The Martinique Principles

TO THE EDITOR: Recently, the Martinique Working Group (MWG), composed of representatives from the American Thyroid Association (ATA), the European Association of Nuclear Medicine (EANM), the European Thyroid Association (ETA), and the Society of Nuclear Medicine and Molecular Imaging (SNMMI), published a white paper referred to as “The Martinique Principles” (1).

As defined by Wikipedia (2), “. . . a white paper is an authoritative report or guide that informs readers concisely about a complex issue and presents the issuing body’s philosophy on the matter. It is meant to help readers understand an issue, solve a problem, or make a decision.” Although not infrequently, “white papers” are characterized as exactly that: mostly “white with very little black ink used to communicate nothing of substance,” tout au contraire! The article by Tuttle et al. (1), referred to as “The Martinique Principles,” documented multiple important accomplishments.

First and foremost, this white paper documents the important establishment of an honest and collegial discussion of differences of practices and opinions regarding the diagnosis and management of differentiated thyroid cancer among prominent members of 4 societies. Arguments can be divisive or constructive. This group’s efforts were constructive and help us all move toward understanding and resolving controversial issues, thereby hopefully improving patient care. Again, the establishment of this new collegial dialogue is the foremost accomplishment of the MWG as demonstrated in this white paper from the 2108 meeting.

Second, the MWG compiled 9 principles (Supplemental Fig. 1 [supplemental materials are available at http://jnm.snmjournals.org]), and the reader is encouraged to read the entire article for a more detailed discussion and appreciation of the value of these principles. Overall, the 9 principles established a valuable foundation from which to proceed. In addition, each principle has its specific value, and I have selected several of the 9 principles to present examples of the value of the individual principles themselves.

Third, and as an example of the above, the MWG established common terminology for the discussion of ¹³¹I therapies based on a combination of definitions proposed by Cooper et al. (3) and Van Nostrand et al. (4) and further supported by Haugen et al. (5). These terms are ¹³¹I remnant ablation, ¹³¹I adjuvant treatment, and ¹³¹I treatment of known locoregional or distant metastases. These definitions are based on different objectives of those ¹³¹I therapies (Supplemental Table 1). In order to make any dialogue about controversies more productive and less confusing, it is paramount that we use the same terms with the same meanings. The MWG established common terminology that was accepted by all the members of the MWG of the 4 societies. I encourage the members of the SNMMI to also accept and use these terms. To use different terms or to use the same terms but with our own individual definitions and objectives will only aggravate the futility of our discussions of controversies. The MWG has achieved reasonable and workable terminology for ¹³¹I therapies.

Fourth, the MWG presented various viewpoints followed by constructive discussions regarding 3 controversial areas (i.e., indications for ¹³¹I adjuvant treatment, the amount of activity for ¹³¹I adjuvant treatment, and what is radioiodine refractory disease). These presentations and discussions allowed a better understanding of the arguments of the opposing sides and that we need better evidence-based medicine.

There are other benefits specific to the individual principles, which I do not discuss here. However, there are also less frequently discussed benefits from “The Martinique Principles,” such as the following 2 examples. By developing the 9 principles through sharing the differences of opinion and, hopefully, understanding those differences better, the MWG will help influence the development of future guidelines to continue to incorporate the spectrums of expert opinions and recognize the frequently inadequate evidence available to us. In addition, I believe that the 9 principles will offer facilitators of Continuing Medical Education programs a document for “needs assessment” to encourage more presentations discussing the various viewpoints of these 3 controversies. These presentations will, in turn, help practicing physicians to better individualize their care to a specific patient in a specific facility in a specific location of the world.

In summary, the MWG and its past 2018 and 2019 meetings have been extremely valuable in organizing our collaborative efforts to establish common terminology, to help identify areas of differences of opinions, to better understand what our differences are, and to recognize that, overall, our intentions of improved diagnosis and management of patients with differentiated thyroid cancer are aligned.

It is now the tasks of the MWG and its present and future members to continue the honest and collegial dialogue in order to move forward toward an ever-better understanding of best practices for our patients with differentiated thyroid cancer.

In the end, follow those who seek the truth and not those who think they know the truth.

• © 2019 by the Society of Nuclear Medicine and Molecular Imaging.