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16th Chancellor Alfredo T. Ramirez MEMORIAL LECTURE Application of the Management Process in Thyroid Nodules – 30 Years of Experience Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg Family of Dr. Alfredo T. Ramirez Ms. Bella Yan-Ramirez Mr. Clark Alfredo Ramirez Foundation for the Advancement of Surgical Education, Inc. Dr. Telesforo Gana UPCM-PGH Department of Surgery Dr. Nelson Cabaluna Postgraduate Courses Committee Dr. Orlino Bisquera Surgical Colleagues Surgical Learners Friends Ladies and Gentlemen Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg 16th Chancellor Alfredo T. Ramirez Memorial Lecturer For his pioneering spirit in burns, trauma and surgical education For his leadership in the field of medical and higher education For his foresight in developing advances in research and postgraduate surgical training PRIVILEGE This memorial lecture is in recognition of his dedication, excellence and contribution in Philippine surgery. For his pioneering spirit in burns, trauma and surgical educationgrateful ROJoson’s memories For his leadership in to illuminate the field of medical and higher education ATR’s pioneering leadership For hisspirit, foresight in developing and advances foresight in in research and surgical higher postgraduate surgical training education, postgraduate This memorial lecture is in training recognition of his and dedication,research! excellence and contribution in Philippine surgery. In 1968, ATR started Surgical Forum, research contest for residents. In 1968, ATR started Surgical Forum, research contest for residents. 1977 Surgical Forum Tumors of the Parotid Gland – A Clinicopathologic Study of 139 Cases Reynaldo O. Joson, MD Carcinoid Tumors of the Gastrointestinal Tract Reynaldo O. Joson, MD I joined it from 1977 to 1979. In 1968, ATR started Surgical Forum, research contest for residents. I joined it from 1977 to 1979. 1978 Surgical Forum Early Surgery for Appendiceal Abscess Management of External Gastrointestinal Fistulas Reynaldo O. Joson, MD Reynaldo O. Joson, MD In 1968, ATR started Surgical Forum, research contest for residents. 1979 Surgical Forum I joined it from 1977 to 1979. Problems and Rehabilitation of Filipino Stoma Patients Reynaldo O. Joson, MD In 1968, ATR started Surgical Forum, research contest for residents. I joined it from 1977 to 1979. Thanks to ATR! It gave me great learning opportunity to become a researcher! ATR as Chairman of the Department of Surgery always encouraged and motivated me to excel in being a medical educator. Letter of Commendation and Encouragement UPCM Year Level IV ATR as Chairman of the Department of Surgery always encouraged and motivated me to excel in being a medical educator. Motivation and Encouragement Citation UPCM Year Level V ATR as Chairman of the Department of Surgery always encouraged and motivated me to excel in being a medical educator. Letter of Commendation and Promotion Assistant Professor IV (1991) ATR as Chairman of the Department of Surgery always encouraged and motivated me to excel in being a medical educator. Thanks to ATR! ATR initiated Master of Science in Clinical Medicine (Surgery) in 1985. Master of Science in Clinical Medicine (Surgery) I was the first graduate in 1998. I was not required to take it. I gave support because I believe in ATR’s pioneering spirit and foresight in higher surgical education. ATR initiated Thanks to ATR! Master of UPCM is the only institution offering MSc in Science in Surgery in the Philippines! Clinical Medicine (Surgery) in 1985. Dr. Carmela Lapitan I was the first graduate in 1998. Dr. Glenn Genuino Dr. Mel Anthony Cruz I was not required to take it. I gave support because I believe in ATR’s pioneering spirit and foresight in higher surgical education. For his pioneering spirit in burns, trauma3and ROJoson’s grateful surgical education memories to illuminate For his leadership in the field of medical and pioneering higherATR’s education spirit, leadership For hisand foresight in foresight in developing advances higher surgical in research and education, postgraduate surgical training postgraduate training and is in This memorial lecture recognition of his research! dedication, excellence and contribution Philippine Thank inyou, ATR! surgery. Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg 16th Chancellor Alfredo T. Ramirez Memorial Lecturer Dedication and excellence of ATR in medical education and research! 