A Multi-level Intervention to Reduce Total Thyroidectomy Overuse for Low-Risk Cancer

PROJECT SUMMARY The majority of patients with low-risk thyroid cancer undergo total thyroidectomy – the riskiest treatment option. Safer, less invasive alternatives offer patients equivalent recurrence and survival with lower risks of debilitating fatigue and serious adverse outcomes. To reduce the long-term morbidity of thyroid cancer and the improve health-related quality of life of survivors, it is imperative to prevent overuse of total thyroidectomy. We have shown that surgeon- and practice-level factors are the most potent actionable contributors to total thyroidectomy overuse. Patients with thyroid cancer would benefit from an intervention that targets known causes of total thyroidectomy overuse at the surgeon and practice levels. In this proposal, our experienced research team will adapt existing evidence-based interventions into a multi- component, multi-level intervention to promote “less extensive surgery by surgeons” (LESS). The intervention components are theoretically-based and grounded in the Behavior Change Ball, a practical tool for designing and evaluating behavior change interventions and policies. After packaging the intervention and completing user testing, we will test the intervention’s effect on rates of total thyroidectomy in an established state-wide value collaborative with a history of successfully implementing surgeon- and practice-level interventions. We will also assess key mechanistic outcomes as the surgeon, practice, and patient levels. The results of the proposed research will provide crucial evidence for a future, large-scale multi-site hybrid type 2 effectiveness—implementation trial to test the effectiveness of LESS on reducing total thyroidectomy rates while simultaneously examining implementation strategies. The intervention will be built on an existing platform designed by physicians and be easily tailored to user needs while remaining scalable. Intervention components will include disease-specific strategic education, communication skills training, and audit-feedback strategies that will have broad applicability for patient-doctor treatment decisions in other cancers. This research is significant because decreasing rates of unnecessary total thyroidectomy in patients with low-risk thyroid cancer will reduce patient harm and improve long-term outcomes—the mission of the NCI. Our experienced multidisciplinary team’s history of successful collaboration and experience in behavioral intervention design and testing with cluster-randomized stepped wedge designs make us well positioned to achieve the aims of this award. This proposal is critical to supporting the long-term health of thyroid cancer survivors and our long- term goal of reducing overtreatment by intervening on surgical decisions.