There is a perfect “thyroid storm” brewing within the thyroid cancer community that will certainly result in preventable deaths. The storm has to do with dangerous misconceptions of appropriate management for so-called “low risk” thyroid cancer.

The problem involves confusing two separate issues: biopsy of nodules under 1 cm and treating biopsy-confirmed thyroid cancers over 1 cm.

A recent piece in the New England Journal of Medicine, has been misconstrued by the national press to mean  that for most cases of thyroid cancer, treatment is not necessary. Here’s the original piece:

There is nothing new reported in this epidemiology paper. It confirms the problem of mass screening of thyroid nodules, and confirms that, yes, many biopsy-confirmed thyroid cancers will likely remain indolent.

Misconceptions arise in how this translates from epidemiology to the bedside.

Here’s where everyone agrees: don’t biopsy thyroid nodules under 1 cm. Leave them alone unless there is some other alarming feature, such as invasion beyond the thyroid capsule or obviously enlarged local lymph nodes.

Here’s where it turns into a game of Russian Roulette with the practitioner holding the gun to the patient’s head: tell the patient you will “place bets” that a small biopsy-confirmed thyroid cancer will remain indolent – something no one can currently predict. Odds are it will. But some of the patients will be the unlucky losers of the Roulette game. In fact, all aggressive thyroid cancers, and all eventual lethal thyroid cancers, started as small tumors.

What do the most recent American Thyroid Association (ATA) clinical practice guidelines say? (See:

Well, the guidelines do not recommend observation-only for biopsy-confirmed thyroid cancer and state that there is “not enough evidence” observation is more beneficial than treatment. But the authors do state that IRB-approved randomized controlled-trials regarding observation for papillary carcinomas under 1 cm, also known as papillary microcarcinomas, would help to generate data on this question. Clearly, there is a big difference between enrolling such patients in a clinical trial to investigate the validity of this approach, and having clinicians routinely do this in their clinical practice outside of a research setting and without any research subject protections in place.

What do guidelines say about radioactive iodine (RAI)? Nuclear medicine experts worldwide recommend RAI as beneficial in follow-up and treatment (See: Of note, the ATA’s recent guidelines were not endorsed by the nuclear medicine community in either the United States or Europe. (See, for example:

As a result, the best consensus guidelines to follow regarding radioactive iodine therapy would be the 2009 ATA guidelines, which were endorsed by the entire nuclear medicine community.

What do bioethicists think? Bioethicists who appreciate the nuances of thyroid cancer treatment believe patients must be told about the full treatment options available, including potential benefits of radioactive iodine, as well as the risks associated with observation. Routine observation should not be done outside of the research setting. We say so here:

What will patients say should they become aware that they were not fully informed of their risks and treatment options? Some will say they were unwitting players in a game of Russian Roulette, which can have serious medico-legal consequences for practitioners who are playing this game.