16th Chancellor Alfredo T. Ramirez Memorial Lecture Application of the Management Process in Thyroid Nodules: Thirty Years of Experience Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg 16th Chancellor Alfredo T. Ramirez Memorial Lecture Application of the Management Process in Thyroid Nodules: Thirty Years of Experience 52th Postgraduate Course Theme Oncologic Surgery Current Concepts and Management 16th Chancellor Alfredo T. Ramirez Memorial Lecture Application of the Management Process in Thyroid Nodules: Thirty Years of Experience Former students so impressed with my • usage of patient management process circa 1985 • Thyroid Surgical Diseases book 1986 (that’s 30 years ago) which I have been using as a basis in the management of patients with thyroid disorders / nodules Management of a Patient Process MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit Clinical Diagnosis (primary / secondary) Paraclinical Diagnosis Processes • Indications (degree of certainty/ effect on tx) • Selection (benefit / risk / cost / availability) • Interpretation Advice Advice Pretreatment Diagnosis Specification of treatment objectives Advice Selection of Treatment Options (benefit / risk / cost / availability) Advice Treatment Advice Advice (health maintenance / disease prevention) Management of a Patient Process MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit Clinical Diagnosis (primary / secondary) Paraclinical Diagnosis Processes • Indications (degree of certainty/ effect on tx) • Selection (benefit / risk / cost / availability) • Interpretation Advice Advice Pretreatment Diagnosis Specification of treatment objectives Advice Selection of Treatment Options (benefit / risk / cost / availability) Advice Treatment Advice Advice (health maintenance / disease prevention) Presentation Template Explanation of the Patient Management Processes Illustration of Application of Processes Application of the Management Process in Thyroid Nodules – 30 Years of Experience Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg MANAGEMENT OF A PATIENT PROCESS PROBLEM-SOLVING AND DECISION-MAKING UNIVERSAL GOALS RESOLUTION OF HEALTH PROBLEM LIVE PATIENT NO COMPLICATION NO DISABILITY SATISFIED PATIENT NO MEDICOLEGAL SUIT MANAGEMENT OF A PATIENT PROCESS PROBLEM-SOLVING AND DECISION-MAKING UNIVERSAL GOALS RESOLUTION OF HEALTH PROBLEM (THYROID DISORDER) LIVE PATIENT NO COMPLICATION NO DISABILITY SATISFIED PATIENT NO MEDICOLEGAL SUIT Management of a Patient Process MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Clinical Diagnosis (primary / secondary) Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit Advice MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA (SIGNS and SYMPTOMS) PATTERN RECOGNITION (MATCHING) - realization that the patient’s presentation conforms to a previously learned picture or pattern of disease PREVALENCE - choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA Knowing the common manifestations of 5 different diseases as follows: Disease A - abcd (manifestations) Disease B - fghi Disease C - klmn Disease D - pqrs Disease E – uvwx Given a patient manifesting with pqrs, your diagnosis is Disease D. What is the process used? Pattern Recognition MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS PROCESSING OF DATA Knowing the common manifestations of 3 different diseases and relative frequency of each as follows: Disease A - abcd (manifestations) Least common Disease B - abcd Disease C - abcd Most common Given a patient manifesting with abcd, your diagnosis is Disease C. What is/are processes used? Pattern Recognition but mainly Prevalence MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Majority of the thyroid disorders can be recognized clinically through pattern recognition and prevalence to the point that a clinical diagnosis can be a histopathologic diagnosis. Common practice by clinicians is to just stop at clinical classification of NNTG; DTG; DNTG; NTG. GO BEYOND CLINICAL CLASSIFICATION! MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Thyroid Pathology in Philippines Can be clinically diagnosed with bases Diffuse colloid adenomatous goiter √ Colloid adenomatous nodule/colloid cyst √ Multiple colloid adenomatous goiter √ Papillary carcinoma √ Follicular carcinoma √ Anaplastic carcinoma √ Medullary carcinoma Difficult unless there is MEN syndrome Follicular adenoma Acute thyroiditis / abscess Chronic thyroiditis Difficult √ Difficult Hyperthyroidism √ Hypothyroidism √ MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Diffuse colloid adenomatous goiter Signs and Symptoms Diffuse goiter PR < 90 / min No signs of malignancy MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Colloid adenomatous nodule/colloid cyst Signs and Symptoms Solitary thyroid nodule Not hard, solid / complex / cystic PR < 90 /min No signs of malignancy MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Multiple colloid adenomatous goiter Signs and Symptoms Multiple thyroid nodules Not hard PR < 90 / min No signs of malignancy MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Papillary carcinoma Signs and Symptoms Solitary thyroid nodule Hard solid PR < 90 / min MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Papillary carcinoma Signs and Symptoms Solitary thyroid nodule Hard solid No compression (dysphagia, dyspnea) Ipsilateral neck node/s PR < 90 / min MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Follicular carcinoma Signs and Symptoms Solitary thyroid nodule Lytic bone lesion suspicious of metastasis No compression (dysphagia, dyspnea) PR < 90 / min MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Anaplastic carcinoma Signs and Symptoms Huge thyroid mass, fixed Neck compression (dysphagia, dyspnea) PR < 90 / min Elderly MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Acute thyroiditis / abscess Signs and Symptoms Tender fluctuant thyroid mass No signs of malignancy MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Chronic thyroiditis Signs and Symptoms Nodular gland with no discrete mass PR < 90 / min No signs of malignancy MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Hyperthyroidism Signs and Symptoms Diffuse goiter PR > 100/ min Sudden weight loss With / without exophthalmos MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Primary Clinical Diagnosis Hypothyroidism Signs and Symptoms Diffuse goiter PR < 90/ min Short obese stature with unusually slow body movement MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Majority of the thyroid disorders can be recognized clinically through pattern recognition and prevalence to the point that a clinical diagnosis can be a histopathologic diagnosis. Common practice by clinicians is to just stop at clinical classification of NNTG; DTG; DNTG; NTG. GO BEYOND CLINICAL CLASSIFICATION! MANAGEMENT OF A PATIENT PROCESS CLINICAL DIAGNOSTIC PROCESS Pattern Recognition and Prevalence Application in Thyroid Disorders Rely more on pattern recognition than on prevalence as a priority but use both. Rely more on physical characteristics of the thyroid lesion than on age and sex. For further reading: Clinical Diagnosis of Thyroid Disorders – ROJoson - 1985 http://www.slideshare.net/rjoson/clinical-diagnosis-of-thyroiddisorders Thyroid Surgical Diseases - 1986 MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process Management of a Patient Process MD Patient Interview (symptoms Physical Exam (signs) Clinical Diagnostic Processes (pattern recognition / prevalence) Goals Resolution of the Health Problem Live Patient No Morbidity No Disability Satisfied Patient No Medico-legal Suit Clinical Diagnosis (primary / secondary) Paraclinical Diagnosis Processes • Indications (degree of certainty/ effect on tx) • Selection (benefit / risk / cost / availability) • Interpretation Pretreatment Diagnosis Specification of treatment objectives Advice Advice MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process Indication - to be more definite on the clinical diagnosis Selection Interpretation MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Indication DATA NEEDED PRIMARY CLINICAL DIAGNOSIS SECONDARY CLINICAL DIAGNOSIS MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Indication PROCESSING OF DATA CERTAINTY OF CLINICAL Dx 1O Dx 60% needed 99% not needed TREATMENT PLAN FOR 1O & 2O Dx Different needed Same not needed MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Indication Primary clinical diagnosis Secondary clinical diagnosis Certainty Plan of Treatment 98% 1-2% Surgical Nonsurgical Is a paraclinical diagnostic procedure needed? NO unless there is a strong reason to do so (exception to the rule) MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Indication Primary clinical diagnosis Secondary clinical diagnosis Certainty Plan of Treatment 60% 40% Surgical Nonsurgical Is a paraclinical diagnostic procedure needed? YES MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Indication Tickler - Which of the following