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Invited Commentary
February 2017

Mutational Markers and Risk Stratification in Thyroid Cancer—The Art of War Refined

Author Affiliations
  • 1Endocrine Center, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
  • 2Division of Endocrinology, Diabetes, and Metabolism, Carolinas HealthCare System, Charlotte, North Carolina
  • 3School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill
  • 4Department of Solid Tumor Oncology and Investigational Therapeutics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina

Copyright 2016 American Medical Association. All Rights Reserved.

JAMA Oncol. 2017;3(2):209-210. doi:10.1001/jamaoncol.2016.3286

All…can see these tactics whereby I conquer, but what none can see is the strategy out of which victory is evolved.

Sun Tzu, The Art of War

In times of war, every piece of intelligence is gathered, processed and weighed into whether it should help direct strategy against the enemy. The fight against cancer is a war, and the perception in thyroid cancer is that we are winning. Of the more than 10 variants of thyroid carcinoma, by far the most prevalent is classic papillary thyroid carcinoma (PTC), which is treatable and almost universally survivable. Even in the setting of metastatic disease at diagnosis, most patients respond well to a combination of therapies. A small minority succumb to progressive, sometimes treatment-refractory disease. While mortality is low, local recurrence is significantly more common and can occur many years later. Traditional staging systems have been effective in predicting the mortality risk but have been less useful in predicting the risk of recurrence. Beginning in 2009, the American Thyroid Association’s (ATA) risk stratification system for persistent and/or recurrent structural disease was proposed, validated, widely embraced and recently revised.1 It is dynamic, allowing for refinement of an individual’s perceived risk over a long period. For example, a patient whose tumor has concerning features resulting in initial ATA classification of intermediate risk may eventually be restratified to low risk as clinical observation over time reveals an excellent response to therapy. Patients who are classified as ATA high risk are targeted for more aggressive interventions aimed at reducing both risk of recurrence and death. With an increase in the diagnosis of thyroid cancer in recent decades, mainly owing to the incidental radiologic discovery of low-risk tumors, the number of patients who have favorable outcomes is increasing. It is important to avoid unnecessary interventions in this favorable-risk group. Thus, the challenge for clinicians is to identify that small but higher-risk population while not overtreating the majority of patients. More aggressive therapy should be reserved for those who truly require it.