Standards of
Service Provision for
Thyroid Cancer Patients
in New Zealand Provisional
National Thyroid Cancer Tumour
Standards Working Group
2013
Citation: National Thyroid Cancer Tumour Standards Working Group. 2013. Standards of
Service Provision for Thyroid Cancer Patients in New Zealand - Provisional. Wellington: Ministry
of Health.
Published in December 2013 by the
Ministry of Health
PO Box 5013, Wellington 6145, New Zealand
ISBN 978-0-478-41544 (online)
HP 5747
This document is available through the Ministry of Health website: www.health.govt.nz
or from the regional cancer network websites:
www.northerncancernetwork.org.nz
www.midland cancernetwork.org.nz
www.centralcancernetwork.org.nz
www.southerncancernetwork.org.nz
Contents
Introduction ............................................................................................................... 1
Background ..................................................................................................... 1
Objective ......................................................................................................... 1
How the thyroid cancer service standards were developed .............................. 2
Equity and Whānau Ora .................................................................................. 2
Summary of the clinical standards for the management of thyroid cancer
services ........................................................................................................... 4
Standards of service provision pathway ........................................................... 4
Summary of standards..................................................................................... 5
1
Prevention and Early Identification................................................................... 8
Rationale ......................................................................................................8-9
Good practice points .....................................................................................8-9
2
Timely Access to Services ............................................................................. 10
Rationale ....................................................................................................... 10
Good practice points ...................................................................................... 11
3
Referral and Communication ......................................................................... 13
Rationale ....................................................................................................... 13
Good practice points ...................................................................................... 13
4
Investigation, Diagnosis and Staging ............................................................. 15
Rationale .................................................................................................. 15-20
Good practice points ................................................................................. 15-20
5
Multidisciplinary Care ..................................................................................... 21
Rationale ....................................................................................................... 21
Good practice points ...................................................................................... 21
6
Supportive Care............................................................................................. 24
Rationale ....................................................................................................... 24
Good practice points ...................................................................................... 24
7
Care Coordination ......................................................................................... 26
Rationale ....................................................................................................... 26
Good practice points ...................................................................................... 26
8
Treatment ...................................................................................................... 28
Rationale .................................................................................................. 28-34
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
iii
Good practice points ................................................................................ 28-34
9
Follow-up and Surveillance ........................................................................... 36
Rationale ....................................................................................................... 36
Good practice points ..................................................................................... 36
10
Clinical Performance Monitoring and Research ............................................. 38
Rationale .................................................................................................. 38-40
Good practice points ................................................................................ 38-40
Appendix 1: National Thyroid Cancer Tumour Standards Working Group
Membership .................................................................................................. 41
Appendix 2: Glossary ............................................................................................. 42
Appendix 3: References ......................................................................................... 47
iv
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Introduction
Background
Thyroid nodules are a common clinical problem; however, thyroid cancer is relatively
uncommon. In 2009, 225 new cases were recorded in New Zealand, of which
22 were papillary microcarcinomas (<10 mm) (Ministry of Health 2012a).
Documented incidence of thyroid cancer over time is rising; in part due to the
increased use of neck ultrasonography, but also reflecting increased numbers of
larger thyroid cancers, including cancers >4 cm (Chen et al 2009). Most patients
have a very good outcome; overall, 10-year survival in New Zealand was recorded
as 87.7 percent in 2004 (Ministry of Health 2010a), although 5–20 percent of
patients develop recurrent disease. Solitary papillary microcarcinomas are mostly
incidental; most have no adverse effect on survival.
The Segi age-standardised death rate per 100,000 from thyroid cancer in New
Zealand from 1996 to 2009 was 0.74 ± 0.67 for Māori and 0.33 ± 0.10 for the total
population (Ministry of Health 2012a).
By far the majority of thyroid cancers are well differentiated (papillary or follicular),
and therefore amenable to treatment with radioactive iodine following surgery.
Medullary, poorly differentiated and anaplastic cancers are rare; treatment for these
cancers is predominantly surgical, although newer medical therapies for advanced
medullary cancers are becoming available (ATA Guidelines Taskforce on Thyroid
Nodules and Differentiated Thyroid Cancer et al 2009). Incidental small papillary
cancers are not uncommon findings in patients having thyroidectomy for other
indications. Very rare types of thyroid cancer such as lymphoma are not specifically
covered by the standards presented in this document.
Given the relatively low numbers of patients presenting with thyroid cancer,
management strategies (such as extent and type of surgery, role and dose of
radioactive iodine or external beam radiotherapy) are based mainly on expert
opinion or retrospective cohort studies reported from overseas institutions, rather
than prospective randomised controlled trials. In developing these standards, the
National Thyroid Cancer Tumour Standards Working Group has used published
guidelines (mainly American and British) or drawn on expert opinion, with regard to
the unique geographical and other characteristics of the New Zealand health care
system.
Objective
Tumour standards for all cancers are being developed as a part of the Ministry of
Health’s ‘Faster Cancer Treatment’ (FCT) programme’s approach to ensuring timely
clinical care for patients with cancer. When used as a quality improvement tool the
standards will promote nationally coordinated and consistent standards of service
provision across New Zealand.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
1
The standards will be the same for all ethnic groups. However, we expect that in
implementing the standards district health boards (DHBs) may need to tailor their
efforts to meet the specific needs of populations with comparatively poorer health
outcomes, such as Māori and Pacific people.
How the thyroid cancer service standards were developed
These standards were developed by a skilled working group, representing key
specialities and interests across the thyroid cancer pathway of care. The group was
chaired by a lead clinician and had access to expert advisors in key content areas
(see Appendix 1).
Existing evidence-based standards, clinical guidelines and patient pathways were
referred to when developing the thyroid cancer standards (see Appendix 4). Where
no clear evidence was available, expert opinion was obtained through the National
Thyroid Tumour Standards Working Group and its advisors.
Tumour-specific national standards were first developed for lung cancer in the
Standards of Service Provision for Lung Cancer Patients in New Zealand (National
Lung Cancer Working Group 2011); these standards have already made
improvements to service delivery and clinical practice.
Subsequently provisional standards have been developed for an additional ten
tumour types: bowel, breast, gynaecological, lymphoma, melanoma, myeloma, head
and neck, sarcoma, thyroid and upper gastrointestinal.
The Ministry of Health required all tumour standards working groups to:
Maintain a focus on achieving equity and whānau ora when developing
service standards, patient pathways and service frameworks by ensuring an
alignment with the Reducing Inequalities in Health Framework and its
principles (Ministry of Health 2002).
Equity and Whānau Ora
The differential health status between Māori and non-Māori is an ongoing challenge
for the health sector (Ministry of Health 2010c). Cancer is an important contributor to
these health inequalities (Blakely et al 2011). Studies have shown that Māori are
least likely to access primary oral health care compared to Pacific and European
people (Ministry of Health 2009). Māori males are twice as likely and females three
times as likely as non-Māori to have a smoking history (Ministry of Health 2010d).
Health inequities or health disparities are avoidable, unnecessary and unjust
differences in the health of groups of people. In New Zealand, ethnic identity is an
important dimension of health disparities. Cancer is a significant health concern for
Māori, and has a major and disproportionate impact on Māori communities.
2
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Inequities exist between Māori and non-Māori in exposure to risk and protective
factors for cancer, in incidence and outcomes, and in access to cancer services.
Barriers to health care are recognised as multidimensional, and include health
system and health care factors (eg, institutional values, workforce composition,
service configuration and location), as well as patient factors (eg, socioeconomic
position, transportation and patient values). Addressing these factors requires a
population health approach that takes account of all the influences on health and
how they can be tackled to improve health outcomes.
A Whānau Ora approach to health care recognises the interdependence of people;
health and wellbeing are influenced and affected by the ‘collective’ as well as the
individual. It is important to work with people in their social contexts, and not just
with their physical symptoms.
The outcome of the Whānau Ora approach in health will be improved health
outcomes for family/whānau through quality services that are integrated (across
social sectors and within health), responsive and patient/family/whānau-centred.
These standards will address equity for Māori patients with thyroid cancer in the
following ways.

The standards focus on improving access to diagnosis and treatment for all
patients, including Māori and Pacific.

Māori access to cancer services will be monitored and evaluated.

Ethnicity data will be collected on all access measures and the FCT indicators,
and will be used to identify and address disparities.

Good practice points include health literacy and cultural competency training for
all health professionals involved in patient care.

Information developed or provided to patients and their family will meet Ministry
of Health guidelines (Ministry of Health 2012b).

Māori participation will be invited in multidisciplinary teams (MDTs) and networks,
to develop treatment plans and care coordination and ensure an effective service
delivery model.

