De-Escalation Implementation in Low-Risk Papillary Thyroid Cancer: A Nationwide Survey

Background: Over the past decade, management of papillary thyroid carcinoma (PTC) has become increasingly individualized, with less aggressive approaches recommended for low-risk disease. However, real-world implementation of these recommendations remains limited. Objective: 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 non-adherence 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, shortage of experienced surgeons outside major centers, and skepticism regarding guideline safety. Conclusion: Our findings underscore persistence practice variation driven by professional experience and local healthcare infrastructure, underscoring the need for targeted local implementation strategies, particularly outside major urban centers.