Clinical Thyroidology® for the Public

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What influences a patient’s choice in choosing active surveillance in low risk papillary thyroid cancer?

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Thyroid cancer is common, especially in women. The vast majority of thyroid cancers respond well to treatment and have a good prognosis. In particular, papillary thyroid cancer, which is the most common type and makes up about 80% of all cases of thyroid cancer, has an excellent outcome. Until recently, a diagnosis of thyroid cancer usually led to a recommendation for surgery, which is often curative. However, many small thyroid cancers are at very low risk to spread outside the thyroid or to cause any health risk. Because of this, the option of following the cancer by ultrasound and deferring surgery, called active surveillance, has become increasingly common.

The concept of active surveillance consists of performing serial ultrasounds of the thyroid (every 6-12 months) to monitor changes in the size of the cancer without performing any medical or surgical treatment. This avoids unnecessary treatments with potential complications or side effects. If at some point, a change in the cancer occurs where, for example, the size becomes bigger or it starts spreading beyond the thyroid, then proceeding to surgery would be the next option. Some large studies suggest that over half of the small low risk thyroid cancers followed by active surveillance never result in surgery. Continued studies in the United States and elsewhere looking at the suitable size of cancer for which active surveillance is safe and appropriate are ongoing. This study looks at factors impacting patients’ choice for active surveillance or surgery in low risk papillary thyroid cancer.

Sawka AM et al for the Canadian Active Surveillance Study Group (Greater Toronto Area) 2022 A quantitative analysis examining patients’ choice of active surveillance or surgery for managing low-risk papillary thyroid cancer. Thyroid 32:255–262. PMID: 35019770.

A total of 200 patients of at least 18 years of age at a single center in Canada from 2016 to present with papillary thyroid cancer <2 cm in size that were considered to be low risk were enrolled in the study. Patients were provided written information about the prognosis of low-risk papillary thyroid cancer and options for surgery vs active surveillance. The goal of the study was to assess the amount of patients choosing active surveillance over surgery and what factors affected their decision.

The average cancer size in these patients was 1.1 cm and 56% were larger than 1 cm. Out of 200 patients, 155 (77.5%) opted for active surveillance while 45 (22.5%) opted for immediate surgical intervention. Patients were more likely to choose active surveillance over surgery if they were older than 40 years of age; this was particularly true for those 65 years or older. Patients choosing active surveillance also had lower formal education. Those who chose surgery reported responsibility for children younger than 18 years as well as those who had already identified a surgeon within the study institution. Most patients in both groups reported independent decision-making (86%), as opposed to shared decision-making with their physician (14%), and 96% reported high satisfaction with their decision. Additional predictors of choosing surgery included fear of disease progression and an active coping style, while predictors of choosing active surveillance included fear of requiring thyroid hormone replacement after surgery.

In this study, results indicate that patients are more likely to choose active surveillance instead of surgery for low-risk papillary thyroid cancer if they were older than 40 years of age, had lower formal education and preferred not to be on thyroid hormone after surgery. Patients choosing surgery reported a fear of cancer progression along with responsibility for their children. Importantly, the vast majority of patients reported making this decision on their own. This highlights an opportunity for doctors to discuss active surveillance with their patients and to be aware of the factors that drive patients to make a decision on treatment options. This study is important as it is of vital importance to understand patient’s values and how others influence their decision when having this discussion.

— Juan Vasquez Mendez, MD, Endocrinology Fellow

— Maria del Pilar Brito, MD


Papillary thyroid cancer: the most common type of thyroid cancer. There are 4 variants of papillary thyroid cancer: classic, follicular, tall-cell and noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).

Active surveillance: the term for avoiding surgery for small thyroid cancers by monitoring them over time with ultrasound and physical exam.

Lobectomy: surgery to remove one lobe of the thyroid.

Total thyroidectomy: surgery to remove the entire thyroid gland.