Communication of Voice-Related Complications in Thyroidectomy: A Qualitative Analysis

Introduction: The disclosure of risks is essential to informed consent and shared decision-making, especially when choosing treatment for low-risk thyroid cancer. Limited research exists on how to best frame and present these risks to patients. The aim of this study was to characterize patient-surgeon discussions of voice-related complications about surgery for low-risk thyroid cancer.

Methods: Pre-operative clinic visits (n=39) between 13 surgeons (6 otolaryngologists and 7 endocrine surgeons) and 39 patients with low-risk (cT1-2, N0) thyroid cancer at 3 academic medical centers were audio-recorded and transcribed. Qualitative content analysis was used to evaluate surgeon counseling strategies and patient concerns related to voice complications.

Results: Patients ranged from 21 to 73 years old, mostly female (79.5%) and White (87.2%). Patients expressed varying degrees of concern with voice changes after surgery, from feeling “super concerned…about losing [their] voice” to feeling “ok” with it “as long as [they’re] around to deal with it.” Surgeons commonly presented risk with negative framing and numerical percentages, citing a 1-2% risk of voice-related complications and qualified the risk as “low” or “small” for a lobectomy, but a “much bigger deal” for bilateral nerve damage in a total thyroidectomy. At a minimum, surgeons referred to voice-related complications as “voice change.” Some surgeons further described “hoarseness” or the “inability to project voice.” Other surgeons imitated what a voice complication would sound like. A few surgeons probed the importance of voice to a patient’s life. Finally, one surgeon imparted that having a voice-related complication “can be really emotional.”

Conclusions: The degree to which patients value voice-related outcomes varied in the face of a cancer diagnosis. Surgeons similarly differed in their descriptions and setting of expectations resulting in a wide spectrum in the level of detail used to describe voice difficulties. Further research is needed to identify optimal disclosure of voice-related risks and expectations if a complication were to occur.