The role of Māori patient advocates and navigators to enhance the patient
journey will be investigated.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
3
Summary of the clinical standards for the management of
thyroid cancer services
Format of the standards
Each cluster of standards has a title that summarises the step of the patient journey
or the area on which the standards are focused. This is followed by the standard
itself, which explains the level of performance to be achieved. The rationale section
explains why the standard is considered to be important.
Attached to the clusters of standards are good practice points. Good practice points
are supported either by the international literature, the opinion of the National
Thyroid Cancer Standard Working Group or the consensus of feedback from
consultation with New Zealand clinicians involved in providing care to patients with
thyroid cancer. Also attached to each cluster are the Ministry of Health’s
requirements for monitoring the individual standards.
Standards of service provision pathway
The thyroid cancer tumour standards are reflected in the following pathway.
4
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Summary of standards
The standards for the management of thyroid cancer have been divided into
10 clusters:

prevention and early identification

timely access to services

referral and communication

investigation, diagnosis and staging

multidisciplinary care

supportive care

care coordination

treatment

follow-up and surveillance

clinical performance monitoring and research.
The standards are as follows.
Prevention and early identification
Standard 1.1: Risk factors and ‘red alert’ signs of thyroid cancer are clearly
communicated to all health care practitioners.
Standard 1.2: People at significantly increased risk of thyroid cancer are offered
surveillance for thyroid cancer.
Timely access to services
Standard 2.1: Patients referred urgently with a high suspicion of thyroid cancer have
their first specialist assessment (FSA) within 14 days.
Standard 2.2: Patients with a confirmed diagnosis of thyroid cancer and requiring
active treatment start their treatment within 62 days of secondary care receiving a
referral.
Standard 2.3: Patients with a confirmed diagnosis of thyroid cancer (including
recurrence) receive their first treatment or other management within 31 days of the
decision to treat.
Referral and communication
Standard 3.1: Patients with suspected thyroid cancer are referred to secondary and
tertiary care following an agreed referral pathway.
Standard 3.2: Patients and their general practitioners (GPs) are provided with verbal
and written information about thyroid cancer, diagnostic procedures, treatment
options (including effectiveness and risks), final treatment plan and support services.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
5
Standard 3.3: Communications between health care providers include the patient’s
name, date of birth, national health index (NHI) number and contact details, and are
ideally electronic.
Investigation, diagnosis and staging
Standard 4.1: Patients with a thyroid nodule suspicious of thyroid cancer undergo
fine needle aspiration (FNA) and/or ultrasound; FNA of a palpable nodule is an
appropriate first step.
Standard 4.2: Imaging investigations follow standardised imaging pathways based
on the Royal College of Radiologists’ Cancer Imaging Guidelines (RCR 2006).
Standard 4.3: Thyroid FNA results for patients referred urgently with a high
suspicion of cancer are reported back to the referrer within five working days.
Standard 4.4: Thyroid FNA specimens are reported using the Bethesda System for
Reporting Thyroid Cytopathology.
Standard 4.5: The histology of excised thyroid cancer specimens is recorded in a
synoptic format.
Standard 4.6: Relevant histology and cytology specimens of thyroid cancers
discussed at regional multidisciplinary meetings (MDMs) are reviewed by a
pathologist with a subspecialty interest in thyroid cancer.
Standard 4.7: Patients with thyroid cancer are staged according to the American
Joint Committee on Cancer (AJCC)’s Tumour, node, metastases (TNM) staging
classification.
Multidisciplinary care
Standard 5.1: Patients with the following are discussed at an MDM:

differentiated thyroid cancer greater than a micro carcinoma (>1 cm in diameter)
or any size cancer with adverse histology (eg, medullary, anaplastic)

a preoperative diagnosis of thyroid cancer with suspicion of extrathyroidal
invasion or lymphadenopathy

recurrent thyroid cancer

metastatic thyroid cancer.
Supportive care
Standard 6.1: Patients with thyroid cancer and their family/whānau have equitable
and coordinated access to appropriate medical, allied health and supportive care
services, in accordance with Guidance for Improving Supportive Care for Adults with
Cancer in New Zealand (Ministry of Health 2010b).
6
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Care coordination
Standard 7.1: Patients with thyroid cancer have access to a clinical nurse specialist
or other health professional who is a member of the MDT to help coordinate all
aspects of their care.
Treatment
Standard 8.1: Thyroid surgery is performed by a surgeon who has undertaken
subspecialty training that includes thyroid surgery.
Standard 8.2: Surgical morbidity and mortality are presented at regular audit
meetings.
Standard 8.3: Patients with differentiated thyroid cancer are considered for
radioactive iodine after surgery following internationally published guidelines.
Standard 8.4: External beam radiotherapy is considered for patients at high risk of
local recurrence.
Standard 8.5: Patients with advanced thyroid cancer have access to appropriate
medical oncology specialist care for consideration of evolving chemotherapies.
Standard 8.6: Patients are offered early access to palliative care services when
there are complex symptom control issues, when curative treatment cannot be
offered, or if curative treatment is declined.
Follow-up and surveillance
Standard 9.1: Follow-up plans include clinical review by appropriate members of the
MDT, working in conjunction with the patient, their family/whānau and their GP.
Clinical performance monitoring and research
Standard 10.1: Data relating to thyroid cancer beyond the fields required by the
Cancer Registry, including treatment data, are reported to existing and planned
national repositories.
Standard 10.2: Patients with thyroid cancer are offered the opportunity to participate
in appropriate research projects and clinical trials where these are available.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
7
1
Prevention and Early Identification
Standard 1.1
Risk factors and ‘red alert’ signs of thyroid cancer are clearly
communicated to all health care practitioners.
Rationale
Tumour stage at diagnosis and patient age are recognised as the most important
prognostic factors for patients with thyroid cancer. Early detection of some thyroid
cancers reduces morbidity and improves survival. Challenges to early diagnosis
include: patient delay in presentation, primary health practitioner delay prior to FNA
or referral to an appropriate specialist and specialist delay in seeing the patient or
arranging appropriate diagnostic procedures.
The only recognised environmental cause of thyroid cancer is radiation of the thyroid
in childhood. Other risk factors include a family history of thyroid cancer or familial
syndromes (eg, familial adenomatous polyposis (FAP) and multiple endocrine
neoplasia type 2 (MEN2)).
Ensuring adequate training of health care professionals regarding risk factors and
patient symptoms and signs that raise suspicion for thyroid cancer should allow
earlier identification of thyroid cancer.
Clinical features associated with malignancy such as voice changes, rapid nodule
growth, lymphadenopathy and certain characteristics of the nodule are important to
recognise. Although the majority of thyroid cancers are asymptomatic, the likelihood
a nodule is malignant is seven-fold increased if it is very firm, is fixed to adjacent
structures, is rapidly growing, is associated with enlarged lymph nodes, causes
vocal cord paralysis or invades into neck structures.
The risk of recurrence and mortality correlates with the size of the primary tumour,
extent of disease spread and patient age; children and adults older than 45
experience poorer outcomes than adults younger than 45.
Good practice points
1.1
Risk factors for thyroid cancer are recorded for patients who have suspicious
thyroid nodules.
1.2
Clinical features associated with malignancy are recorded.
Monitoring requirements
MR1A
8
Record national public health campaigns for identified risk factors.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Standard 1.2
People at significantly increased risk of thyroid cancer are
offered surveillance for thyroid cancer.
Rationale
The only proven environmental risk factor for thyroid cancer is exposure to
irradiation in childhood. Studies following the Chernobyl nuclear disaster show a
markedly increased incidence of thyroid cancer in children from the region; a lesser
risk is associated with therapeutic head and neck irradiation for childhood
malignancy.
Familial syndromes associated with an increased risk of thyroid cancer include
MEN2, FAP, Carney’s complex and Cowden’s disease.
Good health outcomes depend on a range of factors, including access to
information, timely intervention, good practitioner–patient relationships and
communication.
Good practice points
1.3
Screening the general population to detect thyroid cancer is not
recommended.
1.4
Screening for thyroid cancer by clinical examination or thyroid ultrasound is
considered for people exposed as children to irradiation from Chernobyl or
who received head and neck irradiation in childhood.
1.5
Individuals with a known familial syndrome associated with thyroid cancer
undergo surveillance.
1.6
Health literacy is acknowledged as a key component to clinical best practice
and improved clinical outcomes for Māori at risk of or experiencing cancer.
1.7
Clinicians responsible for communicating with patients and their
family/whānau complete health literacy training.
1.8
Information developed for or provided to patients and their family/whānau
meets Ministry of Health guidelines (Ministry of Health 2012b).
Monitoring requirements
MR1B
Record numbers of identified population at increased risk enrolled in
surveillance programmes.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
9
2
Timely Access to Services
Standard 2.1
Patients referred urgently with a high suspicion of thyroid cancer
have their FSA within 14 days.
Standard 2.2
Patients with a confirmed diagnosis of thyroid cancer and
requiring active treatment start their treatment within 62 days of
secondary care receiving a referral.
Standard 2.3
Patients with a confirmed diagnosis of thyroid cancer (including
recurrence) receive their first treatment or other management
within 31 days of the decision to treat.
Rationale
Timely and equitable access to quality cancer management is important to support
good health outcomes for New Zealanders and to reduce inequalities.
Key components of successful cancer management include early recognition and
reporting of symptoms, expertise in triaging patients requiring prompt referral and
rapid access to investigations and treatment.
There is evidence that higher survival rates for thyroid cancer are associated with
detection and treatment of early-stage, less advanced disease.
While many thyroid cancers are associated with a good prognosis, others behave
aggressively. Therefore it is important that health professionals are aware of
important symptoms that may indicate cancer, to ensure prompt and appropriate
referral. Delay in diagnosis can worsen prognosis and cause significant morbidity.
Patient anxiety may contribute to worse clinical outcomes. A suspicion of cancer or
cancer diagnosis is very stressful for patients and family/whānau. Prompt access to
appropriate care will lessen this anxiety.
Timed patient pathways help ensure patients receive quality and equitable clinical
care.
Shorter waits for cancer treatments is a government health target. The FCT
indicators (the standards in this cluster) adopt a timed patient pathway approach
across surgical and non-surgical cancer treatment, and apply to inpatients,
outpatients and day patients.
10
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Good practice points
2.1
General practitioners refer to secondary care services within five working days
of receiving a diagnostic result (usually through FNA) indicating thyroid
cancer.
2.2
Patients presenting with the following are urgently referred:

