Active Surveillance for Low-Risk Papillary Thyroid Cancer

This transcript has been edited for clarity.

Kaniksha Desai, MD: Welcome to the Thyroid Stimulating Podcast. This podcast was created in partnership with the American Thyroid Association to discuss up-to-date diagnosis and management of a wide array of thyroid diseases.

Over the past decade, active surveillance has emerged as a safe, evidence-based strategy for selected patients with low-risk papillary thyroid cancer, challenging the longstanding assumption that all cancers require immediate surgery.

Seminal work from Japan and growing experience in the United States have shown that small thyroid cancers behave indolently, allowing clinicians to monitor them closely with structured follow-up while preserving excellent long-term outcomes. As active surveillance becomes more widely adopted, it requires nuanced clinical judgment, high-quality imaging, and thoughtful conversations about patient values, anxiety, and clear triggers for surgical intervention if needed.

I'm thrilled today to be joined by Dr Whitney Goldner, one of the authors of the 2025 American Thyroid Association differentiated thyroid cancer guidelines, who will share how the new guideline approaches active surveillance.

Dr Goldner is the head of the Division of Endocrinology, Metabolism, and Diabetes at the University of Colorado School of Medicine. She is a nationally recognized expert in thyroid nodules and thyroid cancer. She previously served as professor of medicine and medical director of the Thyroid and Endocrine Tumor Program at Nebraska Medicine, and has had significant leadership roles across the Endocrine Society and the American Thyroid Association, where she's helped shape national conversations on thyroid research, clinical care, and innovation.

Her research interests include environmental exposures and thyroid cancer, molecular testing of thyroid nodules, and quality of life of thyroid cancer survivors, an area which we will also explore in today's discussion. Thank you so much for joining us today, Dr Goldner.

Whitney S. Goldner, MD: Thank you so much, Dr Desai, for having me on this podcast today. It's my pleasure.

Desai: To get started, can you briefly explain what active surveillance is in the context of differentiated thyroid cancer?

Goldner: Sure. I think it's important to start with the definition because this is something that has not necessarily been in our wheelhouse for thyroid cancer until, as you mentioned, the last couple of decades. Even though it has been out there for other cancers, this is something that we were not really accustomed to doing.

When we talk about the term "active surveillance," it's basically watching or choosing as one of the treatment or management methods for thyroid cancers — specifically, differentiated thyroid cancer — to watch the small, low-risk cancers rather than intervene immediately with surgical treatment.

Desai: What types of thyroid cancers are most appropriate for active surveillance? There are some that are not and there are some that are. I think it's really important for our practitioners to differentiate that in the very beginning.

Goldner: Yes. I think it's really important to think about what exactly we are doing for the patients who have these diagnosed cancers. If they have very small, low-risk-appearing differentiated thyroid carcinoma — and usually papillary are the ones that we talk about, (1) because they're the most common ones, and (2) because those are oftentimes the ones that we already know on biopsy that they are a cancer if we biopsy them and it shows papillary thyroid carcinoma.

One of the criteria to consider a tumor for active surveillance is that they have to be low risk by our clinical judgment before we're making this decision. We would not consider watching somebody who we thought had an intermediate- or high-risk cancer, somebody who already had spread outside of the thyroid to either the more local lymph nodes in the neck or distant metastases, or anybody who actually looked like they already had a tumor that was behaving a little bit more aggressively.

If they looked like they had spread outside of the thyroid, if it was touching structures that we didn't want it to touch, like the trachea, or it was very posterior in the gland, and maybe touching the recurrent laryngeal nerve, if somebody looked like they already had some abnormal lymph nodes, none of those are giving me the clinical impression that this is a low-risk thyroid cancer.

Some people will say, "Well, how do you know it's a cancer?" because we oftentimes don't recommend biopsying tumors that are less than 1 cm. That's actually a really good question because many of the studies that initially started this — many of them started in Japan — they did biopsy the tumors less than 1 cm to be able to determine if they were truly cancerous or not.

