New Thyroid Cancer Guidelines Reflect Altered Treatment Landscape

Woman lying back receiving ultrasound on neck.

The use of ultrasound in routine clinical practice has led to an increase in the diagnosis of thyroid cancers.

Newly released thyroid cancer treatment recommendations from the American Thyroid Association (ATA) suggest that monitoring an early-stage papillary thyroid tumor — instead of removing it — can be a very reasonable option.

For nodules or tumors smaller than one centimeter that appear to be confined to the thyroid gland, the new guidelines say, patients may be able to avoid immediate surgery and instead have the tumor observed to see if it grows.

This suggestion is one notable aspect of the ATA guidelines, published in October, which consist of treatment recommendations that address screening, staging, risk assessment, and surgical approaches for thyroid cancer.

Now treatment will be individualized for high- and low-risk patients.
Michael Tuttle Endocrinologist

“The new guidelines are all about risk stratification and are completely removing one-size-fits-all treatment recommendations,” says Memorial Sloan Kettering endocrinologist Michael Tuttle, who has been actively involved in shaping these guidelines. “Now treatment will be individualized for high- and low-risk patients.”

In many cases, the new recommendations reflect a prevailing sentiment among thyroid cancer experts that less extensive treatment often produces the best outcomes for patients because most very small thyroid cancers grow quite slowly and never pose a threat.

In fact, the ATA guidelines advise that growths smaller than one centimeter that do not need treatment should not even be biopsied. And in cases in which surgery is required, the guidelines say that partial removal of the thyroid (lobectomy) should be considered instead of always performing a total thyroidectomy.

Richard Wong, Chief of MSK’s Head and Neck Service, says the guidelines will help prevent unnecessary ultrasounds and needle biopsies and will help reduce the “overdiagnosis of a condition in which the treatment could be more problematic than the underlying disease.”

Overdiagnosis and Overtreatment

Thyroid cancer has been on the rise in the United States over the last several decades, more than doubling between 1973 and 2002. The detection of small thyroid cancers especially increased with the introduction of ultrasounds into routine practice in the 1990’s. Since that time, it has become clear that most of these very small thyroid cancers grow slowly and never pose a threat.

As a result, physicians at MSK and elsewhere have come to recognize that a large number of patients were being biopsied or treated unnecessarily. The new ATA guidelines will help patients and physicians figure out when to intervene and when to take a more conservative approach.

Less extensive treatment often produces the best outcomes for patients because most very small thyroid cancers grow quite slowly and never pose a threat.

The guidelines recommend practices that in most cases are already followed at MSK. For example, the watchful waiting technique — also known as “active surveillance”— used with early-stage papillary thyroid tumors is already part of MSK’s approach. The new ATA guidelines are significant because they “formally endorse observation” as a possible treatment option, Dr. Tuttle says.

 “If at some point we decide that a tumor we have been watching should be removed, the surgical treatment will almost certainly be just as effective in the future as it would have been if we took it out when it was diagnosed,” he says “While some small tumors are not appropriate for this method — depending on location and other factors — these make up a tiny group.” 

Dr. Wong points out that most physicians and hospitals do not currently have an active-surveillance program. He adds that the new ATA guidelines will make practitioners more comfortable with the concept of observing a tiny cancer that is statistically highly unlikely to ever cause harm.

MSK has also been on the forefront with the approach of selecting the more conservative surgery, lobectomy, for low-risk thyroid cancers, Dr. Wong explains. The ATA guidelines are now more supportive of this concept for selected cancers.  Research published more than two decades ago by former MSK Head and Neck Service Chief Jatin Shah and surgical oncologist Ashok Shaha supported such an approach, which was somewhat controversial at the time. “It is gratifying to see how the academic thyroid community has finally followed their lead,” Dr. Wong says.


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While the findings may be true, surgery not being needed as immediate as once thought, the practitioners should take into consideration the quality of life of the individuals being diagnosed with thyroid cancer. Knowingly living with a cancerous tumor as opposed to knowing it has been removed. I can see this as a potential physiological issue depending on the age of the diagnosed.

My thyroid cancer was detected in a blood test screening by my oncologist because of previous breast cancer. I did have tall cell papillary cancer and Dr. Shaha removed my entire thyroid. The 10 lymph nodes that were removed showed cancer in 7 of them. Since both my mother and daughter had "problematic" thyroid surgeries, I'm glad I decided to have the surgery.

