Choosing the Right Treatment for Thyroid Cancer

Hi, I’m Dr. James Wu, endocrine surgeon at UCLA Health. In this video, I want to talk about a really common and important decision in thyroid cancer care—how we choose between surgery and active surveillance for papillary thyroid cancer, and how ultrasound features help guide that decision.

If you’ve recently been diagnosed with papillary thyroid cancer, you might be feeling overwhelmed. And that’s totally understandable. One of the first big questions that usually comes up is, “Do I need surgery?” And if so, “Do I need the whole thyroid removed, or just part of it?” But what you may not realize is that in some cases, we might not need to operate right away at all—we might just monitor the cancer carefully over time, using ultrasound.

This is called active surveillance, and it’s an option for some people with low-risk papillary thyroid cancer. And deciding whether you’re a good candidate comes down largely to what we see on neck ultrasound.

So let’s take a step back and talk about the role of ultrasound in all of this. Ultrasound is our most powerful tool in evaluating thyroid cancer—it gives us a detailed look not just at the nodule itself, but also how close it is to surrounding structures like the trachea and the recurrent laryngeal nerve, and whether there are any suspicious lymph nodes nearby.

For patients with very small tumors, less than 1 and one half centimeters, if the cancer is sitting within the thyroid, not pushing up against critical structures, and we don’t see any suspicious lymph nodes on ultrasound, then you may be a candidate for active surveillance. That means instead of rushing to surgery, we keep a close eye on things with regular ultrasounds—usually every 6 months.

And we’ve learned from long-term studies, from centers of excellence that developed the idea of active surveillance, that this approach is very safe for the right patients. Most small cancers don’t grow at all over many years, and even if they do, we can still do surgery later with the same excellent outcomes.

On the other hand, if the ultrasound shows that the cancer is right up against the trachea, the nerve that controls your vocal cord, or if it’s starting to break through the thyroid capsule, we’re more likely to recommend surgery. These features suggest a slightly higher risk of the cancer spreading or causing complications over time, so we’d rather treat it earlier.

Now, let’s say active surveillance was not a good option, and surgery is preferred. The next big question is—how much surgery do you need? Should we remove just the half of the thyroid with the cancer, which we call a lobectomy, or the entire thyroid, which is a total thyroidectomy?

Again, we look at the ultrasound to help guide this decision.

If the cancer is small, limited to one lobe, and the other side of the thyroid looks completely normal, then a lobectomy is often enough. That’s a great option for many patients because you keep half of your thyroid, so you may not need lifelong thyroid hormone replacement. Less surgery also means less risk of voice change after surgery, and zero risk of low calcium after surgery.

But if the ultrasound shows that there are suspicious nodules on both sides, or if the thyroid cancer is extending outside the thyroid and into what is nearby, we may recommend removing the whole thyroid.

The ultrasound also helps us evaluate the lymph nodes in the neck. If we see abnormal-looking lymph nodes, especially in the central neck or the lateral neck, we may do a needle biopsy to check for spread. If cancer has spread to the lymph nodes, that usually tips the decision toward a total thyroidectomy, along with removing the involved lymph nodes in the same surgery.

So really, the ultrasound is the map that helps us figure out not just whether to operate, but how extensive that surgery needs to be. It’s why we do the ultrasound ourselves or make sure it’s done by someone highly experienced in thyroid imaging—it’s that important.

Now, beyond the imaging, we also look at your individual preferences. Some patients feel more comfortable going straight to surgery, even for small cancers. Others may really value avoiding surgery if it’s safe to do so. There’s no single right answer for everyone—it’s about understanding your options and making the decision that feels right for you.

Most of the time, there are different but equally safe options in thyroid cancer treatment. It is important for your physician to review the imaging in detail and talk about your values and your lifestyle in order to come up with a treatment plan that’s tailored just for you.

If you’d like to learn more or schedule a consultation, visit us at endocrinesurgery.ucla.edu or call 310-267-7838 to make an appointment.

Thanks for watching. I’m Dr. James Wu—take care, and I’ll see you next time.