We, in many iterations of the guidelines, and including the most recent ones, do not recommend routinely biopsying tumors that are less than 1 cm, so you don't have to have a histologic diagnosis. I think most of us who are seeing thyroid cancer patients and looking at ultrasounds on a regular basis, you have high suspicion based off of the imaging characteristics of what is a cancer vs what appears to be more of a low risk of malignancy by ultrasound characteristics.

Desai: I just wanted to summarize. Medullary and anaplastic thyroid cancer would not be considered for this at all. I think you talked about some clinical and ultrasound features. You wanted to ideally have a nodule that's more centrally located in the thyroid gland and not necessarily touching the borders or invading outside of the thyroid gland.

Is there anything else that you would necessarily look for when you're considering a patient, like age, risk profile, or family history?

Goldner: Yes, those are all really good questions. To your first question about which types of cancer, yes, absolutely. We're not talking about anaplastic or what we think would be very aggressive thyroid cancers. That, by definition, would not be a low-risk one. If you had any suspicion that it was a higher-risk one, or you did have some biopsy evidence of a higher-risk tumor, that would not be something that we would consider for active surveillance.

Medullary is also not something that has been included in this group of tumors that have been studied. It really hasn't been looked at extensively for tumors like follicular and oncocytic tumors either, largely because we don't necessarily know that those are cancers when we biopsy them. Those are the tumors that oftentimes are in the indeterminate category when we biopsy them.

We may have additional molecular tests that give us more or less of a suspicion of whether it's truly a malignancy, but oftentimes we won't know that 100% until they're taken out. Much of the conversation has not actually involved those types of tumors, so for the vast majority of the discussion, we're talking about papillary thyroid carcinomas.

Regarding other characteristics, that I would consider — yes, absolutely. Tumors that are in the center of the gland, not touching anything else, with large amounts of rim of normal tissue around them are kind of the perfect cancers or lesions to potentially be able to watch.

Ones that are touching surrounding structures like the trachea, like the back of the thyroid where it might hit the nerve, if it's looking like it's extending outside of the capsule, if it's very near the surface and looks like it might already be extending into, say, the strap muscles overlying it, those are really not ones that we are considering for active surveillance. Ones that have evidence of lymph node metastases are not going to be considered in that category.

Another thing that gets talked about is, well, what about age? Many of the studies that have been done have shown that the older somebody is, the less likely they are to have progression during active surveillance. The Japanese investigators actually were the first to discuss this. They showed that if people were over 60, around 2%-3% progressed in the 10 years that they were followed. That's compared to the younger groups, where if they were under 40, it might be as high as 20% that progressed.

It kind of makes sense that if you're going to follow this long term, somebody who's younger, you're going to have to follow them for much longer; and if their chances of progression are higher, they may not be as good of a candidate as somebody who's older.

I think it also makes logical sense that you need to consider what their other comorbidities are and some of the other factors that go into making this decision. If somebody has other medical problems that actually are of higher risk to their morbidity and mortality than this small thyroid cancer, those might be people that you would consider for active surveillance.

Interestingly, we oftentimes think of whether there is a difference between men and women. It doesn't look like there is necessarily a difference in progression between men and women, but we do know that sometimes men will present with more aggressive disease if they're older.

Those are some of the things that you consider. I think we can't ignore the patient voice in all of this because many times we can think about this scientifically, what the progression rates are and things like that. Some patients feel very strongly they don't want surgery or intervention, and so they might be the ones that really don't want to undergo surgery right away. They want to give it some time and observe it.

We have other people who feel very strongly that they wouldn't want to watch a diagnosed cancer or something that you feel very certain is likely a cancer. I think we have to make that into a shared decision with the patient when making these decisions.

Desai: I'm going to put you on the spot here, but some of the patients that I take care of at my own clinic are on the younger side and female. I've gotten asked on more than one occasion, "Can I watch this and get pregnant?" How do the guidelines address that? How do you address that in your practice? That would maybe be a high-risk group or maybe not?

Goldner: Yes, that's an interesting question about thyroid cancer and active surveillance. We didn't specifically address that in the guidelines for the ATA, calling out pregnancy by itself. However, we do oftentimes recommend that people wait until after pregnancy to do anything invasive so we oftentimes will watch during pregnancy anyway.