After being diagnosed in 2009 with papillary carcinoma and having my entire thyroid and 3 out of 4 lymph nodes positive I have been treated with Synthroid ever sense. I have almost never had s good day. My life has changed physically and I have gone from one endocrinologist to another in hopes of getting a treatment that would allow me to live my best life now. At 66 and in otherswise good health something has changed and I know it is all hormone driven. Aches, pains, weakness, blurred vision, memory issues, cold, hot, night sweats, hypothyroid then after medicine adjustments hyperthyroid. I've developed reactive hypoglycemia and have gone from a weight of 215 to 180 in two months. Over the past 10 months I have been sicker than ever before in my life. I regret ever having my thyroid removed. I am praying that I might see a physician, as last resort, at MSL to see if they can help me live a better quality of life. So glad I saw this article on line today.

We are sorry to hear that you are experiencing these symptoms. We recommend that you consult with a specialist who might be able to help address these effects. For further information, you might also contact the Thyroid Cancer Survivors Association, which has support groups other helpful resources and can be found at this link:

Your article is very interesting, but I wonder about your recommendation of observation and removal of part of the thyroid. I submit the following family history. I am a 79 year old female. My father had thyroid cancer, had 1/2 removed and at that time follow up was not advised. He died about 10 years later of cancer which was in his lungs and brain. In 1997 I was diagnosed with papillary thyroid cancer and given the option of complete or partial thyroid removal. I chose complete removal and there were two treatments with radio active iodine. The wonderful doctor who treated me and most of my family was James Hurley at NY Presbyterian Hospital in NYC. Dr Hurley advised that my siblings and our children be observed. My brother, 6yrs younger that me had thyroid cancer and opted for i/2 removal of his thyroid. He was treated by a different doctor. Two weeks later the tissue came back with microscopic evidence of cancer in the remaining lobe. They needed to go in again and remove the other lobe. My sister ,12 years younger than me was "under observation" . Several years later, she showed evidence of thyroid "changes" and surgery was advised. She elected complete removal. WE have two first cousins ,in England, one of which had thyroid issues (not sure what they were) and the other, in some years after my surgery, was tested and she tested positive for thyroid cancer. Her whole thyroid was subsequently removed. Next generation. MY daughter in her 40's was under yearly observation until in her 50's, when she exhibited definite changes in the structure of her thyroid. It was completely removed. Several years later my son (now in his 50's) went for a check up and he showed definite evidence of thyroid cancer. His complete thyroidectomy showed surrounding tissue involvement and radio active iodine treatment was undertaken. My brother's children -2 daughters have thyroid issues. One has Hashimoto's (sp?)Disease and the other has been under observation for developing polyps which previously were not found. My sister has two children and the younger of the two had been diagnosed with thyroid cancer in his late 30;s. His subsequent complete removal revealed substantial surrounding tissue involvement . The two subsequent radio active iodine were not as successful as he would wish in-spite of constant assurances , by his doctors that he is and will be living a long and healthy life. The next generation has not been tested, but will be.
Ineach of these cases I feel that observation and /or partial removal would have led to unnecessary stress, concern and fear for all and their families as well. That is my story.

As a head and neck surgeon, I believe that over treatment is a major problem in thyroid cancer, but how can we manage the anxiety of patients who recommended to follow up their cancer.

Leila, anxiety is certainly common among people with cancer, and it certainly may be an issue for those who choose active surveillance. We offer assistance to help people with anxiety through our Department of Psychiatry (such as cognitive behavioral therapy), our Social Work Department (counseling, lectures, and support groups), and our Integrative Medicine Service (complementary therapies). There is also patient education information available on our website that can help patients manage stress (blog posts and videos such as this one: We encourage our patients to report any symptoms, including anxiety, to their treating oncologist or nurse for appropriate follow up.


I recently had total
Thyroidectomy for papilary cancer 7mm on ultrasound. I was losing weight, having palpitations, fatigue, memory issues, swallowing problems on this subcentimetere lesion! If my dr has decided it would be worthwhile to just monitor because it is so small, then I cant imagine my life with all these symptoms! I am glad I had my thyroid removed. People ask me how it was diagnosed since it was so small and unlikely to cause symptoms. The symptoms I mentioned above led to a diagnosis by my good dr. I think size alone should not be the basis of whether the cancer needs to be treated. BTW my youngest sister had papilary too but they found it out when it was over 1cm size and had spread to L Ns. She then had 2 RAI and less than 5 years later died of AML at age 34.

