BACKGROUND
Thyroid cancer is common but, fortunately, has an excellent prognosis and the vast majority of patients survive their thyroid cancer. This is because we have very effective treatments. Surgery to usually the first treatment and is often curative. For advanced cancer, radioactive iodine therapy serves as a “magic bullet” to seek out and destroy thyroid cancer cells. Finally, thyroid hormone therapy is often required as thyroid cancer patients are hypothyroid after their thyroid cancer surgery.

For many years, thyroid cancer patients were treated with doses of thyroid hormone aimed at suppressing TSH levels to decrease the risk of thyroid cancer recurrence. Indeed, long-term TSH suppression was the standard of care for patients with thyroid cancer. However, guidelines from both the American Thyroid Association (ATA) and the National Comprehensive Cancer Network (NCCN) now advise reducing TSH suppression for those who are at low risk of recurrence and who remain cancer-free for several years. The recent guidelines include many studies showing that the risk of recurrence does not increase with less suppression and that excessive long-term TSH suppression can cause harm, including, but not limited to, increased risk of abnormal heart rhythms such as atrial fibrillation and thinning of the bones (osteoporosis).

Although clinical practice guidelines include the most current evidence to prove the best patient care, their inclusion into routine practice is frequently delayed and inconsistent. A previous study focused on physician practices regarding TSH suppression and showed that almost 50% of physicians were still recommending TSH suppression for low-risk thyroid cancer. The current study was performed to assess the barriers to physicians in reducing TSH suppression in thyroid cancer survivors.

THE FULL ARTICLE TITLE
Francis-Levin N, Tan CY, Gay BL, et al. A qualitative study of clinician barriers and facilitators to de-escalation of thyroid stimulating hormone suppression in thyroid cancer survivors. Endocr Pract. Epub 2025 Dec 17:S1530- 891X(25)01334-5; doi: 10.1016/j.eprac.2025.12.009. PMID: 41419177.

SUMMARY OF THE STUDY
This study included 8 endocrinologists and 7 primary care physicians to determine barriers to reduce TSH suppression in recurrence-free, low- or intermediate- risk thyroid cancer survivors.

Each physician participated in a focus group following a standardized interview guide. Within the focus group, 14 open-ended questions regarding the knowledge, beliefs, practices, and emotions in relation to thyroid hormone dose reduction were recorded. Participant response transcripts were then coded and analyzed to separate identified barriers and facilitators by patient, clinician, and system levels.

The primary reported patient-level barriers included patient distress or anxiety, patient misinformation, and lack of familiarity or trust surrounding the concept of reducing thyroid hormone doses. Physician-level barriers focused on difficulty understanding thyroid cancer risk stratification, variable use of ATA guidelines among primary care providers (PCPs) and endocrinologists, and unclear responsibilities for long term care of thyroid cancer survivors. Limited clinic visit time to manage and discuss thyroid hormone dose reduction was the main system-level barrier.

The main themes to increase thyroid dose reduction included building a trusting physician–patient relationship while using patient-centered language to dispel patient anxiety. Physicians focused on improved access to guidelines regarding reduction of TSH suppression therapy. They also highlighted the importance of communication between PCPs and endocrinologists, along with using new strategies to better understand thyroid cancer risk stratification. Lastly, endocrinologists focused on the best timing for discharging patients back to primary care while PCPs expressed interest in a more effective handoff process for continued thyroid cancer survivorship care.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
While thyroid cancer guidelines have supported limiting thyroid cancer suppression to advanced thyroid cancer patients, there are still many barriers to implementing these guidelines into clinical practice. Building a trusting physician–patient relationship, improving access to guidelines and better communication between PCPs and endocrinologists were common themes that would improve reducing TSH suppression for low and intermediate risk thyroid cancer patients.

— Alan P. Farwell, MD

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