The role of clinicians in determining radioactive iodine use for low-risk thyroid cancer.

BACKGROUND There is controversy regarding the optimal management of thyroid cancer. The proportion of patients with low-risk thyroid cancer who received radioactive iodine (RAI) treatment increased over the last 20 years, and little is known about the role played by clinicians in hospital-level RAI use for low-risk disease. METHODS Thyroid surgeons affiliated with 368 hospitals that had Commission on Cancer-accredited cancer programs were surveyed. Survey data were linked to data reported to the National Cancer Database. A multivariable analysis was used to assess the relation between clinician decision makers and hospital-level RAI use after total thyroidectomy in patients with stage I, well differentiated thyroid cancer. RESULTS The survey response rate was 70% (560 of 804 surgeons). The surgeon was identified as the primary decision maker by 16% of the surgeons; the endocrinologist was identified as the primary decision maker by 69%, and a nuclear medicine, radiologist, or other physician was identified as the primary decision maker by 15%. In a multivariable analysis controlling for hospital case volume and hospital type, when the primary decision maker was in a specialty other than endocrinology or surgery, there was greater use of RAI at the hospital (P < .001). A greater number of providers at the hospital where RAI was administered and having access to a tumor board also were associated with increased use of RAI (P < .001 and P = .006, respectively). CONCLUSIONS The specialty of the primary decision maker, the number of providers administering RAI, and having access to a tumor board were associated significantly with the use of RAI for stage I thyroid cancer. The findings have implications for addressing nonclinical variation between hospitals, with a marked heterogeneity in decision making suggesting that standardization of care will be challenging.