I am at a cross roads I was told I had papillary thyroid cancer last week then went to Dr today and he said the tests were incunclusive but the nodule is 1.7cm and looks bad should be removed I'm having major issue with not having a thyroid and Really don't want to take the radio iodine I'm worried about the quality of life after but I am also 38 years old and want to be around for my kids, youngest is 4, for many years scheduled for surgery in one week and Dr is pushing for a full thyroidectomy and iodine

I have a 17 yr old son who just had a biopsy done on a 1.7cm nodule and biopsy came back positive for papillary carcinoma. After seeing three different doctors, the third doctor did a complete ultrasound of the neck area and found multiple enlarged lymph nodes measuring 1.7cm both on the right side of the neck and one on the left side. So doctor recommended a CT scan to see if cancer has spread else where. We have not done the CT scan yet. He has an appointment this coming week for that. All three doctors recommended a thyroidectomy. What are yours thoughts on that and would you recommend a PET scan for someone this young?

Sue, thank you for reaching out. We recommend you speak with his physicians on this issue as we are unable to answer specific medical questions on our blog because every individual case is affected by a large number of factors. If you would like to make an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at
800-525-2225 or go Thank you for your comment.

Hello All. My daughter was diagnosed with papillary Thyroid cancer at age 11. It spread throughout her chest area and lungs. Thyroid removed, one rai treatment and it killed it all. She is now 16 and had her five year dr. appointment today. She no longer needs body scans and the endo appointments are down to twice a year. There is scar tissue left in the neck but the thyroglobulin level is undetectible even when off synthroid in prep for scans and TSH level spiked to 100. I am in favor of the thyroid removal and rai treatment. Five yeas ago I had the same emotions as a lot of people about not knowing what to do. This combination very aggressively attacks the disease. I can't say that she will ever be labeled cancer free but being on the proper level of synthroid afterwards will suppress the the tsh level to the point the disease is dormant. The beginning stages of being diagnosed is overwhelming, five years later it will be a foggy memory. Hang in there and be positive. Best of luck to everyone

It is exciting reading this article. I had a total thyroidectomy in 7/2015 due to Papillary Thyroid cancer, underwent the radioactive iodine ablation in 9/2015. Two nodules were find in 12/2015 and 3/2016. Doctors are talking about a repeated surgery (neck dissection this time). I lost my voice for 6 weeks after the last surgery and am not too excited to undergo another surgery. I am glad to read that your doctors have an updated and possible different approach!

Dear KP, we are sorry to hear about your diagnosis and the health issues you’ve experienced. We wish you our best as you continue with treatment. Thank you for your comment.

I have papillary thyroid cancer. No one in my family has or had it, I am the first. I was diagnosed in June 2011. My blood work came back normal. They did ultrasounds and immediately referred me to endo for a needle biopsy. Then I was told on the phone I had cancer. I had a total thyroidectomy along with 3 lymph nodes removed all which came back cancer. I went though RAI-131 not once but twice 4/2012 and 9/2013, second time was questionable to whether I needed it or not. Then was discovered that my body rejects it and is resistant to RAI 131. Both doses of RAI were high. I have yet to be cancer free, in 6/2015 I had a surgical removal of 4 lymph nodes to be tested. All 4 came back with cancer, so I had a total neck dissection done in 8/2015. Several lymph nodes came back positive for cancer. Since then no reoccurence of the cancer yet, but I had several cyst develop all in the z1 and z2 and z5 quadrants and I just went to the doctor yesterday 6/2016 and there is cyst like things that have formed in the thyroid bed itself. My cancer in 4 doctor opinions and 1 too of the line surgeon state that my cancer is very aggressive which is not normal in papillary. So now I am fixing to undergo a needle ultrasound to see what in the world this is in the thyroid bed. Pending results will tell whether or not I have to undergo yet another surgery. If I have to this will be surgery 4 in my neck alone. I wish I could find a doctor that has treated aggressive papillary thyroid cancer and being a spouse of a active duty sailor, it's hard sometimes to find the right one due to moving all the time. But I keep my fingers crossed that I can go into remission sooner rather than later. :-)

Lisa, we’re sorry to hear that you’re going through this. You don’t say where you are currently based, but we recommend that you seek out a National Cancer Institute-designated comprehensive cancer center for a consultation. Most of these centers will have experts in your type of cancer. You can find a list at Thank you for your comment.

