Thyroid Cancer: When Surgery and Radiation Therapy May Not Be Needed

When someone is diagnosed with thyroid cancer, treatment often includes surgery, radiation, chemotherapy, and thyroid hormone therapy. But if it’s papillary thyroid cancer—a typically slow-growing malignancy that accounts for roughly 80% of all thyroid cancers—patients may have other options.

More specifically, if it’s a subtype called small papillary thyroid cancer (defined as having tumors smaller than 1.5 centimeters), the best strategy might be what’s called “active surveillance,” which involves monitoring the cancer through regular screening tests and examinations without undergoing any immediate treatment.

“Small papillary thyroid cancers are typically slow-growing, nonaggressive, and have a high survival rate,” explains Sachin Majumdar, MD, a Yale Medicine endocrinologist, who recently created the Yale Active Surveillance Program for Low-Risk Papillary Thyroid Cancer. “Active surveillance is a good management strategy for such a cancer.”

The goal of active surveillance or “watchful waiting,” an idea that started to gain traction in the 1990s, is to minimize overtreatment and preserve patients’ quality of life. It does so by avoiding or delaying the side effects of treatments like surgery, radiation, or chemotherapy, which can sometimes be more harmful than the cancer itself, especially if the cancer is not aggressive. This approach is commonly used for prostate cancer, some kidney cancers, and certain lymphomas.

Yale’s Active Surveillance Program for Low-Risk Papillary Thyroid Cancer has a dedicated team (with an endocrinologist, radiologist, surgeon, and nurse) that works with patients to decide what treatment method is best for them. If patients opt for active surveillance, they receive ultrasounds and blood work every six months for two years. If there is no cancer progression after two years, the visits change to once a year.

One of the values of the program, says Dr. Majumdar, is having the infrastructure in place that makes sure patients are monitored and come in for their screenings. Without such a program, sometimes screenings can fall through the cracks, he adds.

Below, we talk more with Dr. Majumdar about the Yale Active Surveillance Program for Low-Risk Papillary Thyroid Cancer.

The thyroid is a small, butterfly-shaped gland in the neck. It produces hormones that regulate the body’s metabolism. Cancer occurs when the cells in the thyroid mutate and grow uncontrollably.

Sometimes, thyroid cancer presents in the form of a nodule, a solid or fluid-filled lump that forms in the thyroid. But detecting nodules by feel in someone’s neck is rare and makes up only about 5% of cases, Dr. Majumdar says.

More often, a nodule is discovered when an individual has an imaging study of their neck area for something else. “It could be that someone twists their neck, they get a CT scan, and we see a nodule in that scan. Next, they might get a biopsy, and it turns out to be thyroid cancer,” he says.

One of the reasons patients with thyroid cancer might choose active surveillance is because it has a high survival rate. Of the roughly 44,000 Americans diagnosed with thyroid cancer each year, 98% survive for five years, and 85% survive for 10 years.

“For small tumors confined to the thyroid that have not spread to the lymph nodes or other organs, choosing surveillance over surgery can have many benefits,” says Dr. Majumdar. "One involves the preservation of the important roles the thyroid plays in the body. As children, we need thyroid hormones to guide our growth and development, and, as adults, we need thyroid hormones because they regulate our energy levels.”

Often, when thyroid cancer is found, all or part of the thyroid gland is removed surgically. “And some people don’t feel the same afterward,” Dr. Majumdar says.

That’s because the removal of the thyroid leads to hypothyroidism, resulting in such symptoms as fatigue, weight gain, dry skin and hair, muscle weakness, depression, constipation, and a slow heart rate.

As a result, most patients need to take a thyroid hormone replacement medication, such as levothyroxine, usually in pill form, to treat hypothyroidism for the rest of their lives. That can introduce more challenges. “The medication often has to be readjusted every time someone gains or loses weight, or it may interact with other medications,” Dr. Majumdar says. “It may also increase the risk of osteoporosis. Plus, there’s a lot of blood monitoring involved. It’s a fair amount of complexity for patients to deal with.”

Routine screening for thyroid cancer is not done in the United States and when it has been done in other countries, most notably in Asia, it has led to overdiagnosis and overtreatment, Dr. Majumdar notes.

Active surveillance, on the other hand, has shown greater promise. While such programs for small papillary thyroid cancer are not yet mainstream in the U.S., more are beginning to emerge, Dr. Majumdar says.

Japan, he says, set the model for such surveillance. Researchers there began to monitor patients with small papillary thyroid cancer in 1993 and now have 30 years of follow-up data. “They carefully selected people who they believed would have very little cancer progression,” he says. “And in cases where the cancer did progress to the lymph nodes, they were able to do surgery and remove it, but those numbers were very low.”

After someone is diagnosed with small papillary thyroid cancer, they can meet with an endocrinologist in the program to discuss the diagnosis and their medical history.

“We tell them that one option would be to follow the cancer, and another would be to remove the cancer surgically. Some people immediately say they don’t want surgery, so we can offer surveillance,” he says. “We tell them that we will follow it in a safe manner. And if the cancer grows in the next year or two, it’s easy to take it out. If at any time someone feels uncomfortable, they can talk to one of our surgeons and have it removed.”

Sometimes, patients are diagnosed with small papillary thyroid cancer when they are undergoing treatment for a different cancer.

“For example, we might see a 70-year-old man with lung cancer who, as a result of the imaging scans for lung cancer treatment, is also diagnosed with a small thyroid cancer,” Dr. Majumdar says. “For someone like that, it would be totally acceptable to monitor that thyroid cancer and to treat the lung cancer. And they may never need any treatment for the thyroid cancer.”

And in the absence of another cancer, if a small thyroid cancer has been found incidentally in an older adult with other underlying medical conditions, surveillance might be appropriate for them, he adds.

Dr. Majumdar recognizes the challenges when discussing active surveillance with patients. “When you say the word ‘cancer,’ it’s hard to tell a patient, ‘We’re just going to leave it there and keep an eye on it.’ People aren’t used to that,” he says. “But if it’s a small, nonaggressive cancer, you have to wonder if it’s going to hurt you in life. And it’s probably not. But if it’s a big tumor, most people want to take it out. It's the in-between and smaller cases where it becomes complicated.”

The program, Dr. Majumdar says, can help patients navigate those complex decisions.