statements is the strongest indication for a paraclinical diagnostic procedure? A. You can never be absolutely certain of your clinical diagnosis B. You want to confirm a clinical diagnosis which you are certain of C. You want to document a clinical diagnosis which you are certain of D. When you are not certain of your clinical diagnosis Best Answer is D MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Selection SELECTION PROCESS Options 1 2 3 Benefit Risk Cost Availability MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Options 1 most direct 2 indirect 3 indirect Risk Cost (PhP) Availability acceptable acceptable acceptable 1000 1500 1000 available available available Which is the most cost-effective procedure? Informed consent Option 1 MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Options 1 2 3 Risk accuracy 99% acceptable accuracy 90% acceptable accuracy 50% acceptable Cost (PhP) Availability 5000 3000 1000 available available available Which is the most cost-effective procedure? Informed consent Option 2 or Option 1? MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Selection SELECTION PROCESS Procedure Benefit Options 1 2 3 Risk yield greatest acceptable yield 90% acceptable yield 80% acceptable Cost (PhP) Availability 4000 4000 3000 available available available Which is the most cost-effective procedure? Option 1 Informed consent MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Interpretation INTERPRETATION PROCESS CORRELATE RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE WITH PRIMARY AND SECONDARY CLINICAL DIAGNOSIS CONGRUENT - ACCEPT INCONGRUENT - MAKE A DECISION! (Accept or Hold!) MANAGEMENT OF A PATIENT PROCESS Paraclinical Diagnostic Process - Interpretation Tickler Determine which paraclinical diagnosis should be accepted as the pretreatment diagnosis and which one should be put on hold for further decision-making. Write (A) for accept and (H) for hold. 1. Paraclinical diagnosis is the same as the primary clinical diagnosis. 2. Paraclinical diagnosis is the same as the secondary clinical diagnosis 3. Paraclinical diagnosis is a clinical diagnosis least considered. 4. Paraclinical diagnosis does not jibe with the clinical picture or diagnosis. 1. A 2. A 3. H 4. H MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NO NEED FOR PARACLINICAL DIAGNOSTIC TEST If very certain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are the same. Thyroid Papillary Carcinoma MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NO NEED FOR PARACLINICAL DIAGNOSTIC TEST If very certain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are the same. Thyroid Follicular Carcinoma MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NO NEED FOR PARACLINICAL DIAGNOSTIC TEST If very certain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are the same. Multiple Colloid Adenomatous Goiter MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NEED FOR PARACLINICAL DIAGNOSTIC TEST If uncertain of thyroid hormonal state (hyperthyroid, euthyroid, hypothyroid), do thyroid function tests. MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NEED FOR PARACLINICAL DIAGNOSTIC TEST If uncertain of clinical diagnosis of thyroid structural lesion (malignant, non-malignant), decide on the options (needle biopsy, ultrasound, thyroid scan, etc.) MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NEED FOR PARACLINICAL DIAGNOSTIC TEST If uncertain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are different Options for paraclinical diagnostic tests for thyroid nodules Example of comparative data Options Benefit Risk Cost Availability Needle biopsy Direct exam > 90% yield (overall info) Pain (mild), bleeding PhP1000 and infection (negligible) Available Ultrasound Indirect exam <15% yield for ca Sound wave side effect (negligible) PhP800 Available Thyroid scan Indirect exam <12% yield for ca Radiation (minimal) PhP1200 Available Informed consent MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders NEED FOR PARACLINICAL DIAGNOSTIC TEST If uncertain of clinical diagnosis and treatment plans for1O & 2O clinical diagnoses are different Options for paraclinical diagnostic tests for thyroid nodules Example of comparative data Options Benefit Risk Cost Needle biopsy Direct exam > 90% yield (overall info) Pain (mild), bleeding PhP1000 and infection (negligible) Available Ultrasound Indirect exam <15% yield for ca Sound wave side PhP800 Informed consent effect (negligible) Available