Active Surveillance Best in Thyroid Cancer to Avoid Hypoparathyroidism, Study Finds

Patients with small papillary thyroid cancers should not undergo a total thyroidectomy, but should instead be under active surveillance to monitor the cancer, or remove only a portion of the thyroid. This could avoid the patient developing hypoparathyroidism, according to a new perspective article.

The article, “Saving Thyroids — Overtreatment of Small Papillary Cancers,” was published in the New England Journal of Medicine.

In the United States alone, more than 50,000 people are expected to be diagnosed with thyroid cancer this year. In the past 25 years, the incidence of thyroid cancer has tripled — largely reflecting the detection of small papillary thyroid cancers, the most common type of thyroid cancer, whose main symptom is a mass in the neck.

Interestingly, this increase in diagnosis is attributed to the fact that we now have the tools to detect these small cancers, leading to an over-diagnosis. Thyroid cancers, in general, do not result in death.

“Efforts to reduce thyroid cancer detection are clearly warranted — for example, refraining from screening for cancers and from biopsying small thyroid nodules, as advocated by the American Thyroid Association,” the researchers write.

When a thyroid tumor is discovered, many physicians support performing a total thyroidectomy — a complete removal of the thyroid. However, this procedure can lead to hypoparathyroidism (low levels of the parathyroid hormone) and necessitate lifelong thyroid hormone replacement.

The authors add that while they support the need for active surveillance for selected patients with small papillary thyroid cancers, the thyroid does not necessarily have to be removed, especially not in its entirety.

The less extensive procedure is a thyroid lobectomy, which is the removal of approximately half the thyroid gland. The surgery itself carries less risk and the patient does not need to be on permanent thyroid hormone-replacement therapy.

And, studies have shown that both total thyroidectomy or lobectomy carry the same risk of death.

Despite these statistics that clearly favor lobectomy as the choice of surgery for thyroid cancer, more patients are undergoing total thyroidectomy rather than lobectomy.

The authors believe the decision to for a total thyroidectomy or lobectomy is made by the surgeons and endocrinologists, who “may simply believe that total thyroidectomy is the better strategy and may not believe the data to the contrary.”

Some physicians may choose to conduct a total thyroidectomy simply because they want to follow longstanding practice. These conventions were developed when thyroid cancer was considered a “bulky, palpable disease.”

But standard practices were developed for the treatment of high-risk disease. “It is hard for [healthcare] providers to deintensify care,” researchers write.

Deintensifying care may also worry patients, which can be addressed by educating them about the diversity of “cancer” conditions and how some cancers only present with limited disease.

Voice and hormonal function are naturally important, and all patients who undergo total thyroidectomy for small papillary cancers require thyroid hormone replacement, with thousands experiencing hypoparathyroidism or voice changes.

“These consequences are too important to be influenced by the vicissitudes of our management habits and anxiety about undertreatment,” the authors explain.

The authors believe that patients with small papillary cancers should undergo active surveillance without any surgical intervention.

“And for those who prefer intervention, or whose disease warrants it, we should make it clear that lobectomy is often the best choice,” they add.