AUC for RAI

Appropriate Use Criteria for Nuclear Medicine in the Evaluation & Treatment of Differentiated Thyroid Cancer

Learn What the Implications Are for Your Practice and Your Patients

These newly developed Appropriate Use Criteria (AUC) describe the appropriate use of nuclear medicine scintigraphic imaging and I-131 therapy in patients with Differentiated Thyroid Cancer (DTC). The most common clinical scenarios are addressed. It is hoped that through these recommendations, nuclear techniques will be used to benefit patients with DTC in the most cost-effective manner.

The AUC for Nuclear Medicine in the Evaluation and Treatment of Differentiated Thyroid Cancer are endorsed by the Society of Nuclear Medicine and Molecular Imaging, by the American Academy of Family Physicians, American College of Nuclear Medicine, by European Association of Nuclear Medicine, American Thyroid Association, American Association of Endocrine Surgeons, American Head and Neck Society, American Association of Clinical Endocrinologists, Endocrine Society.

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What Is an AUC?

AUC are evidence-based and expert consensus-driven guidelines developed to assist medical professionals in making the most appropriate diagnostic and therapeutic decisions when they order and perform a medical procedure. By implementing the AUC, medical professionals will fulfill the requirements of the 2014 Protecting Access to Medicare Act (PAMA) mandated by the Centers for Medicare & Medicaid Services (CMS). Since January 1, 2018, CMS requires doctors to consult AUC prior to ordering advanced diagnostic imaging services in order to receive Medicare reimbursement. Early adopters of AUC will be eligible to report this use as a high-weighted improvement activity under the Merit-Based Incentive Payment System (MIPS) based on a rule proposed by CMS. CMS has designated qualified Provider-Led Entities (qPLEs)—such as the Society of Nuclear Medicine and Molecular Imaging (SNMMI)—to develop AUCs under the Medicare Appropriate Use Criteria program.

How the AUC for Nuclear Medicine in the Evaluation and Treatment of Differentiated Thyroid Cancer was developed?

The experts of the AUC workgroup were convened by SNMMI to represent a multidisciplinary panel of health care providers with substantive knowledge of the diagnosis and treatment of DTC. The group included experts from the SNMMI, the European Association of Nuclear Medicine, the American Academy of Family Physicians, the American College of Nuclear Medicine, the American Thyroid Association, the American Association of Endocrine Surgeons, the American Head and Neck Society, the American Association of Clinical Endocrinologists and the Endocrine Society. The wide diversity of the workgroup committee members provided fair balance among a range of interrelated clinical specialties.

The process for AUC development was modeled after the RAND/UCLA Appropriateness Method. Overall 42 clinical scenarios were evaluated and rated for appropriateness by the committee. Ratings were based on the evidence summary of a systematic literature review as well as expert opinions while guided by “the concept of appropriateness, as it applies to healthcare, balancing risk and benefit of a treatment, test, or procedure in the context of available resources for an individual patient with specific characteristics.”

Each indication was scored as “appropriate”, may be appropriate” or not appropriate” on a scale 1 to 9.

Scores of 7 to 9: Use of the procedure is appropriate for the specific clinical indication, and generally considered acceptable.

Scores of 4 to 6: Use of the procedure may be appropriate for the clinical indication; however, more research is needed to classify the indication definitively.

Scores of 1 to 3: Use of the procedure is rarely appropriate for the clinical indication, and generally not

considered acceptable

The AUC has been published on behalf of SNMMI and will be submitted to CMS for approval.¹

Details of AUC for Nuclear Medicine in the Evaluation and Treatment of Differentiated Thyroid Cancer was developed

¹³¹I Therapy for DTC in Patients Who have had total Or Near-Total Thyroidectomy

Introduction

¹³¹I is an effective and well-established therapeutic option for DTC after thyroidectomy has been performed. The 13 clinical scenarios that follow in this section, while not exhaustive, are felt to be the most common scenarios that may be encountered in patients with DTC following thyroidectomy. Many of the clinical scenarios that the expert panel considered in this section were not ranked as an appropriate use of 131I therapy; however, the panel felt it was important to propose and discuss as many clinical scenarios as possible in which 131I therapy may be considered, so that practitioners would have both guidance in favor of 131I therapy, when it is felt to be appropriate, and a discussion of when ¹³¹I therapy is less well supported.

Background

RAI therapy among patients with DTC is considered for the ablation of residual thyroid remnant tissue, suspected residual cancer (adjuvant therapy), and known residual cancer (treatment). Its use is typically considered after optimal resection of the primary tumor with total thyroidectomy and local-regional disease resection. RAI therapy is rarely considered after primary tumor resection with a thyroid lobectomy and almost never considered before addressing the primary tumor and normal thyroid tissue with surgery.

TABLE 5 Clinical Scenarios for ¹³¹| Therapy in Thyroid Cancer

Additional Resources

• Appropriate Use Criteria for Nuclear medicine in the Evaluation and treatment of Differentiated Thyroid Cancer. Donohoe et al. JNM Vol 61, No3, March 2020
• ATA Guidelines. Haugen et al. THYROID. Volume 26, Number 1, 2016
• SNMMI Guidelines. Silberstein et al. JNM. Vol 53, No 10, October 2012
• EANM Guidelines for radioiodine therapy for differentiated Thyroid Cancer. Eur J Nucl Med Mol Imaging. 2008 Oct;35(10)
• EANM practice guideline/SNMMI procedure standard for RAIU and thyroid scintigraphy. Eur J Nucl Med Mol Imaging 46, 2514–2525 (2019)