Managing Thyroid Cancer Without Surgery

Thyroid cancer rates have risen dramatically in the past few decades, likely due to the explosion of imaging technology—the more you look, the more you find.

The good news is life expectancy has not changed significantly. In fact, the mismatch of incidence and death rates proves thyroid cancer is rarely life-threatening. Enter active surveillance, a non-surgical option appropriate for low-risk cancers.

“The rush to remove all suspicious tumors is a thing of the past,” says endocrinologist Hyesoo Lowe, MD, medical director of the Columbia Thyroid Center, referring to the old “if it’s cancer it’s gotta come out” standard of care. Today, low-risk thyroid cancer can be monitored, checking in on tumor growth over time and usually avoiding surgery.

Most thyroid cancers—about 80% of cases—are papillary thyroid cancers (PTC), which have the best prognosis. PTC is often detected incidentally, during a test for something else, like a scan for unrelated neck pain. The tumors are usually small, one reason, along with a lack of symptoms, people may not know they have cancer.

Because PTC is usually slow-growing, patients have two treatment choices: surgery (in which part of the gland is removed) and surveillance. In active surveillance, patients have neck ultrasounds twice a year for two years to monitor changes, if any, in the tumor.

“As we’ve moved forward in thyroid cancer, understanding how it behaves, we’ve realized less is more,” says Lowe. “We do not need extra treatment. A few decades ago, everyone got radioactive iodine, after having their entire thyroid removed. Now we know there can be success in removing only part of the thyroid gland, or sometimes avoiding surgery entirely.”

In the past 10 to 20 years, more than 85% of patients who chose active surveillance never needed surgery—their tumors did not grow or spread to their lymph nodes. Less than 8% had tumor growth, and less than 2% had expansion to the lymph nodes, requiring surgery. And surgeries were successful; the delay did not cause negative impact.

Patients have options, says Lowe. “We can customize treatment to their considerations, clinically and personally.”

That said, there’s strict criteria for active surveillance:

• Low-risk cancer and/or patient 
• Small tumor (typically <1.5 cm) 
• Tumor contained inside thyroid 
• No evidence tumor extends to lymph nodes 

There are a variety of reasons a patient chooses active surveillance, including age (some older patients simply wish to avoid surgery and recovery time), prioritization of other medical or non-medical concerns, and a preference for fewer procedures.  

“It goes back to the patient and their considerations,” says Lowe. “We make decisions together, considering all options.”