47 yr old female patient with reoccurring follicular thyroid cancer. TT three years ago and high dose RAI. One year scan found reoccurrence in neck bed. Since then, an additional surgery and two ethanol ablations. Now three more tumors in neck bed and possibly in lungs. Looking for alternative options to treat. Cedars Sinai in LA recommended MSKCC for 2nd opinion. Due to travel, limites resources, can consult appointments with your team be done together?

Dear Sherri, we are sorry to hear about your diagnosis. To arrange for a consultation, please call our Physician Referral Service at 800-525-2225. They can answer your questions and provide more information. Thank you for reaching out to us.

Hi There- I'm so happy I saw this article but I do believe the total removal of my husbands thyroid was appropriate. He had a 6.6cm papillary carcinoma with nodal involvement in 2011. Had I131 the following year and Tg levels had been great since. Then earlier this year in Feb. his Endo does the routine labs but then had to move out of State. He notified us but my husband didn't think to review the labs with the Endo's office. After a routine CT for another reason showed 6 lung nodules the largest of which was 9mm and ground glass; we thought to obtain the labs from Feb which showed a Tg level of 3.2 (all previous Tg levels since the TT were .7 or lower). We scrambled to find a new Endo at The Frist Center in Nashville but the soonest they can get him in is October. So in the meantime, we had his PCP do another round of labs to see what the levels were now. Got those results back today and his Tg is now at 10.1. We're having his PCP send the report over to the Frist Center in hopes that they will be able to bump up his appointment. I feel that in certain situations (size of lesion/tumor, cystic nature, and local/distant metastasis) a total removal of the thyroid is warranted. Especially due to the high recurrence rate of PTC. Thanks for letting me share, though.

What is the difference between papillary thyroid carcinoma, classical variant and papillary thyroid carcinoma, Warthin-like variant?

Joan, thank you for reaching out. We consulted with MSK endocrinologist Michael Tuttle, who responds:

“When pathologist look at papillary thyroid cancers under the microscope, they can divide them up into a variety of subtypes depending on what the cells in the nuclei look like. Sometimes, the subtypes are more aggressive than classic papillary but other times they are expected to have essentially the same outcomes. The subtype of papillary thyroid cancer that’s referred to as Warthin-like is generally considered to have the same expected good outcomes as classic papillary thyroid cancer.”

Family member with a 5.6 left lobe thyroid tumor. Tumor cells positive for PAX8,TTF-1 CK7,thyroglobin. Positive for follicular carcinoma .Pulmonary nodules positive.
Starting on Lenvima this week.

I read in depth your wonderful article about the new guidelines for treating thyroid cancer. I have hypothyroidism, and as a work up of my symptoms, had an ultrasound about a year ago, showing a thyroid nodule at 1.1 cm with no cervical lymph node involvement. My repeat ultrasound this year, showed an identical 1.1 cm nodule again with no cervical lymph node involvement. The new TI-RADS systems was used this time, and the nodule was rated a 5, as "highly suspicious of malignancy." A biopsy was recommended both times, however, in scheduling my biopsy, I was able to speak with the chief radiologist who referenced the new guidelines of surveillance. I am an opera singer, and while the Ultra sound guided FNA biopsy itself has little risk, there is a small risk of bleeding, hematoma, while rare. The doctor said he supported surveillance, and said he thinks, if it is cancer, is most likely papillary, which in many cases, stays the same, does not grow or spread. I would like to know, in this wonderful forum, if you see any risks from the biopsy alone to the voice or nerves, and if it would seem prudent to watch and wait. I am right on the border with the size of the nodule at 1.1 cm. Singing is my life, and any side effect could alter my profession. In this forum, it sounds like papillary cancer for many has spread. I was under the opposite impression, and would welcome any advice. I had a test for Calcitonin, that came back normal, however my CEA and Thyroglobulin (Tg) were high, just over the border of normal. Thank you for all that you do.

Dear Rebecca, we’re sorry to hear you’re going through this. Unfortunately we are not able to make medical recommendations on our blog. If you would like to arrange for a consultation with one of our endocrinologists, you can call 800-525-2225 or go to for more information on making an appointment. Thank you for your comment, and best wishes to you.

On February 15,2006 it was first discovered that I had a 2,5 nodule in the left side of my thyroid, . a fnb was done results was nonconcliusive. in September 2018 while getting a mri of my cervical spine that sane nodule was mentioned
an ultrasound was done and i followed up with an indocrinologist. who has now scheduled an needle biopsy for this week Thursday the 26th
I am 77 years old with a history of breast cancer.
i wan to know should i get the 2nd opinion before or after the results of the needle biopsy is done.