There is a guideline published by the Japan Association of Endocrine Surgery that was published in Thyroid in 2021, where they do address this issue of whether active surveillance is safe in pregnancy. They say that it is safe to recommend active surveillance for people who want to become pregnant if they have a low-risk-appearing papillary thyroid microcarcinoma, or something less than 1 cm.

They still should be monitored, but they feel that is a safe decision to let them continue to do active surveillance.

Desai: Thank you for sharing that guideline. For our listeners, this is different than someone who is diagnosed with thyroid cancer during pregnancy, which is a whole separate issue. This would be for somebody who was diagnosed with thyroid cancer prior to even getting pregnant.

What is monitoring? You alluded to it that it is safe during pregnancy, but can you talk a little bit about what monitoring looks like?

Goldner: Most people who have suggested monitoring — and really, we take the lead from how the studies were designed, how often they followed them. Most guidelines specify following with a high-level ultrasound. You want to make sure that you're not only getting great detail of the thyroid and the nodule itself, but also of the central and lateral neck lymph nodes every single time.

You want to make sure that you trust the ultrasounds that you're getting to give you a good look at the whole neck, and that's roughly every 6 months for the first couple of years. After that point, I think that then depends on whether there has been any change at all. Where's the patient at? What are the other things that they're planning to do? Like you said, if somebody wants to get pregnant, would we alter that timeline or would we increase it depending on what's happened? That's generally what we do.

There's not really a recommendation to stop following with ultrasound because this is a relatively new area; we haven't had that many years to necessarily follow people and then stop it. I think that that data will be forthcoming in the future, but for now, it doesn't really stop, but it may decrease in frequency to follow them.

Certainly, you want to follow thyroid function tests and make sure that they're in the normal range, but there's not really an indication to suppress thyroid hormone levels fully like you would with somebody who's had a more advanced cancer. We did address thyroglobulin in the ATA guidelines, and it is not recommended to use that serially because thyroglobulin could be coming from normal and abnormal or cancerous tissue. That has not really been studied extensively in this setting and doesn't really have a big prognostic role at this point.

Desai: No thyroglobulin, TSH normal: Just to clarify, you would not give any sort of thyroid hormone as long as the TSH is normal?

Goldner: I think that it would depend on where their TSH was. In the newer guidelines, we have changed the categories of where the TSH should be to state in the normal range vs subnormal, rather than getting more prescribed values, like 0.5 to 2, where it was previously.

In somebody with a diagnosed cancer, I probably would want to keep them on the lower end of the normal range. If they're hanging out at 4.5, I probably would give them a little bit of thyroid hormone just so that we're not seeing their TSH rise and potentially stimulate growth.

If it's in the normal range and they're not already on something, I don't think that you need to start them on something to suppress their levels. Lower end of normal, from my standpoint, I think would be reasonable.

Desai: If you're watching the nodule on ultrasound imaging, what would you consider a trigger for surgical intervention?

Goldner: From objective standpoints, it's if anything changes with that nodule while you're monitoring it, so if it develops any of those more worrisome characteristics. It's starting to touch the trachea and looks like it might be potentially invading outside of the thyroid capsule or it's growing and touching the posterior capsule. If somebody develops new hoarseness that you think actually might be related. If somebody develops lymph nodes that look abnormal and you've biopsied them and they’re metastases. All of those things would be reasons to convert to then taking them to surgery.

You also want to consider how the patient is doing with the active surveillance. Is this something that they're very comfortable with, and with each time that it shows stability, they feel more comfortable with it? Do they get very nervous and anxious every time and it's actually creating more of a problem than just addressing it with a surgical treatment?

Some of the studies that have informed these guidelines, when they followed people over time, some of the reasons for surgery were because they had progression. Usually less than 10% of people progressed. Some of the time, people ended up having surgery because it was patient preference, not because the tumor was necessarily changing. You have to take all of that into account, too.

Desai: You were just mentioning that only 10% of them grew. What are the long-term outcomes over 5, 10, or 15 years? I think in Japan they maybe have some decades of experience with this. What does it show?

