Real-world performance of the American Thyroid Association Risk estimates in predicting 1-year differentiated thyroid cancer outcomes: a prospective multicenter study of 2000 patients

Background: One of the most widely used risk stratification systems for estimating individual patients' risk of differentiated thyroid cancer (DTC) persistence or recurrence is proposed by the American Thyroid Association (ATA) guidelines. The 2015 revision, that has increased the number of patients considered at low or intermediate risk, has been validated in several retrospective, single referral-center studies. The aims of this study were to evaluate the real-world performance of the 2015 ATA Risk Stratification System in predicting the response to treatment 12 months after the initial treatment and to determine the extent to which this performance is affected by the treatment center in which it is used. Methods: A prospective cohort of DTC patients collected by the Italian Thyroid Cancer Observatory (ITCO) web-based database was analyzed. We reviewed all records present in the database and selected consecutive cases that satisfied inclusion criteria: 1) histological diagnosis of DTC, with the exclusion of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP); 2) complete data of the initial treatment and pathological features; 3) results of 1-year follow-up visit (6-18 months after the initial treatment), including all data needed to classify the estimated response to treatment. Results: The final cohort was composed of 2071 patients from 40 centers. The ATA risk of persistent/recurrent disease was classified as low in 1109 patients (53.6%), intermediate in 796 (38.4%), and high in 166 (8.0%). Structural incomplete responses were documented in only 86 (4.2%) patients: 1.5% in the low-risk, 5.7% in the intermediate-risk, and 14.5% in the high-risk group. The baseline ATA risk class proved to be a significant predictor of structural persistent disease, both for intermediate- (OR 4.67; 95% CI 2.59-8.43) and high-risk groups (OR 16.48; 95% CI 7.87-34.5). The individual recruiting center did not significantly influence the prediction of the 1-year status. Conclusions: The ATA risk stratification system is a reliable predictor of short-term outcomes in patients with DTC in real-world clinical settings characterized by center heterogeneity in terms of size, location, level of care, local management strategies, and resource availability.