14. Quality indicators – Thyroid Cancer
Quality indicators are measures that are used to assess the quality of the underlying structures, processes and results. Quality indicators are an important instrument of quality management. The aim of their use is the continuous improvement of care by presenting, critically reflecting on and, if necessary, improving the results of care. This selection of quality indicators was created in accordance with the methodology of the German Guideline Program in Oncology [1341]. A "Quality Indicators Working Group" (Working group QI) was formed for the derivation process. This group created the final set of quality indicators on the basis of the strong recommendations ("shall") of the newly developed guideline on thyroid cancer, as well as the results of the search for existing international quality indicators. The exact procedure and composition of the QI working group are described in the guideline report.
After two online meetings of this working group, the final set of 7 quality indicators (QI) was defined and adopted.
Quality indicators 1, 2, 4 and 5 are to be documented with the oncological basic data set of the cancer registries (as of 10/2023).
Ratio of tumor-infected to examined lymph nodes
Numerator
Patients of the denominator with indication of the ratio "lymph nodes affected by tumor to total lymph nodes examined"
Denominator
All patients with a first diagnosis of thyroid carcinoma with resection and with histopathologically examined lymph nodes
Quality target / reference range
Consensus-based recommendation
strong consensus
Notes
Quality objective:
As often as possible, information on the ratio of "lymph nodes affected by tumors to total lymph nodes examined"
Reference recommendations
The histopathological findings shall report the number of tumor-infected lymph nodes in relation to the total number of lymph nodes examined.
- Consensus
- Strong consensus (100%)
No histological confirmation of anaplastic thyroid carcinoma (ATC) or intrathyroid lymphoma by fine needle biopsy
Numerator
Patients of the denominator with fine needle biopsy
Denominator
All patients with a first diagnosis of anaplastic thyroid carcinoma or intrathyroid lymphoma
Quality target / reference range
Consensus-based recommendation
strong consensus
Notes
Quality objective:
If possible, no histological confirmation of anaplastic thyroid carcinoma or lymphoma by fine-needle biopsy
Reference recommendations
If anaplastic thyroid carcinoma or lymphoma is suspected, a histological confirmation shall be carried out instead of a fine needle biopsy - e.g. by means of a punch biopsy.
- Consensus
- Strong consensus (100%)
Indication of TNM classification, histological type and extranodal tumor growth in the histopathological report
Numerator
Patients of the denominator with all details in the histopathology report: - Staging according to the current TNM classification of the UICC - Classification of the histological types of thyroid carcinoma according to the current WHO classification, if applicable histological subtypes - as far as they are described in the current WHO classification. - Capsular growth of lymph node metastases.
Denominator
All patients with a first diagnosis of thyroid cancer and resection
Quality target / reference range
Consensus-based recommendation
Strong consensus
Notes
Quality objective:
Complete reports with TNM classification, histological subtype and capsule-exceeding growth of lymph node metastases as frequently as possible.
Reference recommendations
The following information shall be provided in the pathological findings of surgical specimens:
- Staging according to the current TNM classification of the UICC.
- Classification of the histological types of thyroid carcinoma according to the current WHO classification, if applicable histological subtypes - insofar as they are described in the current WHO classification.
- Capsular growth of lymph node metastases.
- Consensus
- Strong consensus (100%)
Intraoperative neuromonitoring
Numerator
Patients of the denominator with intraoperative neuromonitoring (IONM)
Denominator
All patients with thyroid cancer and bilateral thyroid surgery
Quality target / reference range
Evidence-based recommendation
GRADE ⊕⊕⊝⊝⊝
Notes
Quality objective:
Intraoperative neuromonitoring as frequently as possible in bilateral thyroid surgery
Reference recommendations
Intraoperative neuromonitoring (IONM) shall be used for bilateral thyroid surgery, preferably in the form of continuous neuromonitoring (CIONM) in the case of special risk constellations.
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- 1a
- Consensus
- Strong consensus (100%)
- References
- [534]
Interdisciplinary recommendation for radioiodine therapy in the tumor board
Numerator
Patients of the denominator with pre-therapeutic presentation in the interdisciplinary tumor conference
Denominator
All patients with thyroid cancer and radioiodine therapy
Quality target / reference range
Consensus-based recommendation
Strong consensus
Notes
Quality objective:
Recommendation for radioiodine therapy based on the clinical and histopathological findings as frequently as possible in the interdisciplinary tumor board
Reference recommendations
The recommendation for radioiodine therapy shall be made on the basis of the clinical and histopathological findings in an interdisciplinary tumor board.
- Consensus
- Strong consensus (100%)
Postoperative calcitonin/CEA level and molecular genetic analysis of RET protooncogene in medullary thyroid carcinoma
Numerator
Patients of the denominator with pTNM and postoperative calcitonin and CEA levels (6-8 weeks after surgery)
Denominator
Patients of the denominator with molecular genetic germline analysis RET protooncogene
Quality target / reference range
Consensus-based recommendation
Strong consensus
Notes
As frequently as possible
- Determination of pTNM, calcitonin and CEA
- Molecular genetic germline analysis RET protooncogene
Reference recommendations
The following findings shall be available for planning risk-adapted postoperative follow-up care of a histologically and immunohistologically confirmed MTC:
- pTNM classification = staging
- postoperative basal Ctn and CEA levels (6-8 weeks after surgery)
- molecular genetic analysis for pathogenic germline variant in the RET protooncogene
- Consensus
- Strong consensus (93,33%)
Molecular pathological examination of the RET gene in sporadic medullary thyroid carcinoma
Numerator
Patients of the denominator with molecular pathological examination of the tumor for somatic variant in the RET gene before system therapy
Denominator
All patients with metastatic sporadic medullary thyroid carcinoma (MTC), N1 and/or M1 and systemic therapy
Notes
Quality objective:
Molecular pathological analysis for the presence of a somatic variant in the RET gene as frequently as possible before starting systemic therapy
Reference recommendations
In patients with metastatic sporadic MTC, a molecular genetic analysis of the tumor for the presence of a somatic variant in the RET gene shall be performed before starting systemic therapy with regard to the use of selective RET inhibitors and vandetanib.
- Consensus
- Strong consensus (100%)
References
[1341] Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF), Entwicklung von leitlinienbasierten Qualitätsindikatoren. Methodenpapier für das Leitlinienprogramm Onkologie, Version 3.0, 2021., https://www.leitlinienprogramm-onkologie.de/methodik/grundlegende-informationen-zur-methodik
[534] Cirocchi, R, Arezzo, A, D'Andrea, V, Abraha, I, Popivanov, GI, Avenia, N, et.al. Intraoperative neuromonitoring versus visual nerve identification for prevention of recurrent laryngeal nerve injury in adults undergoing thyroid surgery., Cochrane Database Syst Rev, 2019. 1 (1)(1): p. CD012483., https://pubmed.ncbi.nlm.nih.gov/30659577/