Goldner: In general, some actually got a little bit smaller. Many stayed stable, and depending on the age group and the study that you look at, generally the progression rate, if you're looking at all-comers, was that roughly less than 10% went on to have surgery.

Now, as I mentioned before, it depends on the age. The younger ones seemed to have more progression than the older-aged patients. You have to take that into consideration. That's partly why active surveillance has become acceptable as one of the treatments for low-risk, less than 1 cm papillary or differentiated thyroid carcinomas, because it does appear to be so safe.

Even when they've compared waiting and then doing surgery later to just doing upfront surgery, people seem to have the same outcomes. They do not have increased mortality, and size oftentimes doesn't make them into an intermediate- or higher-risk category. Oftentimes, they are still low risk in the vast majority of cases when they convert to surgery.

Desai: Delaying it might not necessarily make a huge outcome in the long term. This is a safe alternative and it's been around, right? Why isn't it more adopted? Can you talk a little bit about what some of those barriers might be?

Goldner: Many times in medicine we want to make sure things have been studied and looked at over and over again before we adopt new things, especially when it is in the realm of cancer and deescalating treatments, because that can be a scary thing for people.

As you mentioned, the Japanese groups started this decades ago and have been doing it for a long time, and that's where we look to for much of our data and our knowledge about this. They have, as a society, been more adopting of active surveillance and treatment of their patients than things have been, say, in the United States.

In the last set of guidelines, prior to this most recent one, it was mentioned to consider it for low-risk papillaries but was not a recommendation like it is now as an effective alternative. I think that it just took that much more time for data, but I also think that there sometimes is a trend toward being slow to adopt things that are deescalating care, especially in the United States.

We have just been a little bit slower in the United States to offer that, I think, as a group of practitioners. If we are not comfortable with it as physicians, then we're not going to necessarily recommend it to our patients. In the recent guidelines, we tried to summarize all of the previous data, the safety data, and looking at whether this truly looks like it is equivalent.

The data have been there for decades, especially with the Japanese group, showing that it does look like it is a safe alternative for patients who feel like that's an appropriate choice for them. I think that it is gaining some traction, and more and more people are discussing it, and patients are actually hearing about it.

They're seeing things online about it. They're hearing these medical statements. They're seeing what guidelines come out, and so it may be that patients, as they develop more knowledge about it, may be asking for that more also, as well as physicians presenting it as an option.

I think that wave may be changing, but it's certainly not the option for everybody. We still need to think about the individualized approach to each person.

Desai: Hopefully the new guidelines will really empower people to suggest this more frequently and be more accepting of it if it's a patient's suggestion, and really expanding on that doctor-patient relationship and patient-centered care. You talked a little bit about how patients can read about it, and they're really more invested culturally now in their own care as well. Do you have any tips or information that you'd like to share with patients who are newly diagnosed with these small papillary thyroid cancers?

Goldner: It's always great to take these questions to your physicians because there can be a large amount of information out there on the internet. Much of it's really good, but a large amount of it is not necessarily in line with what we'd recommend. As a consumer, when I'm reading about things that I don't know much about, I don't know sometimes which things to believe and which things not to.

If you're running across things as a patient, I would take those questions to your provider and ask about whether you are eligible for certain things. What are the characteristics of your tumor that make it acceptable or not acceptable? Talk through many of the issues that need to be considered.

I also think that it's good to go to things like university websites that have information about some of these medical topics or societies, such as the American Thyroid Association, the Endocrine Society, and various organizations, that actually spend time putting together patient information.

ThyCa is a great patient support group that has a large amount of information. Those are places where we try to keep the data as up-to-date as possible. I think that it's always good to have these dialogues with your providers, and then say, "Okay, am I the perfect per person for this?" After you have your discussion, make an informed decision with your physician so that it can be something that you're both comfortable with.

Desai: On the back end of that, what advice do you have for clinicians who want to incorporate this into their practice? Any tips you have for them?

Goldner: As I mentioned before, sometimes we want to wait until there's enough data that we feel comfortable making these recommendations. In the guidelines, we spell out the recommendation itself. The reason that the guidelines are so long is because the recommendation is stated, but then all the data to support that recommendation are written in the text of the guidelines.