unexplained voice changes associated with goitre

a thyroid nodule in a child

cervical lymphadenopathy

rapidly enlarging painless thyroid mass.
2.3
Immediate (same-day) referral is considered in some cases (eg, for a patient
presenting with stridor and a thyroid lump).
2.4
Referrals are made electronically, or over the telephone.
2.5
General practitioners or referring doctors are informed if a specialist
downgrades an urgent case of suspected cancer to a lower priority.
2.6
Non-urgent assessment of thyroid nodules is considered for patients
presenting with the following:

a thyroid lump that is newly presenting, or increasing in size over months

history of sudden onset of pain in a thyroid lump (likely to have bled into a
cyst)

thyroid nodules associated with abnormal thyroid function tests (these
patients are referred to an endocrinologist)

impalpable nodules with low risk for cancer.
2.7
In patients with thyroid cancers exhibiting indolent growth, treatment is
initiated within 62 days of referral; however, treatment is commenced earlier
than this where appropriate.
2.8
The referral pathway, including urgent referral criteria, is easily accessible to
primary care and is available electronically. Development of a standardised
referral system for thyroid cancer is considered.
2.9
Strategies such as improved education of health professionals, a clear
pathway and appropriate access to community and hospital services are
considered, in order to shorten waiting times for treatment.
2.10 Delays in reporting of FNA results are minimised where possible, to reduce
patient distress and ensure that patients receive appropriate, timely treatment.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
11
2.11 To ensure tests confirming cancer are not overlooked, a clear pathway is in
place for reporting of concerning results.
2.12 Fine needle aspiration results are reported electronically, and results
confirming cancer are highlighted.
Monitoring requirements
12
MR2A
Track FCT indicators.
MR2B
Audit imaging waiting times and reporting times for radiology.
MR2C
Collect and analyse ethnicity data on all access targets and indicators.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
3
Referral and Communication
Standard 3.1
Patients with suspected thyroid cancer are referred to
secondary and tertiary care following an agreed referral
pathway.
Standard 3.2
Patients and their GPs are provided with verbal and written
information about thyroid cancer, diagnostic procedures,
treatment options (including effectiveness and risks), final
treatment plan and support services.
Standard 3.3
Communications between health care providers include the
patient’s name, date of birth, NHI number and contact details,
and are ideally electronic.
Rationale
Thyroid nodules are common; they are found in 5 percent of thyroid glands on
palpation and 50 percent of older adults when examined by ultrasound, although
only 5–10 percent of thyroid nodules are malignant. It is important that health care
professionals have ready access to a simple, clear pathway to investigate thyroid
nodules, including when referral to a specialist is indicated.
Patients may wish to discuss their diagnosis and treatment with their GP. General
practitioners need basic information to be transferred rapidly, in order to support
their patients at a time of stress. The majority of thyroid cancer cases have a good
long-term prognosis.
Good practice points
3.1
General practitioners refer electronically, to facilitate triage.
3.2
General practitioners receive communications of a cancer diagnosis within
seven days.
3.3
General practitioners receive MDMs’ treatment recommendations within seven
days of the MDM. Once treatment is complete, GPs receive reports of
treatment (including details such as operation notes and radioactive iodine
administration) within 14 days.
3.4
Two-way communication occurs between primary and secondary care.
3.5
Patients are informed face-to-face of a diagnosis of confirmed thyroid cancer
as soon as is practical, and are invited to bring a support person to the
consultation.
3.6
Written information is provided at an appropriate reading age for patients and
family/whānau, and is available in a number of languages.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
13
3.7
Cancer services develop and implement a did-not-attend (DNA) reduction and
follow-up protocol that particularly focuses on reducing inequalities for Māori.
3.8
Staff responsible for engagement with patients and/or their families/whānau
undertake and complete cultural competency training.
3.9
The reporting terminology used for thyroid cytology is the Bethesda System for
Reporting Thyroid Cytopathology.
Monitoring requirements
14
MR3A
Provide evidence of clear and accessible referral pathways.
MR3B
Audit the percentage of thyroid cancer referrals received through the
appropriate pathway and on the appropriate proforma.
MR3C
Record the percentage of diagnostic information provided within seven days.
MR3D
Audit information sent to multidisciplinary clinic patients at their first visit.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
4
Investigation, Diagnosis and Staging
Standard 4.1
Patients with a thyroid nodule suspicious of thyroid cancer
undergo FNA and/or ultrasound; FNA of a palpable nodule is an
appropriate first step.
Rationale
There are many international guidelines for investigation of patients with thyroid
nodules, although there is controversy about the most cost-effective approach to the
diagnostic evaluation of a thyroid nodule. Whether ultrasound imaging should be
performed prior to all thyroid FNAs is controversial; this procedure may lead to delay
in diagnosis, if ultrasound is not readily available. However, ultrasound is more
accurate than clinical examination in detecting the size and number of nodules, and
is able to define which nodules have suspicious features, and therefore need FNA.
Good practice points
4.1
The initial investigation of a thyroid nodule is for the purposes of measuring
thyroid-stimulating hormone (TSH). Clinicians consider radionuclide imaging in
patients with a low TSH.
4.2
For patients with a clearly palpable thyroid nodule, an appropriate first step is
FNA or a thyroid ultrasound.
4.3
Ultrasound guidance of FNA is available for selected nodules (non-palpable,
partly cystic, posteriorly located, previously inadequately sampled). Thyroid
nodules <1 cm do not require FNA evaluation, unless an ultrasound detects
factors associated with increased cancer risk.
4.4
Ultrasound assessment of the thyroid focuses on identifying nodules with
suspicious features. Standardised ultrasound reporting criteria are followed
indicating position, shape, size, margins, echogenicity and the vascular
pattern of the nodule(s). Features that may increase the probability that a
nodule is malignant include: microcalcifications, irregular margins,
hypoechogenicity, prominent internal vascularity, absent halo, nodule ‘taller
than wide’ and cervical lymph adenopathy.
4.5
For patients with multinodular goitres, clinicians consider FNA for selected
nodules (eg, where suspicious features are detected through ultrasound, or in
the case of non-palpable nodules with risk factors), rather than just larger or
clinically dominant nodules.
Monitoring requirements
MR4A
Audit appropriateness of nodule FNA versus final pathology.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
15
Standard 4.2
Imaging investigations follow standardised imaging pathways
based on the Royal College of Radiologists’ Cancer Imaging
Guidelines (RCR 2006).
Rationale
Diagnosticians (such as radiologists and endocrinologists) involved in thyroid imaging
should be familiar with the full range of imaging modalities, including ultrasonography,
computed tomography (CT), magnetic resonance imaging (MRI), nuclear scintigraphy
(NS) and positron emission tomography (PET), and understand the relevant roles,
benefits and limitations of each, in order to optimise assessment outcomes.
MRI and CT have no role in the characterisation of thyroid nodules.
Good practice points
4.6
Ultrasound or other imaging where appropriate is performed within 21 working
days of referral.
4.7
At the time of reporting, all other relevant imaging results are available for
reference.
4.8
Accurate staging of thyroid malignancy often requires a combination of
imaging modalities, including ultrasound, cross-sectional imaging (CT/MRI)
and radionuclide imaging.
4.9
Neck ultrasound and/or FNA or whole-body radioiodine scanning is
considered in the presence of suspected recurrent thyroid cancer based on
elevated thyroglobulin levels.
4.10 For patients with medullary thyroid cancer who have elevated or rising calcitonin
levels, ultrasound and/or PET-CT scanning and FNA are considered.
4.11 Computed tomography scanning is considered as an adjunct to restaging
patients with recurrent thyroid cancer and assessing potential metastatic
disease.
4.12 Clinicians consider performing CT scans without iodinated contrast, because
of the risk of subsequent impaired uptake of radioiodine.
4.13 Clinicians consider MRI for the purposes of assessing local invasion and local
disease recurrence in selected cases.
Monitoring requirements
16
MR4B
Ensure that radiology departments demonstrate written evidence of
standardised imaging protocols.
MR4C
Audit appropriateness of imaging processes.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Standard 4.3
Thyroid FNA results for patients referred urgently with a high
suspicion of cancer are reported back to the referrer within five
working days.
Standard 4.4
Thyroid FNA specimens are reported using the Bethesda
System for Reporting Thyroid Cytopathology.
Rationale
The use of standardised diagnostic terminology in cytopathology reports facilitates
investigation and management of thyroid nodules in accordance with evidencebased clinical guidelines.
Good practice points
4.14 Suspicious nodules are subjected to FNA without delay, to accurately assess
preoperative cancer risk.
4.15 The preoperative thyroid cytology or core biopsy specimens of patients
referred for thyroid surgery from an outside institution are reviewed by a
pathologist affiliated with the centre at which the surgery will be performed.
Monitoring requirements
MR4D
Audit cytology and histology diagnosis correlation using data from the proposed
national database for thyroid cancer.
MR4E
Audit timeframes for FNA reports.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
17
Standard 4.5
The histology of excised thyroid cancer specimens is recorded
in a synoptic format.
Rationale
Treatment decisions require a minimum data set of diagnostic and prognostic
features relevant to the tumour being treated. Synoptic reporting facilitates concise
and complete recording of this information. Minimum data sets should include:

cancer type

maximum diameter

differentiation/grade

margins

capsular invasion

vascular invasion

extrathyroidal invasion

nodal information (count, level, extracapsular spread)

