Do low grade thyroid cancers really require thyroidectomy?

Hlodnicki, who has personally experienced thyroid cancer,1 poses some interesting questions in his rapid response to Brito and colleagues’ article arguing that zealous imaging has increased the detection and treatment of low risk tumours.2

He states that we should not lie or tell half truths to patients. If more patients were fully informed, I think they would opt for a conservative approach. Most patients I see with thyroid cancer have little insight into how indolent the disease can be. They are scared by being diagnosed as having “cancer” and assume that it is aggressive. They are glad it was found “early.” Nobody tells them that this may be an incidental finding of no consequence or educates them about the natural course of the disease. Nobody mentions the nuances of our histopathological understanding or the high rate of “thyroid cancer” on autopsy in people dying from other causes. They would feel much more reassured if they knew that 30% of the population have thyroid cancer but are unaware of it. Instead, the doctor acts as a hero, proclaiming the disease cured by thyroidectomy, but warranting close follow-up to exclude recurrence.

Hlodnicki also questions what we know of the natural course of these low grade cancers in the long term. But I would ask: “Are you completely certain about the long term morbidity of thyroidectomy?” How will over-replacement or under-replacement affect bone or cardiac function over 30 years? We don’t really achieve “physiological” replacement with long acting thyroxine alone. What are the long term consequences of suppressive doses of thyroxine in people with very low risk thyroid cancer?