De-escalation implementation in low-risk papillary thyroid cancer: a nationwide survey

Background: Over the past decade, the management of papillary thyroid carcinoma (PTC) has become increasingly individualized, with less aggressive approaches recommended for low-risk diseases. However, the real-world implementation of these recommendations remains limited. Objective: This study aims to assess real-world management patterns and therapeutic preferences regarding surgical extent, radioactive iodine (RAI) use, and thyrotropin (TSH) levels in low- and low-to-intermediate-risk PTC through a nationwide survey. Methods: A nationwide web-based survey was conducted among members of the Greek Endocrine Society (25% response rate) between November 2023 and April 2024. The questionnaire comprised demographic items, 12 clinical scenarios, and a final section exploring general reasons for nonadherence to clinical guidelines; this report focuses on eight scenarios related to low- and low-to-intermediate-risk papillary thyroid carcinoma. Results: For an 18 mm intrathyroidal low-risk PTC, 67.7% of respondents recommended total thyroidectomy, while 51.8% favored adjuvant RAI. When reclassified as low-to-intermediate risk, 92.5% endorsed RAI, often at higher doses (70 mCi), particularly among more experienced and those practicing in large cities. TSH suppression targets in case of excellent response varied: nearly half selected 0.5-2.0 μU/mL for low-risk PTC, but most favored tighter suppression (0.1-0.5 μU/mL) in low-to-intermediate-risk scenarios. Senior endocrinologists prefer traditional approaches. Barriers to guideline adherence included limited access to molecular and ultrasonography testing, a shortage of experienced surgeons outside major centers, and skepticism regarding guideline safety. Conclusion: Our findings underscore persistent practice variation driven by professional experience and local healthcare infrastructure, underscoring the need for targeted local implementation strategies, particularly outside major urban centers.