Active Surveillance (AS) of indolent malignancies of the thyroid gland is defined as an approach that comprises a period of watching and routine ultrasound examinations, rather than prompt definitive treatments, such as surgery, which are not without risks of meaningful damage, until their disease has advanced to a stage that ensures such interventions.1 It might be of service in diminishing exposure of patients to unneeded interventions and costs and, most importantly, could lift the standards of personalized patient care. In preceding years, AS of small-scale papillary thyroid carcinomas, labeled Papillary Thyroid Microcarcinomas (PTMCs), most of which are 10 mm or lesser, has been the focus of discussion worldwide.2,3 As a matter of fact, most of PTMCs would never become clinically significant or end in death. If undiscovered, PTMCs will possibly remain asymptomatic and have scant to no impact on a patient’s health, quality of life, or life expectancy.4,5

The outcomes are quite attractive and favorable experiences have also been lately reported, chiefly in Japan, Korea, US, Italy, Argentina and Brazil.6–9 However, PTCM has been treated over the past few decades by surgery which can comprise hemithyroidectomy or removing the full gland (total thyroidectomy). The sequela of a total thyroidectomy for all patients is hypothyroidism, requiring lifelong oral replacement of thyroid hormones. The risk of complications raises with the length of surgery and have central lymph-node dissection increases the inherent risk of comorbidities like recurrent laryngeal nerve, leading to permanent hoarseness and damage to the parathyroid glands, which can be either temporary or permanent. The American Thyroid Association (ATA) guidelines supported AS for these patients and favored narrow surgical treatment to hemithyroidectomy.10 Notwithstanding, AS studies would demand outcome data from plentiful decades in order to totally calculate the likely percentage of disease progression and disease specific mortality.11 A study performed in Brazil showed that two thirds of patients with PTMCs designated the choice for AS to the doctor or wished to know his/her predilection before deciding for AS and that it can be strong endorsed if doctors were persuaded that it is the first option for patients with PTMCs.8

In Brazil, an ubiquitous Instant Messenger Applications (IMAs) such as WhatsApp® has been more and more used for clinical case discussion and splitting of relevant journal articles among endocrinologists and head-and-neck surgeons communities portrayed by groups of physicians who partage a tenacious common interest in thyroid diseases, building affinity and continually interacting online.12–14 Considering this context, WhatsApp® endocrinologists and surgeons communities would be very useful to figure out the beliefs, thinking mechanism and mindset of doctors about treatment of PTMCs.15

This was a pilot study that is considered “exploratory research” to investigate if a snowball sampling strategy to conduct survey among Brazilian endocrinologists and surgeons is feasible to investigate doctors’ concerns towards the AS indication for small, low-risk DTC patients.

To our knowledge, this is the largest survey study focused on physician’s clinical conduct regarding PTMC management in Brazil. The use of social media as one of the recruitment strategies associated with snowball sampling strategy might be particularly effective in reaching hard-to reach groups, such as doctors of different specialties, in different work environments and cities, especially in a large country as Brazil. One third of all responders were less than 40-years old. No difference in respect of age was demonstrated between adopters and non-adopters of AS, except in Cases 2, 3 and 6. Our strategy could thus increase the probability of attracting younger participants, who will be the future generation to continue the follow-up of the patients under AS. Our data shows differences between endocrinologists and surgeons with regard to their choices on management of PTCMs patients in a variety of clinical scenarios. Overall, surgeons were significantly less likely than endocrinologist to adopt AS in the great majority of cases.

Based on answers related to Case 1 management, it is possible that most doctors still perform Fine-Needle Aspiration Cytology (FNAC) for suspicious nodules ≤10 mm and do not propose AS as the management choice of PTMC. However, recently, a Brazilian experts opinion panel was published and AS in adult patients, with low risk PTMC, was recommend as the first-line management.16 Nonetheless, a tendency towards acceptance AS was shown in elderly patients, while nodule posteriorly located, multicentricity and previous exposition to radiation negatively influenced the adoption of AS, in our survey. In contrast to our results, a recent survey study from Unites States noticed that AS was preferred by more than half of the responders.17,18 Similarly, the management of PTMCs in Japan was recently surveyed and more than 50% of low-risk PTMCs were on AS.5 If surgery is an option, generally HT has been considered as the best option for patients with PTMC who are not candidates for AS because of age, proximity of the tumor to the trachea or recurrent laryngeal nerve, or because they opted for surgery.

A recent study, which surveyed North American endocrinologist, surgeons and otolaryngologists, found that years of practice did not have significant effect on considering AS an appropriate option for some patients with thyroid cancer. Curiously, in this study, the majority (76%) of responders believed that AS was a possible management, but only 44% used it in their practice. In contrast, among physicians who believed that AS was possible in some cases but did not use in their practice, those with more years of practice were less likely to use AS.19 In the light of these results, strategies to improve awareness about best practices for PTMC should be highly inclusive, covering young future specialists and those with years of clinical practice.

This study must be considered in the context of its limitations: (i) Only ∼11% of potential target population have completed the questionnaire, (ii) This survey was conducted through the WhatsApp and the data integrity cannot be completely confirmed, (iii) It is a self-report survey, consequently it is not possible to confirm if the data collected through the survey reflects the clinical practice, (iv) Included physicians mainly from two regions of Brazil, who belong to the endocrinologist and head-and-neck surgeons ‘communities. Indeed, every survey is subject to social desirability bias, which reflects a tendency to answer self-report questions correctly, to be viewed favorably by others, even considering that the data was collected in an anonymous way. Therefore, it certainly does not reach all Brazilian physicians that treat PTMC, possibly causing a strong selection bias. We are aware that the response rate in the present survey does not covers the majority of endocrinologists and surgeons that treat thyroid cancer in Brazil and, consequently, the answers collected in this study does not reflect the real clinical practice of the responders, in concern of the management of PTMCs.

Using snowball sampling strategy to conduct a survey about management of PTMCs and AS adoption among Brazilian doctors was feasible and applicable but the rate of responders was still very low. Our results pinpoint that AS should be further investigated as a non-invasive established practice in Brazil and a nationwide, long-term continuous case accumulation survey system should be performed.

The authors declare no conflicts of interest.