Thyroid scan Indirect exam <12% yield for ca Radiation (minimal) Available PhP1200 Availability MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders FINE NEEDLE ASPIRATION BIOPSY vs NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON) Most clinicians, when they do needle aspiration, do not do gross examination of the non-fluid aspirate obtained. They just wait and rely on the report of the pathologists. I usually do “needle evaluation” rather than just “needle aspiration.” • Feel the lump with the needle • Examine the aspirate on a gross level • Examine the aspirate through a microscope (through a pathologist) MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders FINE NEEDLE ASPIRATION BIOPSY vs NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON) Dirty-white bits of tissues from a solid thyroid nodule – PAPILLARY CARCINOMA MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders FINE NEEDLE ASPIRATION BIOPSY vs NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON) Colloid gelatinous substance in sample – COLLOID ADENOMATOUS NODULE MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders FINE NEEDLE ASPIRATION BIOPSY vs NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON) Colloid fluid with complete disappearance of mass – COLLOID CYST MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders FINE NEEDLE ASPIRATION BIOPSY vs NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON) Pus from thyroid nodule – THYROID ABSCESS MANAGEMENT OF A PATIENT PROCESS PARACLINICAL DIAGNOSTIC PROCESS Application in Thyroid Disorders FINE NEEDLE ASPIRATION BIOPSY vs NEEDLE EVALUATION WITH ASPIRATION BIOPSY (ROJOSON) For further reading: Thyroid nodule aspiration: diagnostic usefulness and limitations. Joson RO; Manalang LR; Ramirez CB; Ick JJA; Avila JM; Abelardo AD. Philipp J Surg Spec 1989;44(2):45-57. Needle Evaluation of Surface Lumps - 1989 MANAGEMENT OF A PATIENT PROCESS Treatment Process MANAGEMENT OF A PATIENT PROCESS Treatment Process - Selection DATA NEEDED PRETREATMENT DIAGNOSIS SEVERITY OR STAGE GOALS AND OBJECTIVES TREATMENT OPTIONS MANAGEMENT OF A PATIENT PROCESS Treatment Process - Selection SELECTION PROCESS Options 1 2 3 Benefit Risk Cost Availability MANAGEMENT OF A PATIENT PROCESS Treatment Process - Selection SELECTION PROCESS Treatment Benefit Options Risk Cost (PhP) Availability 1 2 3 acceptable acceptable acceptable 5000 4000 3000 available available available greatest surv rate rate < 1 > 3 least surv rate Which is the most cost-effective treatment option? Option 1 Informed consent MANAGEMENT OF A PATIENT PROCESS Treatment Process - Selection SELECTION PROCESS Treatment Benefit Options Risk Cost (PhP) Availability 1 2 lesser more 5000 5000 available available SR1 = SR2 SR2= SR1 Which is the more cost-effective treatment option? Option 1 Informed consent MANAGEMENT OF A PATIENT PROCESS Treatment Process - Selection SELECTION PROCESS Treatment Benefit Options Risk Cost (PhP) Availability 1 2 acceptable acceptable 8000 4000 available available as effective as 2 as effective as 1 Which is the more cost-effective treatment option? Option 2 Informed consent MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Grade I to 2 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous Goiter Example of comparative data Options Benefit Risk Cost Availability Hormonal Suppressive Therapy Response rate - Medications 17% - 50% side effects 76% (88% > 50% reduction) PhP 11 / 100mcg tab (may take 12 months) at 2 tabs per day (P660 /month) = P7920 /year Available Surgery Resolution of mass in one sitting PhP 31,000 (PHIC) Available Observation Potential of No medications None growing bigger / operation with no side effects medication Operation side effects Available Informed consent MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Grade 3 Colloid Adenomatous Nodule or Multiple Colloid Adenomatous Goiter Example of comparative data Options Benefit Risk Cost Availability Hormonal Response rate Medications Suppressive - <5% side effects Therapy PhP 11 / 100mcg tab (may take 12 months) at 2 tabs per day (P660 /month) = P7920 /year Available Surgery PhP 31,000 (PHIC) Available Resolution of mass in one sitting Observation Potential of growing bigger with no medication Operation side effects No None medications / operation side effects Available Informed consent MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis Example of comparative data Options Benefit Risk Cost Availability Subtotal 