BACKGROUND
Thyroid cancer has increased over the last several decades in part due to increased detection of small thyroid cancers that are not aggressive. Most of these small cancers are papillary thyroid cancer. There has also been recognition that treatment of these low-risk cancers with immediate surgery may not always be necessary and exposes the patient to risks associated with surgery. Many of these small thyroid cancers never grow significantly in size or spread outside of the neck. This has led to following a small, low-risk thyroid cancer with ultrasound and deferring surgery until the cancer shows evidence of significant growth or the cancer changes. This is called active surveillance and is an alternative option for the management of low-risk papillary thyroid cancer. Various factors will be taken into consideration to determine if active surveillance is an appropriate management option for a particular patient, including the patient’s age.

This study evaluates the durability of active surveillance in patients with small, low-risk papillary thyroid cancer.

THE FULL ARTICLE TITLE
Sawka AM, et al. Long-term durability of active surveillance of small, low-risk papillary thyroid cancer. JAMA Surg 2025;160(10):1117–1124; doi: 10.1001/ jamasurg.2025.2957. PMID: 40833769.

SUMMARY OF THE STUDY
This study was conducted at an acute care hospital in Toronto, Canada and recruited adult patients with known or suspected papillary thyroid cancer that measured less than 2 cm and did not have any high-risk features on ultrasound. Patients were excluded from the study if there was spread of cancer to the lymph nodes in the neck or elsewhere in the body, evidence of direct extension of the cancer beyond the thyroid gland or if there was a high risk for invasion of important structures surrounding the thyroid gland (trachea and recurrent laryngeal nerve). Patients were offered a choice between active surveillance and surgery.

Out of the 200 patients enrolled, 155 (78%) selected active surveillance and 45 (22%) selected to undergo immediate surgery. Older patients were more likely to select active surveillance over the option of surgery. During an average follow up period of 71 months, there were no thyroid cancer-related deaths or spread of the cancer outside of the neck in either group.

Among patients who initially chose active surveillance, the cross over rate (patients who initially chose active surveillance and later underwent surgery or were recommended an intervention) was 23.9% – in 57% the reason was progression of disease and in 41% it was due to patient preference. The five-year cumulative crossover rates were 41.5% in patients younger than age 45, 20.9% in patients aged 45 to 64%, and 5.1%, in patients aged 65 or older, respectively.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
The decision between active surveillance and surgery for patients with low-risk papillary thyroid cancer needs to be individualized. This study is consistent with prior research that suggests the long-term outcome for active surveillance is favorable in appropriately selected patients. In older patients, active surveillance can be considered as part of the management strategy, particularly when co-existing health conditions may make surgery a less preferred option.

— Poorani Goundan, MD

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