TNM staging.
Good practice points
4.16 Pathology reporting of thyroid cancer resection specimens follows an agreed
proforma chosen by or developed in consultation with an endocrine or head
and neck cancer MDT. The Thyroid Cancer Histopathology Reporting
Proforma of the Royal College of Pathologists of Australasia is an example
(RCPA 2011).
4.17 Resected specimens containing thyroid cancer likely to require further surgery,
adjuvant radioiodine treatment or external beam radiotherapy are reviewed by
a pathologist with experience in thyroid cytology who is a member of an
endocrine or head and neck cancer MDT.
Monitoring requirements
MR4F
18
Audit pathology departments’ registers of synoptic reports.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Standard 4.6
Relevant histology and cytology specimens of thyroid cancers
discussed at regional MDMs are reviewed by a pathologist with
a subspecialty interest in thyroid cancer.
Rationale
Thyroid cancer can present diagnostic discrepancies because of the diverse range
of cancers that present in this region, many of which are relatively uncommon or
have prognostically important, variant subtypes.
Good practice points
4.18 Where there is major discordance between a reporting and a reviewing
pathologist, the difference in opinion is discussed. If the disagreement cannot
be resolved, an independent national or international expert opinion is sought
before treatment is commenced.
Monitoring requirements
MR4G
Audit MDMs’ records of pathology reviews.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
19
Standard 4.7
Patients with thyroid cancer are staged according to the AJCC’s
TNM staging classification.
Rationale
Staging at diagnosis predicts survival rates and guides appropriate management of
patients with thyroid cancer.
Good practice points
4.19 All patients undergo clinical review and staging at an MDM.
4.20 Staging is based on a combination of clinical findings, imaging findings and
pathology results.
Monitoring requirements
MR4H
20
Audit MDMs’ records of patient staging.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
5
Multidisciplinary Care
Standard 5.1
Patients with the following are discussed at an MDM:

differentiated thyroid cancer greater than a micro carcinoma
(>1 cm in diameter) or any size cancer with adverse histology
(eg, medullary, anaplastic)

a preoperative diagnosis of thyroid cancer with suspicion of
extrathyroidal invasion or lymphadenopathy

recurrent thyroid cancer

metastatic thyroid cancer.
Rationale
International evidence shows that multidisciplinary care is a key aspect to providing
best-practice treatment and care for patients with cancer. Multidisciplinary care
involves a team approach to treatment planning and care provision along the
complete patient cancer pathway.
Cancer MDMs are part of the philosophy of multidisciplinary care. Effective MDMs
result in positive outcomes for patients receiving the care, for health professionals
involved in providing the care and for health services overall. Benefits include
improved treatment planning, improved equity of patient outcomes, more patients
being offered the opportunity to enter into relevant clinical trials, improved continuity
of care and less service duplication, improved coordination of services, improved
communication between care providers and more efficient use of time and
resources.
Evidence from large randomised controlled trials to support particular methods of
patient management for thyroid cancer is lacking, partly because of the relative rarity
of thyroid cancers. However, there is clear support for a team approach.
Patients with recurrent/metastatic thyroid cancer can be complex to manage, and
may require input from a variety of health professionals.
Good practice points
5.1
Most patients with thyroid cancer are discussed at an MDM.
5.2
One clearly identified lead clinician is responsible for coordinating patient care.
5.3
The core membership of a thyroid MDM includes:

an endocrinologist

a thyroid surgeon

a radiologist
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
21
5.4

specialist pathologists (histopathology and cytopathology)

a clinical nurse specialist or team care coordinator/data clerk

at least one team member trained and licensed to give radioactive iodine (a
nuclear medicine physician, a radiation oncologist or a radiologist).
The MDT has contact with and appropriate access to the following support
services:

FNA cytology

flexible laryngoscopy

radiation oncology

medical oncology

clinical genetics

clinical biochemistry

adolescent and young adult services

psychology/social work.
5.5
Smaller provincial MDTs or treating clinicians from smaller centres aim to
present patients to their regional MDT in person, via teleconferencing or via
email discussion (ie, to attend a ‘virtual MDM’).
5.6
Meeting frequency is dictated by patient numbers.
5.7
The multidisciplinary discussion report includes treatment recommendations
and intent where possible, as well as reasons for any variation from standard
practice.
5.8
Treating clinicians record reasons for not following treatment plans
recommended by the MDM.
5.9
Patients and their GPs are informed of the MDM’s recommendations within
seven days of the meeting.
5.10 Recommendations of the MDM are available as an electronic record, and
accessible to other members of the health care team.
5.11 The MDT records information in a database that can be collated and analysed
locally, regionally and nationally.
5.12 An electronic MDM reporting system is developed and available online, for
uniform recording of information at a national level.
5.13 In order to meet Māori needs and reduce inequalities, cancer care services
are focused on Māori priorities. This may involve the reorientation of existing
services or the development of new services or initiatives. Some specific
areas of good practice include:
22
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional

involving Māori expertise and the range of relevant Māori services and
providers in MDTs and networks

prioritising Māori in the piloting of developments or initiatives in service
delivery

developing tools (such as Whānau Ora assessments) to meet the needs of
Māori, which can be used to inform patient treatment plans and care
coordination

involving Māori patients and their family/whānau in MDMs to discuss
treatment options and plans

