BACKGROUND
The majority of patients with thyroid cancer do very well. Indeed, almost 40% of thyroid cancers are less than 1 cm and have an excellent prognosis. Despite the excellent prognosis, many patients with thyroid cancer are treated with thyroid hormone doses aimed at achieving a low TSH (TSH suppression) and are monitored frequently for cancer recurrence with neck ultrasound studies and lab tests (thyroglobulin, Tg). Prior ATA guidelines introduced the idea of risk assessment of cancer recurrence after initial treatment as well as alternative treatment options for lower-risk cancers, including cutting back on thyroid hormone dosing to keep the TSH normal.

To further assist clinicians with the rational targeting of treatment and monitoring, the 2025 ATA guidelines introduce the “DATA Framework” (Diagnosis, Assessment, Treatment, Assessment). The concept recommends continuing risk assessment after each treatment decision and subsequent action to reassess the risk of cancer recurrence. The appropriate future monitoring and treatment is therefore based on the new risk assessment, rather than the initial risk assessment driven largely by the initial diagnosis and cancer staging data. Thus, treatment and monitoring can be “de-escalated,” or cut back, in patients with a low risk of thyroid cancer recurrence.

THE FULL ARTICLE TITLE
Ringel MD et al. 2025 American Thyroid Association management guidelines for adult patients with differentiated thyroid cancer. Thyroid 2025;35(8):841–985.

SUMMARY OF THE STUDY
The 2025 ATA thyroid cancer guidelines refer to patients with differentiated thyroid cancer, almost all of which are papillary thyroid carcinoma.

TSH Suppression: A key set of recommendations to be “de-escalated” in the new guidelines pertain to the use of TSH suppressive therapy, or thyroid hormone dosing to achieve a low or suppressed TSH. The rationale in the past was that the low TSH levels would avoid any TSHstimulation to any remaining thyroid cancer cells. However, the guidelines note that data are quite mixed as to benefit, especially for lower risk thyroid cancer and tended to support equal benefits for moderate suppression (TSH, 0.1–0.5 mIU/L) as for lower TSH levels. The guidelines therefore recommend that TSH suppression should be used mainly for high-risk patients with persistent thyroid cancer.

Thyroglobulin (Tg) measurement: With Tg as a cancer marker, monitoring patients with thyroid cancer has a major advantage in the early detection of recurrence compared to many other cancers. However, the ability to monitor Tg means that aggressive initial treatment decisions to drive Tg levels to undetectable still dominate decision-making. The new guidelines support a de-escalation in this case by providing guidance on monitoring Tg in total thyroidectomy patients who have not undergone radioactive iodine therapy. In this patient group, initial Tg levels <2.5 ng/ml did not appear to be associated with increased recurrence risk. These guidelines also note that Tg levels should not be monitored after lobectomy, although a one-time measure may be helpful to ensure that there is not an overlooked major elevation that might signal a wider problem.

Length of monitoring: Entirely new to these guidelines is a discussion of whether and when monitoring can be discontinued. The guidelines introduce idea of “complete remission,” which means no evidence of cancer in response to therapy. Although this does not mean that all such patients are cured and will not have a recurrence, this determination can provide significant psychological and financial benefits to patients. Therefore, in low-risk patients, monitoring with a neck ultrasound every 1 to 3 years can be discontinued after 5 to 8 years in the setting of a continued excellent response to therapy. In total thyroidectomy patients, Tg monitoring can be discontinued after 10–15 years.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
The 2025 ATA thyroid cancer guidelines now recommend changes to long-term management in the setting of an excellent response to therapy, particularly in patients who are low-risk for thyroid cancer recurrence. In these low-risk patients, treatment and monitoring can be deescalated by adjusting the levothyroxine dose to achieve normal TSH, neck ultrasounds can be discontinued after 5–8 years, and Tg monitoring can be discontinued after 10–15 years. Further, patients with a low risk of thyroid cancer recurrence can be considered to be in complete remission, a term that has not been previously been used in thyroid cancer patients. As always, these decisions should result from a shared-decision making discussion with the patient and their doctor.

— Alan P. Farwell, MD

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