Low Risk for Recurrence of Differentiated Thyroid Cancer: A Paradigm Shift to De-Escalation and Simplifying Care for Long Term Follow-up

Résumé

The incidence of thyroid cancer in Canada increased from 1984 to 2013, followed by a subsequent decline; the most recent projections estimate 6,100 cases in 2026. Low-risk differentiated thyroid cancer (DTC), with an excellent treatment response, is associated with a recurrence risk of less than 2% and a 20-year disease specific mortality of less than 1%. In alignment with the 2025 American Thyroid Association DTC Guidelines and the Follow-up and Transition of Care for Low Recurrence Risk Thyroid Cancer Patients in Canada, thyroid cancer care is undergoing a major evolution. This shift is centred around de-escalation of care, and for the first time, provides guidance on when to consider cessation of surveillance. For patients who have undergone hemithyroidectomy, recommended follow-up includes a one-time post-operative measurement of thyroglobulin (TG) with thyroglobulin antibodies (TGAB), annual thyroid-stimulating hormone (TSH) monitoring (targeted within the reference range), and ultrasound surveillance at 1–3 years. Consideration may then be given to cessation of all monitoring after 5–8-years. For patients undergoing total thyroidectomy (TT) without radioactive iodine (RAI), the new target for a biochemical excellent response is <2.5 ng/mL as well as a TSH level within the normal reference range.

In this population, ultrasound is recommended at 1–3-year intervals following the initial assessment, with consideration of discontinuation between years 5–8 in patients demonstrating an excellent response; Canadian guidelines also recommend cessation of surveillance at year 5. Furthermore, for patients undergoing TT with or without RAI who maintain an excellent response, continued biochemical monitoring beyond 10–15 years is not required. Key elements of care for patients with low-risk thyroid cancer include reduced ultrasound surveillance, maintaining the TSH target within the normal reference range, annual TG/TGAB monitoring, and consideration of cessation of surveillance. Adoption of these principles will enhance patient care while maintaining excellent outcomes.