offering all Māori patients and their family/whānau access to Whānau Ora
assessments and cultural support services.
Monitoring requirements
MR5A
Audit MDM documentation, including records of meeting dates and times (actual
or virtual), patients discussed and names of involved MDT members.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
23
6
Supportive Care
Standard 6.1
Patients with thyroid cancer and their family/whānau have
equitable and coordinated access to appropriate medical, allied
health and supportive care services, in accordance with
Guidance for Improving Supportive Care for Adults with Cancer
in New Zealand (Ministry of Health 2010b).
Rationale
The psychological, social, physical and spiritual needs of cancer patients are many
and varied. These needs can to a large extent be met by allied health care teams in
hospitals and in the community. Adults with cancer enjoy improved quality of life
following needs assessment and provision of supportive care.
Non-government organisations, including the Cancer Society, perform an important
role in providing supportive care.
Good practice points
24
6.1
Patients undergo regular assessment of their supportive care and
psychosocial needs.
6.2
A structured referral pathway is in place based on sources and degrees of
distress, so that patients can quickly be referred to appropriate services.
6.3
All patients have access to a social worker.
6.4
A clearly recorded discussion of preferred priorities of care (advance care
directives and planning) takes place when it becomes clear that cure is not
possible. Wherever possible, this is not left until the terminal stages of the
illness.
6.5
All nursing staff working with thyroid cancer patients receive clinical training in
monitoring thyroid cancer patients before and after surgery and, where
relevant, the appropriate and safe care of patients receiving radioiodine
therapy.
6.6
Nurses working in outpatient clinics have skills relating to the ongoing care of
thyroid cancer patients, including those who have had radiation therapy or
radioiodine treatment.
6.7
Patients who travel long distances to regional treatment services have access
to information on the Ministry of Health’s National Travel Assistance Scheme
(Ministry of Health 2006).
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Monitoring requirements
MR6A
Provide evidence of culturally appropriate patient and family/whānau satisfaction
surveys, and audit complaints processes.
MR6B
Collect and analyse ethnicity data on all treatment, timeliness and access
targets and indicators.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
25
7
Care Coordination
Standard 7.1
Patients with thyroid cancer have access to a clinical nurse
specialist or other health professional who is a member of the
MDT to help coordinate all aspects of their care.
Rationale
The management of cancer is complex, and it is not uncommon for a patient to be
seen by a number of specialists within and across multiple DHBs and across the
public and private sectors. A patient’s quality of life is improved when a dedicated
cancer care coordinator facilitates their access to services.
‘Care coordination’ refers to a system or a role primarily intended to expedite patient
access to services and resources, improve communication and the transfer of
information between services, address patients’ information needs and improve
continuity of care throughout the cancer continuum.
Patients and caregivers should be able to access care coordination through a single
point of contact through the various stages of the thyroid cancer journey.
Good practice points
26
7.1
Regional cancer centres employ a dedicated thyroid cancer contact person to
support patients’ access to psychosocial support and information and
coordinate their cancer journeys.
7.2
Patients are provided with their care coordinator’s name and contact details,
and the initial contact between patient and care coordinator is made within
seven days of the initial diagnosis becoming known to the patient.
7.3
Patients are kept informed, in a manner appropriate to their individual needs,
about the processes involved in the diagnosis, treatment and management of
their cancer.
7.4
Cancer-related information is free and easily accessible to the patient, their
family/whānau and the public. Such information meets the needs of diverse
audiences, is written in everyday language, is accurate and unbiased, and is
based on the best available evidence.
7.5
Māori patients and their family/whānau are offered access to Whānau Ora
assessments and cultural support services.
7.6
Patients with English as a second language have access to an interpreter.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Monitoring requirements
MR7A
Ensure that MDMs record identified care coordinators.
MR7B
Provide evidence of culturally appropriate patient and family/whānau satisfaction
surveys, and audit complaints processes.
MR7C
Collect and analyse ethnicity data on all treatment, timeliness and access
targets and indicators.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
27
8
Treatment
Standard 8.1
Thyroid surgery is performed by a surgeon who has undertaken
subspecialty training that includes thyroid surgery.
Rationale
Thyroid surgery is a highly specialised field; the best patient outcomes in terms of
morbidity and low recurrence rates are achieved by surgeons who have undergone
extra training and who regularly perform procedures.
Good practice points
8.1
Individual surgical departments identify the surgeons who will undertake
thyroid surgery, and audit their results.
8.2
In centres where case volumes are low, surgeons are encouraged to visit
major centres, to maintain the required skill set.
8.3
Referral to a surgeon with a high case load is encouraged in complex cases,
such as the presence of involved central and regional nodes, extrathyroidal
extension and recurrent laryngeal nerve involvement.
8.4
Surgeons consult with all patients undergoing surgery for cancer and their
family/whānau about final disposal of tissue or body parts surgically removed.
8.5
Patients, particularly Māori and Pacific patients, are given the option of
retaining tissue postoperatively.
Monitoring requirements
MR8A
28
Surgical departments provide documentation on surgeons who are credentialed
for thyroid surgery.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Standard 8.2
Surgical morbidity and mortality are presented at regular audit
meetings.
Rationale
As mortality for thyroid cancer is low and stable, and the incidence of thyroid cancer
is increasing, the emphasis is currently on reducing treatment morbidity.
Regular audit improves performance. Identification of a higher than expected
morbidity rate affords the opportunity for retraining, or redistribution of the thyroid
surgery workload.
Good practice points
8.6
Thyroid function and a baseline serum calcium are measured prior to
thyroidectomy.
8.7
Evaluation of vocal cord mobility is undertaken before and after thyroid
surgery.
8.8
For patients with medullary thyroid cancer, phaeochromocytoma is excluded,
plasma calcitonin is measured and RET proto-oncogene mutation screening is
considered prior to surgery.
Monitoring requirements
MR8B
Audit records of morbidity and mortality meetings.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
29
Standard 8.3
Patients with differentiated thyroid cancer are considered for
radioactive iodine after surgery following internationally
published guidelines.
Rationale
Radioactive iodine has been shown to reduce recurrence rates for patients with
differentiated thyroid cancer, although low-risk patients may not benefit.
Good practice points
8.9
Patients with differentiated thyroid cancer are seen by a specialist with
experience in the use of I131 who is familiar with published international
guidelines on I131 administration.
8.10 I131 is only given by an appropriately licensed medical practitioner.
8.11 Clear written radiation precautions are in place for administration of I131 to
inpatients; this is supervised by an appropriately trained and licensed
practitioner, in conjunction with a physicist.
8.12 Patients receiving I131 give appropriate informed written consent prior to the
dose being administered. The consent process includes the provision of
written information about the treatment and side-effects, as well as the
immediate post-I131 radiation precautions to be taken.
8.13 For female patients of childbearing age, pregnancy is excluded prior to I 131
administration.
8.14 Breastfeeding patients stop breastfeeding four to eight weeks before therapy,
and do not resume after therapy. Patients are advised to avoid pregnancy for
six months after I131 administration.
8.15 The timing of I131 administration is carefully planned with each patient. For
some patients it can be given as early as three weeks post-operatively; for
others it may be delayed for many months.
8.16 Clinicians follow international guidelines in determining the timing of
withdrawal of thyroxine (or administration of recombinant TSH) before I131 is
given, the dose of I131 used, the need for and timing of blood tests for TSH,
thyroglobulin and thyroid antibodies (and urine iodine), the indication for and
type of pre- and post-I131 scans, and the timing of post-dose thyroxine
recommencement.
8.17 The need for complex scheduling for patients is acknowledged, and clear
internal arrangements are in place to ensure that patients progress through
the I131 schedule correctly.
8.18 A clear plan for specialist follow-up for patients receiving I131 is developed in
accordance with international guidelines.
30
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Monitoring requirements
MR8C
Audit records of the provision of written I131 precautions advice to patients before
treatment.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
31
Standard 8.4
External beam radiotherapy is considered for patients at high
risk of local recurrence.
Rationale
The aim of external beam radiotherapy is to improve local control of the cancer.
Good practice points
8.19 Adjuvant radiotherapy is considered where there is gross residual tumour,
where visible extra-thyroid extension is seen at surgery or where there is a
high likelihood of microscopic residual disease.
8.20 Radiotherapy is considered as part of the primary treatment for unresectable
tumours, with or without adjuvant radioiodine treatment.
8.21 If intensity modulated radiotherapy is used, every radiotherapy plan is
subjected to robust quality assurance plan verification.
8.22 Treating oncologists aspire to treat patients with the best available techniques,
taking into account potential impacts on departmental treatment resources.
8.23 Periodic (preferably daily) verification of patient positioning and treatment
volumes is undertaken, to detect and correct for any change in patient position
and tumour size/position.
Monitoring requirements
MR8D
32
Audit records of radiotherapy departments’ written treatment protocols.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Standard 8.5
Patients with advanced thyroid cancer have access to
appropriate medical oncology specialist care for consideration of
evolving chemotherapies.
Rationale
New systemic medical therapies (such as tyrosine kinase inhibitors) that molecularly
target thyroid cancer that no longer responds to radioactive iodine are under
development. To ensure optimal outcomes for patients, providers need to facilitate
access to such treatments as their worth is proven and they become generally
available.
Good practice points
8.24 Patients with advanced metastatic thyroid cancer are referred to appropriate
medical oncologists for consideration of their eligibility for new therapies.
Monitoring requirements
MR8E
Record the number of patients referred for tyrosine kinase inhibitor therapy and
other evolving chemotherapies.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
33
Standard 8.6
Patients are offered access to palliative care services when
there are complex symptom control issues, when curative
treatment cannot be offered, or if curative treatment is declined.
Rationale
A diagnosis of cancer and its subsequent treatment can have a devastating impact
on the quality of a person’s life, as well as on the lives of families/whānau and other
