Beyond Guidelines: Nonclinical Drivers of Surgical Recommendations in Low-Risk Thyroid Cancer

Introduction The 2015 and 2025 American Thyroid Association guidelines recommend thyroid lobectomy as an appropriate alternative to total thyroidectomy for low-risk thyroid cancer (LRTC). Over the last decade, variation has persisted, and total thyroidectomy has remained the predominant procedure suggesting unexplored nonclinical factors impacting treatment decisions. This study aimed to identify nonclinical, surgeon-, practice-, and patient-level factors affecting surgical decision-making for LRTC. Methods Semistructured interviews were conducted with surgeons (general, endocrine, and otolaryngology) from community and academic centers. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Results Nineteen surgeons participated. The mean age was 46.6 ± 8.2 y. Overall, 68.4% were men, and 78.9% were White. Several nonclinical, surgeon-, practice-, and patient-level factors influenced surgical decision-making and fell within two overarching themes: (1) "The Team, the Team, the Team" and (2) "The Patient as a Whole." In "The Team, the Team, the Team," surgeons described two different team dynamics that shaped surgical recommendations decisions—the surgeon–practice team and the surgeon-referring provider team. In "The Patient as a Whole," surgeons emphasized that decisions were swayed by patients' explicit preferences, desired quality of life, prior experiences with cancer, socioeconomic barriers (e.g., insurance, transportation), psychological factors, and desire for resolution. These two interconnected team- and patient-level factors were often balanced with clinical considerations in determining operative extent. Conclusions This study identified important nonclinical, surgeon-, practice-, and patient-level factors that may contribute to variability in treatment decisions about LRTC. Interventions targeted at these factors may be necessary to decrease overtreatment of LRTC.