Active Surveillance for Small Papillary Thyroid Cancer

thyroid ultrasound, active surveillance, thyroid cancer, papillary thyroid cancer
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When your doctor finds a cancerous thyroid nodule, the typical treatment recommendation is for you to have surgery to remove the nodule. Often, a lobe (half) of your thyroid is surgically removed, and in some cases, the full thyroid is surgically removed. Many patients having even a partial thyroidectomy require lifelong thyroid hormone replacement, and everyone who has had a total thyroidectomy relies on thyroid hormone medication after surgery.

Now, for some small, low-risk, slow-growing papillary types of thyroid cancer, experts are starting to recommend a new approach: active surveillance.

Researchers reporting in the journal JAMA-Otolaryngology–Head & Neck Surgery have shown that active surveillance—also known as watchful waiting—of these microcarcinomas may be a better option for patients than surgery, as long as the monitoring incorporates three-dimensional imaging technologies such as ultrasound.

The American Thyroid Association also endorsed the use of active surveillance as an alternative to traditional thyroid cancer treatment in selected patients with low-risk thyroid cancer.

The JAMA study’s lead author, R. Michael Tuttle, MD, of the Memorial Sloan Kettering Cancer Center, New York City, told Medscape: 

Many won't need surgery for years, and maybe never. We are moving away from the mindset that as soon as you get a diagnosis of thyroid cancer you have to rush and do the surgery. Now, it's more of a commonsense approach, and in fact there are groups of patients in the US that this should be perfectly acceptable for. There are patients in the US who don't immediately want surgery for every little, small thyroid cancer.

The researchers monitored a group of patients who had very small—less than 1.5 mm in size—thyroid tumors. Over a period of years, the tumor size was measured three-dimensionally with ultrasound every six months to a year. The researchers found that after 5 years, only 12 percent of the patients saw their tumors grow to 3 mm or more in size.

No regional or distant spread of the cancer developed in the patients studied during active surveillance.

Dr. Tuttle said that three-dimensional ultrasound measurement of tumor volume is a new and important concept that makes active surveillance more viable and effective. Doing an ultrasound every six months during the first two years of surveillance allows experts to establish a growth rate. If that rate is fast, then surgery is recommended. But, according to Dr. Tuttle, since the majority of the cancers they studied did not grow or grew very slowly, the researchers recommend that doctors offer active surveillance as an option to low-risk patients.

As Dr. Tuttle told Medscape:

Rushing to surgery may be the right thing for an individual patient, but there's no hurry if they are willing to watch. A lot of people value their thyroid and don't want to be on thyroid hormone for life, so if they have the option of watching, they see that as a valuable option.

A Word From Verywell

Keep in mind that active surveillance of your cancerous thyroid nodule requires a knowledgeable, skilled, and specialized team of medical professionals. You want your team members to have experience in this fairly new approach to thyroid cancer.

Experts also caution that the outcome may be less favorable for those patients who are receiving care outside of medical centers that have extensive thyroid cancer experience, or health care providers who specialize in thyroid cancer diagnosis and treatment, with a knowledge of active surveillance protocols. The take-home message: active surveillance can be a viable and safe option for you, but only when done in the hands of experts.

Another important guideline to keep in mind: the key to active surveillance is consistent follow-up and monitoring. If you choose this approach, make sure that you have regular three-dimensional ultrasounds, and follow with your thyroid cancer experts.

Regular checkups are essential to active surveillance, and should be able to detect any significant changes to your cancerous tumor that would warrant medical intervention and treatment in the future.

Finally, researchers suggest that the best candidates are those who are diagnosed after the age of 50. If you are under the age of 50, your tumor will tend to grow, so surgery will still be recommended more frequently if you are diagnosed with a cancerous papillary microcarcinoma.

Sources:

Leboulleux, S. et al. "Papillary thyroid microcarcinoma and active surveillance."  The Lancet Diabetes & Endocrinology , Volume 4 , Issue 12 , 976 - 977. December 2016.

Tuttle, M MD et. al. "Natural History and Tumor Volume Kinetics of Papillary Thyroid Cancers During Active Surveillance." JAMA Otolaryngol Head Neck Surg. Published online August 31, 2017.  http://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2650803

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