If you have questions about what data led to this decision to recommend active surveillance, you can actually go and see all of the data that were reviewed and what informed that guideline, because that may be something that your patients ask you, too, or you can get a little bit more information about some of the things we talked about today.

I also think that it's reasonable to reach out to your peers, other physicians, and have a dialogue about it, about what people have experienced being the physicians offering it vs ones who haven't. What have people experienced in the real world? Because sometimes it's easy to read it in a guideline but harder to know how that actually goes.

Having communities of physicians who discuss this means we'll learn more. We don't know everything there is to know about all the criteria to do this. One of the things we haven't talked about, or I didn't mention, is, what is the optimal size? Right now, the guidelines just recommend it for T1a or tumors that are less than 1 cm.

There have been groups who've tried to look at whether we can do this in tumors that are bigger than 1 cm. There are some data on that, that we discuss in the guidelines also, with what was out there. It may be that the size threshold continues to increase over time as we have more data.

It's also important for us to keep studying this. I don't think that we know everything there is to know. Continuing to do studies and trials to figure out what is the right approach is also important to inform future guidelines.

Desai: What new developments do you see coming in this space? I know one of them is obviously size, which you mentioned, so there might be more data on size. Do you see any role of active surveillance vs radiofrequency ablation, or are there other areas you see where there might be more research coming out?

Goldner: In the guidelines, we addressed that issue also. Active surveillance is now recommended as an alternative for the low-risk, T1a tumors, but so are potentially nonsurgical techniques like radiofrequency ablation for those who are eligible for active surveillance but may not want to observe, and that lesion may be amenable to treating it with radiofrequency ablation. I can see this being a good alternative for people who don't feel comfortable just watching, but they also don't feel very comfortable going straight to surgery if that feels too invasive for them.

There are fewer data about that, but there are many things emerging in this space. We know that radiofrequency ablation has been found to be a good treatment alternative for many benign nodules. Now, it's emerging for some of these small, low-risk thyroid cancers that could be treated. In that case, some of the studies have shown that they do go away completely in some of the patients, or they certainly shrink because they're undergoing a treatment.

I think more data are going to emerge in that area, and that may be a really good option for people who are in between active surveillance and wanting to go to surgery, and then they feel like they've had yet a third option.

Desai: Thank you for sharing that. What pieces of advice do you have for our listeners today if they had to take away a couple of points from this topic?

Goldner: I think that when people initially think of cancer, their initial thought is, okay, I have to go get it taken out right away. In the realm of low-risk thyroid cancers, we now are providing an alternative for that.

Not everybody has to race to surgery as their only option for treatment, which I think is actually a good option for patients. That's something to keep in mind — that there may be something other than just going straight to surgery.

The second thing would be, this is not for everyone, but it may be for a subset of people who have low-risk cancers who really want to avoid any surgical intervention, want to not have to take thyroid hormone or things like that, and who look like they are not having aggressive disease.

This may be a really good option, especially in potentially older patients who have lower risks of it progressing and may have comorbidities that make them not want to undergo general anesthesia for a surgery.

Third is just remembering that this is an emerging field, and so there's going to be a large amount of research and data coming out, I think, in the next few years and decades that will probably continue to inform how we approach these, and probably change our practices even further. Continue to ask the questions and see where we're at with our newest data.

Desai: Thank you. Thank you for joining us today for this important discussion on active surveillance in thyroid cancer.

Goldner: Thanks for the invitation, and I hope it's been helpful for all the listeners.

Desai: Thank you, everyone. We're grateful to have Dr Goldner here today, sharing her experience and insights, and we hope this conversation helps clinicians and patients navigate this evolving area of care with confidence.

If you want to hear more about the 2025 thyroid cancer guidelines, make sure to check out Dr Sosa's episode on the guideline overview. This will be our final episode of 2025, so stay tuned for more conversations and upcoming topics in 2026, including one in January with Dr Tufano on nanosecond pulse-field technology for thyroid nodules.

Cite this: Active Surveillance for Low-Risk Papillary Thyroid Cancer - Medscape - Dec 10, 2025.