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Research Letter
October 1, 2020

Association Between Implementation of the 2009 American Thyroid Association Guidelines and De-escalation of Treatment for Low-risk Papillary Thyroid Carcinoma

Author Affiliations
  • 1Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Otolaryngol Head Neck Surg. 2020;146(11):1081-1082. doi:10.1001/jamaoto.2020.3024

De-escalation of therapy for papillary thyroid carcinoma (PTC) has been evolving in American Thyroid Association (ATA) guidelines for patients with ATA low-risk category cancers, ie, patients with PTC tumors of 4 cm or smaller, and with no clinically-positive lymph nodes or extrathyroidal extension (ETE). In 2009, radioactive iodine (RAI) ablation was no longer recommended for patients with tumors smaller than 1 cm; hemithyroidectomy, or at most total thyroidectomy, was endorsed. For patients with larger tumors (1-4 cm), hemithyroidectomy or total thyroidectomy (with or without RAI) were still options.1 To our knowledge, the outcomes of these de-escalation recommendations on the rates of hemithyroidectomy, total thyroidectomy, and total thyroidectomy with RAI for low-risk PTC have not been studied. In 2015, newer guidelines recommending further de-escalation for patients with low-risk disease were published,2 and although National Surgical Quality Improvement Program data evaluated outcomes, population-level data are not yet available.3 We evaluated rates of various treatment options before and after publication of the 2009 guidelines using Surveillance, Epidemiology, and End Results (SEER) data available through 2016. We examined 2 groups of patients with low-risk disease: those with tumors of 1 cm or smaller and those with tumors 1 to 2 cm. Although guidelines make recommendations for low-risk tumors up to 4 cm, we chose to examine trends in patients with tumors only up to 2 cm because there should be less debate about adhering to guideline recommended de-escalation for these patients.