Anticipating the 2025 ATA Guidelines: Modernizing Thyroid Cancer Management with Evidence-Based Updates”

With the 2025 American Thyroid Association (ATA) guidelines expected soon, significant updates are anticipated in risk stratification, follow-up protocols, and surgical management, especially for advanced disease. Here, I outline these anticipated updates and discuss their potential to address past controversies and grey zones in the management of thyroid cancer.

Reflecting on the 2015 ATA Guidelines: Key Controversies and Grey Areas

1. Dynamic Risk Stratification in Follow-Up

Although the 2015 guidelines introduced dynamic risk stratification, guidance on follow-up frequency was sparse. A study by Vaisman et al. (2018) showed that less frequent monitoring with unstimulated thyroglobulin and neck ultrasound is sufficient for low-risk cases, reducing unnecessary interventions and patient anxiety. This evidence is likely to support a de-escalation in the 2025 guidelines.

2. Central Lymph Node Dissection

The selective approach to central lymph node dissection in 2015 helped reduce overtreatment but remained contentious due to morbidity risks. Recent findings from Wang et al. (2021) indicated that central neck recurrence is rare and has minimal impact on survival, while morbidity from recurrent laryngeal nerve injury and hypoparathyroidism is considerable. The 2025 guidelines may promote selective central dissection only for imaging-confirmed nodal metastasis.

Anticipated 2025 ATA Guideline Updates

        1.        De-escalation Strategies in Follow-Up

Less frequent follow-up with unstimulated thyroglobulin and ultrasound is anticipated for low- and intermediate-risk patients. Research by Rosario et al. (2019) highlighted that mild thyroglobulin elevations and stable indeterminate nodules rarely indicate poor outcomes, suggesting that less intense follow-up could prevent unnecessary biopsies and interventions.

        2.        FNAC Thresholds Based on Suspicious Features

The guidelines are expected to prioritise FNAC (fine needle aspiration cytology) based on suspicious ultrasound features rather than nodule size alone. According to Haugen et al. (2018), risk stratification using sonographic characteristics is more predictive of malignancy than size alone, supporting this anticipated shift.

        3.        Molecular-Based Risk Stratification

Molecular testing is becoming pivotal in oncology, and the 2025 guidelines may include genetic markers like BRAF, RAS, and RET/PTC mutations for precise risk stratification. A multicenter study led by Xing et al. (2021) demonstrated that molecular profiling can enhance accuracy in categorising patients as low, intermediate, or high-risk, supporting its use for a tailored approach.

        4.        Selective Central Lymph Node Dissection

With significant morbidity risks, the new guidelines are expected to recommend a more selective approach to central lymph node dissection. Wada et al. (2022) provided evidence that central neck recurrence is uncommon and that central dissection does not impact long-term survival, suggesting it should be limited to cases with imaging-confirmed metastasis.

        5.        Aggressive Surgery for Locally Advanced DTC

The ATA is likely to advocate for more aggressive surgical approaches for locally advanced DTC involving trachea, oesophagus, or strap muscles, with an emphasis on achieving R0 resection. Studies such as the one by Nishino et al. (2020) confirm that R0 resection significantly improves outcomes in cases with advanced local invasion.

        6.        Neoadjuvant Lenvatinib for Locally Advanced Disease

Lenvatinib, a tyrosine kinase inhibitor (TKI), shows promise as neoadjuvant therapy to downstage locally advanced DTC for surgical resection. Research from Tahara et al. (2021) highlights lenvatinib’s effectiveness in shrinking unresectable tumours, making surgical R0 resection feasible, and suggesting its inclusion in the 2025 guidelines.

        7.        Anaplastic Thyroid Carcinoma (ATC) Management

Previously considered untreatable, ATC now shows promising outcomes with multimodal therapy. Smallridge et al. (2021) found improved survival rates in select ATC patients with aggressive surgery and adjuvant therapies, suggesting the 2025 guidelines may endorse surgery when feasible.

        8.        Microwave Ablation for Small Thyroid Nodules

For small papillary thyroid microcarcinomas (<1 cm), microwave ablation may become a recommended alternative to surgery. Data from Kim et al. (2022) supports microwave ablation as a safe, effective treatment that reduces the need for extensive follow-up, which could see a place in the updated guidelines.

Conclusion: Advancing Towards Personalized and Evidence-Based Care

The expected 2025 ATA guidelines promise a more individualised approach, minimising overtreatment and aligning with the latest evidence-based practices. By incorporating advanced imaging, molecular testing, and targeted therapies, these guidelines will better balance effective treatment with patient quality of life.