carers. Patients may face new fears and uncertainties, and may have to undergo
unpleasant and debilitating treatments. Patients should expect to be offered optimal
symptom control and psychological, cultural, social and spiritual support. They may
want to be assured that their families/whānau and carers will receive support during
illness and, if they die, following bereavement.
Palliative care is the care of people who are dying from active, progressive diseases
or other conditions that are not responsive to curative treatment. Palliative care
embraces the physical, social, emotional and spiritual elements of wellbeing –
tinana, whānau, hinengaro and wairua – and enhances a person’s quality of life
while they are dying. Palliative care also supports the bereaved family/whānau
(Ministry of Health 2001).
The objective of palliative care is to alleviate suffering and provide compassionate
care for the patient and their family/whānau. Competence in palliative medicine and
sensitivity to people’s beliefs and values are two key prerequisites for a provider of
palliative care. Clinicians should form a care plan for palliative patients with a view to
ensuring that pain and other potentially distressing symptoms are relieved, dignity is
preserved and there is engagement with family/whānau (Ministry of Health 2001).
Good practice points
8.25 Screening for palliative care needs, comprehensive assessment and care
planning are undertaken at appropriate intervals to meet the needs and
wishes of the patient and their family/whānau.
8.26 Access to palliative care, decision-making and care planning are based on a
respect for the uniqueness of the patient and their family/whānau, independent
of their current health status, diagnosis, age, gender, cultural background or
geography.
8.27 Provider organisations ensure that patients and their family/whānau have easy
access to a range of free, culturally and educationally appropriate, high-quality
information materials about cancer and palliative care services in a variety of
formats.
8.28 Patients and their families/whānau are offered palliative care options and
information in plain language that is targeted to their particular needs; this is
incorporated into care plans.
34
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
8.29 Practitioners recognise dying patients in a timely manner, and discuss
advance care planning and end-of-life goals of care with patients and their
family/whānau, using end-of-life care pathways.
Monitoring requirements
MR8F
Audit proposed plans of care, onward referrals and follow-up responsibilities
recorded at MDM reviews and in patients’ notes.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
35
9
Follow-up and Surveillance
Standard 9.1
Follow-up plans include clinical review by appropriate members
of the MDT, working in conjunction with the patient, their
family/whānau and their GP.
Rationale
While the majority of differentiated thyroid cancer (DTC) recurrences occur within
five years, late recurrences up to 20 years after initial treatment are encountered.
The majority of DTC patients (~80%) may be classified as low risk after the initial
treatment phase (this classification applies to patients for whom disease has been
excised, for whom radioiodine ablation has been completed, and who have received
a negative result for thyroglobulin and/or a clear post-radioactive iodine whole body
scan at 6–12 months after treatment).
Low-risk patients have an expected survival close to that of age-matched control
groups. Those with persistent disease have a lower but variable survival rate,
dependent on tumour and clinical features. Follow-up will usually include a
combination of clinical evaluation, thyroglobulin monitoring, ultrasound and I131
whole-body scanning. Patients should also receive appropriate TSH suppression.
Good practice points
36
9.1
Follow-up plans are formulated according to a national follow-up programme,
and follow nationally agreed guidelines (under development).
9.2
Long-term plans are developed for patients with DTC following international
guidelines, and are supervised by an appropriate member of the MDT
(surgeon, endocrinologist or oncologist).
9.3
Special subgroups of patients with thyroid cancer (eg, those with medullary
thyroid cancer or lymphoma) will require a different follow-up pathway.
9.4
Patients with persistent post-operative voice change are referred to an
appropriate ear nose and throat specialist.
9.5
Post-operative hypoparathyroidism is appropriately managed to determine if it
is permanent. Care is taken to avoid complications of long-term treatment.
9.6
Thyroid stimulating hormone suppression is managed according to the risk
status of the patient, and is reviewed over time.
9.7
Thyroglobulin (Tg) measurements are taken while a patient is on TSH
suppression every 6–12 months, and in combination with measurement of Tg
antibodies (since the presence of these antibodies can give a false Tg result).
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
9.8
Rising Tg levels over time suggest cancer recurrence; in such cases, a neck
ultrasound and a radioactive iodine whole-body scan are considered.
9.9
Local recurrence is surgically excised if possible.
9.10 Distant metastases are managed by an MDT; treatment modalities including
radioactive iodine, radiotherapy, surgery, systemic therapy and biologic agents
are considered.
9.11 Discharge to primary care for low-risk disease-free patients is considered after
five years, along with a plan for ongoing monitoring of Tg and neck evaluation.
9.12 Clinicians consider offering extra support or counselling to patients with thyroid
cancer in their childbearing years.
9.13 Patients treated for medullary thyroid cancer receive intermittent monitoring of
plasma calcitonin and carcinoembryonic antigen levels. There is no role for
TSH suppression in these cases.
9.14 Cancer services develop and implement DNA reduction strategies that
particularly focus on reducing inequalities for Māori.
Monitoring requirements
MR9A
Audit follow-up protocols, including with regards to patient, family/whānau and
GP access.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
37
10 Clinical Performance Monitoring and Research
Standard 10.1
Data relating to thyroid cancer beyond the fields required by the
Cancer Registry, including treatment data, are reported to
existing and planned national repositories.
Rationale
The aim of this standard is to construct a database for thyroid cancer to integrate
demographic, diagnostic, treatment, outcome, genetic and other relevant information
to contribute to service and clinical performance monitoring and research to improve
patient outcomes.
Data of newly diagnosed thyroid cancer cases and deaths due to thyroid cancer are
currently collected by the New Zealand Cancer Registry. However, mandatory data
collection is currently limited to demographics, histopathology, and histopathological
staging. Hospital discharge data is collected by the National Minimum Dataset, and
mortality data are obtained through death certificates.
Thyroid cancer data beyond the fields required by the Cancer Registry, including
treatment data, should be reported to existing or planned future national repositories
rather than to stand-alone regional or national thyroid cancer-specific databases.
The National Thyroid Tumour Standards Working Group is developing a data set for
information required for MDT discussion, and a second minimal data set that can be
used for service and clinical monitoring. This will allow future local, regional and
national collation and analysis of thyroid cancer data, and provide useful and
accurate statistical data on the incidence and outcomes of patients with thyroid
cancer in New Zealand.
Prospective data collection will encourage clinicians involved with thyroid cancer to
remain actively engaged with data collection, and encourage audit of individual,
institutional and regional outcomes compared to national data. This will allow early
identification and intervention for any apparent substandard outcomes for patients
treated for thyroid cancer.
Good practice points
10.1 Patients are informed that their information is being recorded to help the MDT
propose a treatment plan and to monitor and evaluate access to services.
10.2 Data are collected in accordance with the National Cancer Core Data
Definitions Interim Standards (IT Health Board 2011).
10.3 Clinical information on patients with thyroid cancer is collected systematically
using a generic thyroid cancer MDM proforma, to integrate relevant clinical
information with the currently collected Cancer Registry data.
38
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
10.4 Clinicians have ready access to other specialties’ ‘stand-alone’ records, to
allow better and more efficient patient management.
10.5 Collected information is integrated with the Cancer Registry database.
10.6 Individual MDTs are responsible for collecting and forwarding information
relating to patients with thyroid cancer.
10.7 Regional thyroid cancer centres employ a data manager.
10.8 Collect local data in addition to the minimum data set, as for the national
thyroid cancer database.
10.9 Share regional data of interest at forums such as national, Australasian and
international clinical meetings.
Monitoring requirements
MR10A
Audit the completeness and accuracy of data supplied to the Cancer Registry.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
39
Standard 10.2
Patients with thyroid cancer are offered the opportunity to
participate in appropriate research projects and clinical trials
where these are available.
Rationale
The outcomes of research are diverse, and can include survival benefits for patients
through more effective early diagnosis and management and improved coordination
of post-intervention services to reduce or manage morbidity. The availability of data
is currently poor due to the lack of robust audit procedures and low rate of
recruitment into clinical trials.
One of the key findings of Access to Cancer Services for Māori (Ministry of Health 2005)
was the lack of information on cancer services specifically produced for Māori, including
discussion of interventions. Several areas arise as priorities for further research.
Good practice points
10.10 All referrals to an MDM are entered into a national database, to maximise the
chance of use of information for clinical research. Analysis of this data set is
undertaken annually.
10.11 Collected data include details of intervention and post-intervention treatment
and management.
10.12 Employing organisations value and facilitate the participation of clinicians in
research and audit, and demonstrate this by allocating time, administrative
support and access to research teams.
10.13 Research with Māori cancer patients, their family/whānau and their
communities is prioritised.
10.14 The role of Māori patient advocates or navigators and other interventions is
investigated, to enhance the patient journey for Māori patients and their
family/whānau.
10.15 Māori perspectives of barriers and facilitators to access of cancer services
are explored, along with preferences and priorities for interventions to
address access issues.
10.16 The role of differential access to timely and appropriate cancer services in
inequalities in cancer outcome between Māori and non-Māori is considered.
Monitoring requirements
MR10B
40
Provide records of the number and proportion of patients offered entry into
research projects each year, and of those patients who are actually recruited.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Appendix 1:
National Thyroid Cancer Tumour Standards
Working Group Membership
Chair
Associate Prof Geoff Braatvedt, Endocrinologist, University of Auckland/Auckland
DHB
Members
Mr Richard Harman (deputy chair), Consultant Surgical Oncologist, Waitemata DHB
Mr Robert Allison, Consultant Otolaryngologist/Head and Neck Surgeon, Canterbury
DHB
Dr Mark Bolland, Consultant Endocrinologist, Counties Manukau DHB/University of
Auckland
Dr Penny Hunt, Consultant Endocrinologist, Canterbury DHB/University of Otago
Mr Nick McIvor, Head and Neck Surgeon, Auckland DHB
Mr Win Meyer-Rochow, Consultant Endocrine Surgeon, Waikato DHB
