management.