New guidelines from the American Thyroid Association (ATA) for managing adults with differentiated thyroid cancer (DTC) include several recommendations aimed at de-escalating treatment where possible, while also suggesting further work is needed to address financial toxicity of this disease.

The guidelines, published in Thyroid in August, represent the first major update for the management of DTC in a decade. The task force that compiled the new guidelines was composed of members from multiple specialties involved in thyroid cancer care, as well as a patient advocate and an expert in systematic reviews, meta-analyses, and guidelines. 

“Over the last 25-30 years, there have been remarkable advances in knowledge affecting the diagnosis and treatment of DTC, but clinical controversy continues to exist in many areas,” the task force wrote.

The new guidelines include more than 80 specific recommendations, many of which will be discussed during a number of presentations at the 2025 ATA Annual Meeting in Scottsdale, Arizona. 

Notable Changes

Among the major changes is an effort to help clinicians better predict risk of recurrence for each of the three main types of DTC — papillary, follicular, and oncocytic — Julie Ann Sosa, MD, of the University of California, San Francisco, told Medscape Medical News. 

Sosa was a co-chair of the current task force and part of the team that published the 2015 guidelines.

Another notable change builds on a small shift made in the previous guidelines regarding treatment of papillary thyroid microcarcinomas, or cancers < 1 cm without extrathyroidal extension and cN0, she added. 

For many years, physicians uniformly performed up-front surgery to address these small, low-risk tumors. In 2015, there was a subtle, but powerful, change in the language marked by use of the word “if,” Sosa said. The 2015 recommendation began: “If surgery is chosen for patients,” and then detailed considerations for clinicians who proceeded with this option.

“We used that little word that most people didn't even notice to say, ‘Well, maybe active surveillance could be considered,’” Sosa said.

The 2025 guidelines now spell out options for a patient with a ≤ 1 cm tumor with low-risk features, including thyroid lobectomy (up-front surgery), active surveillance, or even percutaneous ablative technologies. Guidance is also provided around how best to potentially monitor these patients (with ultrasound), how to define progression of disease, and when to cross patients over to a surgical strategy.

This is an example of what Sosa calls “evidential equipoise,” referring to a careful balancing of medical evidence and a patient’s needs and situation in coming to a decision in these kinds of cases. 

For example, physicians need to consider how anxiety may lead some patients to prefer lobectomy over active surveillance. Or patients may live far from medical centers, making it tougher for them to comply with the needed follow-up for active surveillance.

Digging In

As part of their work in updating the guidelines, Sosa and other task force members did their own systematic review of published research on active surveillance and immediate surgery for low-risk DTC. 

The findings of this review were published in Thyroid in 2022. The task force also did a systematic review of research on serum thyroglobulin measurement following surgery without radioactive iodine (RAI) for DTC and thyroid lobectomy, which was published the same year.

In writing the new guidelines, the authors sought to make clear the varied strengths of the evidence backing each recommendation. 

For example, recommendation 32, stating that remnant ablation is not recommended routinely after total thyroidectomy for patients with ATA low-risk DTC is classified as a “strong recommendation,” made with “high certainty evidence.”

In other cases, the data were not as clear and the authors spelled this out.

For example, when addressing the question, “Can monitoring be de-escalated or discontinued in patients with low-risk DTC?”, the guidelines include a conditional recommendation, based on low certainty of evidence, for discontinuing routine ultrasound for patients with low-risk DTC treated with total thyroidectomy and RAI and a sustained excellent response 5-8 years after initial therapy (recommendation 48). These patients may be followed by checking biochemical markers every 1-2 years. 

In some cases, the evidence was supportive but not compelling enough for a graded recommendation, so the authors offered “good practice statements” as an alternative label in these cases. 

These statements served in cases where “the benefits of the recommended intervention must be obvious and actual certainty of benefits must be high despite the lack of direct evidence demonstrating benefits,” the authors wrote.

Sosa noted that there’s a high bar set for good practice statements in that they require the unanimous consensus of task force members.

“If you're going to use a good practice statement, you must have 100% consensus of all task force members, short of those who have to recuse themselves if they have a perceived conflict in that particular area,” she said.

Active Surveillance and Remission

The 2015 guidelines raised the idea of active surveillance in certain cases such as papillary microcarcinoma. But at the time, more research was needed, the authors concluded. They then called for studies that would examine decision-making and acceptability of an active surveillance approach to thyroid cancer in patients, family members, and clinicians.

The new ATA DTC guidelines now highlight this option in some situations and call for use of the term “complete remission” in some carefully selected cases.

Recommendation 48 includes a good practice statement about phasing out biochemical monitoring. 

“Patients with low-risk DTC treated with total thyroidectomy and RAI and sustained excellent response for 10-15 years do not require continued routine biochemical monitoring for thyroid cancer and should be considered to have achieved a complete remission,” the authors wrote.

‘A Major Shift’

The changes in the 2025 guidelines mark a major shift in how physicians care for patients with thyroid cancer after initial treatment, said Mara Y. Roth, MD, an endocrinologist at the Fred Hutch Cancer Center, Seattle, Washington.

Previously, patients with small, low-risk features were followed indefinitely, said Roth, who was not part of the team that updated the guidelines. This created a lot of anxiety and financial burden for patients. 

“In the past, we followed these patients indefinitely, and so given the financial toxicity and the anxiety that that contributes for patients, I think that's really a huge change in these guidelines, identifying that we can actually stop surveillance for carefully selected low-risk patients and tell these patients that they're in complete remission and get them back to their primary care provider so they don't need to continue to be seen in a specialty clinic,” said Roth, who is also an associate professor in the division of metabolism, endocrinology, and nutrition at the University of Washington School of Medicine.

“There's a lot of clarity with that. Previously most providers were not confident or comfortable providing active surveillance for patients, and so they had to go specifically to a specialized center to have this,” Roth said.

Sometimes ‘More Is More’

In some cases, the guidelines help clinicians and patients weigh the benefits of additional treatment of more advanced cancer.

“Less is more for some, specifically those with very low- and low-risk disease,” Sosa said. “But for some, more is more.” 

In patients with advanced disease “we focus on small molecule therapies directed to druggable targets,” she explained. 

Although recommendation 10 of the guidelines says that genomic evaluation of confirmed DTC prior to surgery is not recommended routinely, there are exceptions. 

These tests can be helpful in determining whether a patient’s tumor will respond to some of the newer cancer drugs, Sosa said. She cited situations she has seen in her practice as a surgeon with tumors that may be borderline resectable. In these cases, “we are now saying to consider molecular testing” to see if a medicine might work to shrink the tumor, thus improving the outcome of surgery, she said.

Sosa recalled a recent case in which a patient with a borderline resectable thyroid tumor underwent molecular testing, although it is “not routinely recommended for biopsies in the guidelines.”

The patient “had a druggable target. We started a drug and 6 months later, his tumor was easily resectable,” she said.

These guidelines were funded by the ATA without support from any commercial sources. The authors of the guidelines, including Sosa, reported no significant financial or competing interests to disclose. Roth reported no relevant financial disclosures. 

Kerry Dooley Young is a freelance journalist based in Washington, DC. She has covered medical research and healthcare policy for more than 20 years.