Dr Nichola Naidoo, Consultant Radiation Oncologist, Capital & Coast DHB
Dr Hament Pandya, Consultant Radiologist, Waitemata DHB
Dr Lisa Sweetman, Consultant Radiologist, Capital & Coast DHB
Dr Simon Young, Consultant Endocrinologist, Waitemata DHB
Ex officio members
Emma Maddren, Project Manager, Northern Cancer Network
Deirdre Maxwell, Network Manager, Northern Cancer Network
Dr Richard Sullivan, Network Clinical Director, Northern Cancer Network
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
41
Appendix 2:
Glossary
42
Adjuvant therapy
Additional treatment to increase the effectiveness of the main
treatment (often surgery), such as chemotherapy, systemic
therapy or radiotherapy
Advance care
planning
A process of discussion and shared planning for future health care
Allied health
professional
One of the following groups of health care workers:
physiotherapists, occupational therapists, dietitians, paramedics,
prosthetists/orthotists, speech-language therapists, psychologists
and social workers
Asymptomatic
Without obvious signs or symptoms of disease. In early stages,
cancer may develop and grow without producing symptoms
Best practice
A method or approach that is accepted by consensus to be the
most effective way of doing something, in the circumstances; may
or may not be based on evidence
Biopsy
Removal of a sample of tissue or cells from the body to assist in
the diagnosis of a disease
Cancer journey
The individual and personal experience of a person with cancer
throughout the course of their illness
Cancer Networks
Cancer Networks were formed in response to national policy to
drive change and improve cancer services for the population in
specific areas. There are four regional networks: Northern,
Midland, Central and Southern
Cancer service
pathway
The cumulative cancer-specific services that a person with cancer
uses during the course of their experience with cancer
Carcinoma
Cancer of the lining tissue that covers all the body organs. Most
cancers are carcinomas
Care coordination
Entails the organising and planning of cancer care, who patients
and family/whānau see, when they see them and how this can be
made as easy as possible. It may also include identifying who
patients and family/whānau need to help them on the cancer
pathway
Chemotherapy
The use of drugs that kill cancer cells, or prevent or slow their
growth (also see systemic therapy)
Clinical trial
An experiment for a new treatment
Computed
tomography (CT)
A medical imaging technique using X-rays to create crosssectional slices through the body part being examined
Confirmed diagnosis
(used in FCT
indicators)
The preferred basis of a confirmed cancer diagnosis is
pathological, noting that for a small number of patients cancer
diagnosis will be based on diagnostic imaging findings
Curative
Aiming to cure a disease
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Cutaneous
Skin
Decision to treat
(used in FCT
indicators)
A decision to begin a patient’s treatment plan or other
management plan, following discussion between the patient and
treating clinician
DHB
District Health Board
Excision
The removal of tissue by surgery
Family/whānau
Can include extended family/whānau, partners, friends, advocates,
guardians and other representatives
Faster cancer
treatment (FCT)
A Ministry of Health programme that will improve services by
standardising care pathways and timeliness of services for cancer
patients throughout New Zealand
Faster Cancer
Treatment indicators
Measures of cancer care collected through DHB reporting of
timeframes within which patients with a high suspicion of cancer
access services. The indicators are internationally established and
provide goals for DHBs to achieve over time
Fine needle aspiration
cytology (FNA)
The use of a fine needle to biopsy a tumour or lymph node to
obtain cells for cytological confirmation of diagnosis
First specialist
assessment (FSA)
Face-to-face client contact (including telemedicine) between a
patient and a registered medical practitioner or nurse practitioner
for the purposes of first assessment for their condition for that
specialty
First treatment (used
in FCT indicators)
The treatment or other management that attempts to begin the
patient’s treatment, including palliative care
GP
General practitioner
Health equality/equity
Absence of unnecessary, avoidable and unjust differences in
health (Ministry of Health 2002)
Health
inequality/inequity
Differences in health that are unnecessary, avoidable or unjust
(Ministry of Health 2002)
High suspicion of
cancer (used in FCT
indictors)
Where a patient presents with clinical features typical of cancer, or
has less typical signs and symptoms but the clinician suspects that
there is a high probability of cancer
Histological
Relating to the study of cells and tissue on the microscopic level
Intensity modulated
radiation therapy
The attempt to optimise dose distribution during external beam
radiotherapy delivery. Each radiation field is divided into small
segments with varying radiation intensity, defining target shape,
location and the geometry of overlaying tissues. Intensity
modulated radiation therapy fields are typically designed using
computer-driven (or -aided) optimisation. This is often referred to
as ‘inverse treatment planning’
Local recurrence
Local persistence of a primary tumour due to incomplete excision
Lymphadenopathy
Disease or swelling of the lymph nodes
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
43
44
Magnetic resonance
imaging (MRI)
A non-invasive method of imaging, which allows the form and
metabolism of tissues and organs to be visualised (also known as
nuclear magnetic resonance)
Margin
The edge or border of tissue removed in cancer surgery
Medical oncologist
A doctor who treats cancer patients through the use of
chemotherapy and, for some tumours, immunotherapy
Medical oncology
The specialist treatment of cancer patients through the use of
chemotherapy and, for some tumours, immunotherapy
Metastases
Cancerous tumours in any part of the body that have spread from
the original (primary) origin. Also known as ‘secondaries’
Metastatic disease
A disease that has spread from the organ or tissue of origin to
another part of the body
Morbidity
The state of being diseased
Mortality
Either (a) the condition of being subject to death or (b) the death
rate, which reflects the number of deaths per unit of population in
any specific region, age group, disease or other classification,
usually expressed as deaths per 1000, 10,000 or 100,000
Multidisciplinary
meeting (MDM)
A deliberate, regular, face-to-face meeting (which may be through
videoconference) to facilitate prospective multidisciplinary
discussion of options for patients’ treatment and care by a range of
health professionals who are experts in different specialties.
‘Prospective’ treatment and care planning makes
recommendations in real time, with an initial focus on the patient’s
primary treatment. Multidisciplinary meetings entail a holistic
approach to the treatment and care of patients
Multidisciplinary team
(MDT)
A group of specialists in a given disease area. The MDT meets
regularly to plan aspects of patient treatment. Individual patient
cases might be discussed at an MDM, to best plan approach to
treatments
National Health Index
(NHI) number
A unique identifier for New Zealand health care users
Oncology
The study of the biological, physical and chemical features of
cancers, and of the causes and treatment of cancers
Palliative
Anything that serves to alleviate symptoms due to an underlying
cancer but is not expected to cure it
Palliative care
Active, holistic care of patients with advanced, progressive illness
that may no longer be curable. The aim is to achieve the best
quality of life for patients and their families/whānau. Many aspects
of palliative care are also applicable in earlier stages of the cancer
journey in association with other treatments
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Pathologist
A doctor who examines cells and identifies them. The pathologist
can tell where a cell comes from in the body and whether it is
normal or a cancer cell. If it is a cancer cell, the pathologist can
often tell what type of body cell the cancer developed from. In a
hospital practically all the diagnostic tests performed with material
removed from the body are evaluated or performed by a
pathologist
Pathology
A branch of medicine concerned with disease; especially its
structure and its functional effects on the body
Patient pathway
The individual and personal experience of a person with cancer
throughout the course of their illness; the patient journey
Positron emission
tomography (PET)
A highly specialised imaging technique using a radioactive tracer
to produce a computerised image of body tissues to find any
abnormalities. PET scans are sometimes used to help diagnose
cancer and investigate a tumour’s response to treatment
Positron emission
tomography and
computed
tomography (PET-CT)
An advanced imaging technique combining an injected material
(18 Fluorine) which is taken up by cancer cells and a CT scan
Primary care
Primary-level health services provided by a range of health
workers, including GPs and nurses
Prognosis
A prediction of the likely outcome or course of disease; the chance
of recovery or recurrence
Quality assurance
All the planned and systematic activities implemented within the
quality system, and demonstrated as needed
Radiologist
A doctor who specialises in creating and interpreting pictures of
areas inside the body using X-rays and other specialised imaging
techniques. An interventional radiologist specialises in the use of
imaging techniques for treatment; for example catheter insertion
for abscess drainage
Radiology
The use of radiation (such as X-rays, ultrasound and magnetic
resonance) to create images of the body for diagnosis
Radiotherapy
(radiation treatment)
The use of ionising radiation, usually X-rays or gamma rays, to kill
cancer cells and treat tumours
Randomised
controlled trial
A study in which people are allocated by chance alone to receive
one of several interventions, one of which is the standard of
comparison
Recurrence
The return, reappearance or metastasis of cancer (of the same
histology) after a disease free period
Referred urgently
(used in FCT
indicators)
Describes urgent referral of a patient to a specialist because he or
she presents with clinical features indicating high suspicion of
cancer
Resection
Removal of tissue from the body by surgery
Stage
The extent of a cancer; especially whether the disease has spread
from the original site to other parts of the body
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
45
46
Staging
Usually refers to the Tumour, node, metastasis system for grading
tumours by the American Joint Committee on Cancer
Supportive care
Supportive care helps a patient and their family/whānau to cope
with their condition and treatment – from pre-diagnosis through the
process of diagnosis and treatment to cure, continuing illness or
death, and into bereavement. It helps the patient to maximise the
benefits of treatment and to live as well as possible with the effects
of their disease
Synoptic report
A standardised proforma for reporting of cancer
Systemic therapy
Treatment using substances that travel through the bloodstream,
reaching and affecting cells all over the body
Tertiary
Third level. Relating to medical treatment provided at a specialist
institution
Tumour, node,
metastasis (TNM)
A staging system that describes the extent of cancer, developed
by the American Joint Committee on Cancer
Ultrasound
A non-invasive technique using ultrasound waves (high-frequency
vibrations beyond the range of audible sound) to form an image
Unresectable
Unable to be removed by surgery
Whānau
Māori term for a person’s immediate family or extended family
group. In the modern context, sometimes used to include people
without kinship ties
Whānau Ora
An inclusive interagency approach to providing health and social
services to build the capacity of New Zealand families. It
empowers family/whānau as a whole, rather than focusing
separately on individual family members
X-ray
A photographic or digital image of the internal organs or bones
produced by the use of ionising radiation
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Appendix 3:
References
Development of the thyroid cancer standards was informed by key national and
international documents. Those documents that most directly influenced the
development of the standards are listed below:
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, et al. 2009. Revised American Thyroid Association management
guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):
1167–214.
British Thyroid Association, Royal College of Physicians. 2007. Guidelines for the
Management of Thyroid Cancer (2nd edition). London: British Thyroid Association, Royal
College of Physicians.
Ministry of Health. 2011. Targeting Shorter Waits for Cancer Treatment. Wellington: Ministry
of Health.
National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung
Cancer Patients in New Zealand. Wellington: Ministry of Health.
NCCN. 2012. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) – Thyroid
Carcinoma (version 3). Fort Washington: National Comprehensive Cancer Network (member
access only).
NHS Wales. 2005. National Standards for Thyroid Cancer Services. Cardiff: NHS Wales.
Introduction
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, et al. 2009. Revised American Thyroid Association management
guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):
1167–1214.
Blakely T, Shaw C, Atkinson J, et al. 2011. Social inequalities or inequities in cancer
incidence? Repeated census-cancer cohort studies, New Zealand, 1981–1986 to
2001–2004. Cancer Causes and Control 22(9): 1307–18.
Chen AY, Jemal A, Ward EM. 2009. Increasing incidence of differentiated thyroid cancer in
the United States 1988–2005. Cancer 115: 3801–7.
Ministry of Health. 2002. Reducing Inequalities in Health. Wellington: Ministry of Health.
Ministry of Health. 2009. Our Oral Health: Key findings of the 2009 New Zealand Oral Health
Survey. Wellington: Ministry Health.
Ministry of Health. 2010a. Cancer Patient Survival Covering the Period 1994–2007.
Wellington: Ministry of Health.
Ministry of Health. 2010c. Tatau Kahukura Māori Health Chart Book 2010 (2nd edition).
Wellington: Ministry of Health.
Ministry of Health. 2010d. Tobacco Use in New Zealand: Key findings from the 2009 New
Zealand Tobacco Use Survey. Wellington: Ministry of Health.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
47
Ministry of Health. 2012a. Cancer: New Registrations and Deaths 2009. Wellington: Ministry
of Health.
Ministry of Health. 2012b. Rauemi Atawhai: A guide to developing health education
resources in New Zealand. Wellington: Ministry of Health.
Prevention and early identification
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, et al. 2009. Revised American Thyroid Association management
guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):
1167–1214.
British Thyroid Association, Royal College of Physicians. 2007. Guidelines for the
Management of Thyroid Cancer (2nd edition). London: British Thyroid Association, Royal
College of Physicians.
Ministry of Health. 2012b. Rauemi Atawhai: A guide to developing health education
resources in New Zealand. Wellington: Ministry of Health.
NCCN. 2012. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) – Thyroid
Carcinoma (version 3). Fort Washington: National Comprehensive Cancer Network (member
access only).
Timely access to services
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, et al. 2009. Revised American Thyroid Association management
guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):
1167–1214.
British Thyroid Association, Royal College of Physicians. 2007. Guidelines for the
Management of Thyroid Cancer (2nd edition). London: British Thyroid Association, Royal
College of Physicians.
Ministry of Health. 2011. Targeting Shorter Waits for Cancer Treatment. Wellington: Ministry
of Health.
National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung
Cancer Patients in New Zealand. Wellington: Ministry of Health.
NHS Wales. 2005. National Standards for Thyroid Cancer Services. Cardiff: NHS Wales.
NZGG. 2009. Suspected Cancer in Primary Care: Guidelines for investigation, referral and
reducing ethnic disparities. Wellington: New Zealand Guidelines Group.
Referral and communication
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. 2009.
Revised American Thyroid Association management guidelines for patients with thyroid
nodules and differentiated thyroid cancer. Thyroid 19(11): 1167–1214.
British Thyroid Association, Royal College of Physicians, Cooper DS, Doherty GM, et al.
2007. Guidelines for the Management of Thyroid Cancer (2nd edition). London: British
Thyroid Association, Royal College of Physicians.
48
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Jameson JL, De Groot LJ. 2010. Endocrinology: Adult and Paediatric (6th edition).
Philadelphia: Elsevier Health Sciences.
NHS Wales. 2005. National Standards for Thyroid Cancer Services. Cardiff: NHS Wales.
Investigation, diagnosis and staging
Ali SZ, Cibas ES (eds). 2010. The Bethesda System for Reporting Thyroid Cytopathology.
Definitions, Criteria and Explanatory Notes. New York: Springer.
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, et al. 2009. Revised American Thyroid Association management
guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):
1167–214.
Baloch ZW, Hendreen S, Gupta PK, et al. 2001. Interinstitutional review of thyroid fineneedle aspirations: impact on clinical management of thyroid nodules. Diagnostic
Cytopathology 25(4): 231–4.
Bongiovanni M, Spitale A, Faquin WC, et al. 2012. The Bethesda System for Reporting
Thyroid Cytopathology: a meta-analysis. Acta Cytologica 56(4): 333–9.
British Thyroid Association, Royal College of Physicians. 2007. Guidelines for the
Management of Thyroid Cancer (2nd edition). London: British Thyroid Association, Royal
College of Physicians.
Crowe A, Linder A, Hameed O, et al. 2011. The impact of implementation of the Bethesda
System for reporting cytopathology on the quality of reporting, ‘risk’ of malignancy, surgical
rate, and rate of frozen sections requested for thyroid lesions. Cancer Cytopathology
119(5): 315–21.
Edge SB, Byrd DR, Compton CC, et al (eds). 2010. AJCC Cancer Staging Manual
(7th edition). New York: Springer.
Ellis DW. 2011. Surgical pathology reporting at the crossroads: beyond synoptic reporting.
Pathology 43(5): 404–40.
Hamady ZZ, Mather N, Lansdown MR, et al. 2005. Surgical pathological second opinion in
thyroid malignancy: impact on patients’ management and prognosis. European Journal of
Surgical Oncology 31: 74–7.
Kahn C, Simonella L, Sywak M, et al. 2012. Postsurgical pathology reporting of thyroid
cancer in New South Wales, Australia. Thyroid 22(6): 604–10.
Kronz JD, Westra WH. 2005. The role of second opinion in the management of lesions of the
head and neck. Current Opinions in Otolaryngology and Head Neck Surgery 13: 81–4.
LiVolsi VA, Baloch ZW. 2012. On pathology reports of thyroid cancer specimens: What
should the clinician expect? Thyroid 22(6): 563–5.
Lueck N, Jensen C, Cohen MB, et al. 2009. Mandatory second opinion in cytopathology.
Cancer Cytopathology 117: 82–91.
NHS Wales. 2005. National Standards for Thyroid Cancer Services. Cardiff: NHS Wales.
RCP and RCR. 2012. Evidence-based Indications for the Use of PET-CT in the United
Kingdom. London: Royal College of Physicians and Royal College of Radiologists.
RCPA. 2011. Thyroid Cancer Histopathology Reporting Proforma. Sydney: Royal College of
Pathologists of Australasia.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
49
RCR. 2006. Recommendations for Cross-Sectional Imaging in Cancer Management.
London: Royal College of Radiologists.
Spanu A, Solinas ME, Chessa F, et al. 2009. 131I SPECT/CT in the follow-up of
differentiated thyroid carcinoma: incremental value versus planar imaging. Journal of Nuclear
Medicine 50(2): 184–90.
Yan YY, Kebebew E, Reiffe E, et al. 2007. Does routine consultation of thyroid fine-needle
aspiration cytology change surgical management? Journal of the American College of
Surgery 205(1): 8–12.
Multidisciplinary care
National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung
Cancer Patients in New Zealand. Wellington: Ministry of Health.
NHS Wales. 2005. National Standards for Thyroid Cancer Services. Cardiff: NHS Wales.
Supportive care
Ministry of Health. 2006. The National Travel Assistance Scheme: Your guide for claiming
travel assistance: brochure. URL: www.health.govt.nz/publication/national-travel-assistancescheme-your-guide-claiming-travel-assistance-brochure (accessed 14 August 2013).
Care coordination
Greenberg A, Angus H, Sullivan T, et al. 2005. Development of a set of strategy-based,
system-level Care Performance Indicators in Ontario, Canada. International Journal of
Quality in Health Care 17: 107–14.
Ministry of Health. 2010b. Guidance for Improving Supportive Care for Adults with Cancer in
New Zealand. Wellington: Ministry of Health.
National Health Priority Action Council. 2006. National Chronic Disease Strategy. Australian
Government Department of Health and Ageing. Canberra: National Health Priority Action
Council.
NICE. 2001. Guidance for Cancer Services: Improving Outcomes for Head and Neck
Cancers – The Manual. London: National Institute for Clinical Excellence.
Northern Cancer Network. 2011. Regional Cancer Care Coordination Model Project.
Auckland: Northern Cancer Network.
Treatment
Brierley J, Sherman E. 2012. The role of external beam radiation and targeted therapy in
thyroid cancer. Seminars in Radiation Oncology 22(3): 254–62.
British Thyroid Association, Royal College of Physicians. 2007. Guidelines for the
Management of Thyroid Cancer (2nd edition). London: British Thyroid Association, Royal
College of Physicians.
Hospice New Zealand. 2012. Standards for Palliative Care: Quality review programme and
guide. Wellington: Hospice New Zealand.
Ministry of Health. 2001. The New Zealand Palliative Care Strategy. Wellington: Ministry of
Health.
50
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
Ministry of Health. (nd). Cancer Data and Stats. URL: www.health.govt.nz/nz-healthstatistics/health-statistics-and-data-sets/cancer-data-and-stats (accessed 31 August 2013).
NCCN. 2012. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) – Palliative
Care. Fort Washington: National Comprehensive Cancer Network (member access only).
NICE. 2004. Improving Supportive and Palliative Care for Adults with Cancer. London:
National Institute for Clinical Excellence.
Palliative Care Australia. 2005. Standards for Providing Quality Palliative Care for all
Australians.
Powell C, Newbold K, et al. 2010. External beam radiotherapy for differentiated thyroid
cancer. Clinical Oncology 22(6): 456–63.
Sawka AM, Thephamongkhol K, Brouwers M, et al. 2004. Clinical review 170: systematic
review and meta analysis of the effectiveness of radioiodine remnant ablation for well
differentiated thyroid cancer. Journal of Clinical Endocrinology and Metabolism 89: 3668–76.
Schlumberger M, Sherman SL. 2009. Clinical trials for progressive differentiated thyroid
cancer: patient selection, study design and recent advances. Thyroid 19: 1393–1400.
Thyroid Carcinoma Task Force. 2001. AACE/AAES Medical/Surgical Guidelines for Clinical
Practice: Management of thyroid carcinoma. Jacksonville: American Association of Clinical
Endocrinologists.
Follow-up and surveillance
ATA Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer,
Cooper DS, Doherty GM, et al. 2009. Revised American Thyroid Association management
guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19(11):
1167–214.
British Thyroid Association, Royal College of Physicians. 2007. Guidelines for the
Management of Thyroid Cancer (2nd edition). London: British Thyroid Association, Royal
College of Physicians.
Jameson JL, De Groot LJ. 2010. Endocrinology: Adult and Paediatric (6th edition).
Philadelphia: Elsevier Health Sciences.
Clinical performance monitoring and research
IT Health Board. 2011. National Cancer Core Data Definitions, Interim Standard, HISO
10038.3. Wellington: IT Health Board.
Ministry of Health. 2012a. Cancer: New Registrations and Deaths 2009. Wellington: Ministry
of Health.
Appendices
Ministry of Health. 2002. Reducing Inequalities in Health. Wellington: Ministry of Health.
Standards of Service Provision for Thyroid Cancer Patients in New Zealand Provisional
51