10-yr diseaseThyroidectomy free survival rate – 99% Hypothyrodism – 13% Permanent hypoparathyroidism – 0.3% Lower Available (anesthesia time) Total 10-yr diseaseThyroidectomy free survival rate – 99% Hypothyrodism – 100% Permanent hypoparathyroidism – 7% Higher Cancer Institute Hospital, Tokyo American Association of Endocrine Surgeons (AAES) 2014 Annual Meeting; April 29, 2014; Boston, Massachusetts. Abstract 34. Available Informed consent MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis Example of comparative data Options Benefit Risk Cost Availability Subtotal Survival rate Thyroidectomy no significant difference with TT Hypothyrodism – Lower Available lower (anesthesia Permanent time) hypoparathyroidism – lower Total Survival rate Thyroidectomy no significant difference with STT Hypothyrodism – Higher 100% Permanent hypoparathyroidism – higher Ref: Shaha A., Memorial Sloan-Kettering Cancer Center, Ann N Y Acad Sci. 2008 Sep;1138:58-64. Selective surgical management of well-differentiated thyroid cancer. MD Anderson Available Informed consent MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis Example of comparative data Options Benefit Risk Cost Availability Subtotal Survival rate Thyroidectomy lower than TT Hypothyrodism – lower Permanent hypoparathyroidism – lower Lower Available (anesthesia time) Total Survival rate Thyroidectomy higher than with STT Hypothyrodism – 100% Permanent hypoparathyroidism – higher Higher Ref: National Comprehensive Cancer Network (NCCN) Guidelines Available Informed consent MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Follicular and Papillary Thyroid Ca, One Lobe, No Nodes, No Metastasis Example of comparative data Options Benefit Subtotal Survival rate Thyroidectomy same with TT (Tokyo, Memorial) Conflicting data Risk Cost Availability Hypothyrodism – Lower Available lower (anesthesia Permanent time) hypoparathyroidism – lower Survival rate lower than TT (NCCN) Total Survival rate Thyroidectomy higher than with STT (NCCN) Hypothyrodism – Higher Available 100% Permanent hypoparathyroidism Informed consent – higher MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Personal recommendations on thyroid nodule/s: Operation – if malignant or if there is high chance of malignancy Trial of hormonal suppressive therapy (levothyroxine) for as long as one year – if benign and not more than 4 cm If nodule does not disappear, but has decreased in size and remained stationary, maintain on levothyroxine and continue to monitor. If there is appearance of sign or symptom of malignancy, operate. Clinical response of nodular colloid adenomatous goiters Joson RO. Philipp J Surg Spec 1998; 53(1):31-34. 1998 MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders For further reading: Thyroid Disorders - Indications for Surgery - 1990 https://sites.google.com/site/rojosonwritings/thyroid-disorders--indications-for-surgery Clinical response of nodular colloid adenomatous goiters Joson RO. Philipp J Surg Spec 1998; 53(1):31-34. 1998 MANAGEMENT OF A PATIENT PROCESS TREATMENT PROCESS Application in Thyroid Disorders Personal recommendation on extent of thyroidectomy for unilobar well-differentiated thyroid cancers, no nodes, no metastasis: SUBTOTAL THYROIDECTOMY I believe in the data of Cancer Institute Hospital, Tokyo and Memorial Sloan-Kettering Cancer Center as they jibe with my personal experience. Clinical Care Pathway, Management of a Patient Process, and Clinical Practice Guidelines Clinical Care Pathway Diagnosis Management of a Patient Process Clinical diagnostic Paraclinical diagnostic Treatment Treatment Clinical Practice Guidelines Clinical diagnosis Paraclinical diagnosis Treatment PROBLEM-SOLVING and DECISION-MAKING INFORMED CONSENT Management of a Patient Process and NCCN Guidelines 1985 Options 2015 Benefit Risk Cost Availability Presentation Template Explanation of the Patient Management Processes Illustration of Application of Processes Application of the Management Process in Thyroid Nodules – 30 Years of Experience Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg 16th Chancellor Alfredo T. Ramirez Memorial Lecture Application of the Management Process in Thyroid Nodules: Thirty Years of Experience 52th Postgraduate Course Theme Oncologic Surgery Current Concepts and Management Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg 16th Chancellor Alfredo T. Ramirez Memorial Lecturer Dedication and excellence of ATR in medical education and research!