Highlights From New ATA Guidelines for Thyroid Nodules and Cancer

Thyroid ultrasound
Thyroid ultrasound
The American Thyroid Association's updated thyroid cancer guidelines address risk assessment, personalized treatment, and more.

Important advances have occurred since the American Thyroid Association’s (ATA) 2009 revision of guidelines for the management of thyroid nodules and differentiated thyroid cancer.1

For the latest periodic update mandated by the ATA leadership and published in October 2015 in Thyroid, the task force added expertise in the specialties of medical oncology, pathology, systematic reviews, and epidemiology to complement existing expertise in the areas of endocrinology, surgery, radiology, and nuclear medicine, according to Bryan R. Haugen, MD, a professor of medicine and pathology at the University of Colorado Denver, who led the revision process.2 

“We also adopted a new grading system, revised our questions, extensively reviewed the literature, and generated 21 new recommendations, as well as significantly revised 21 of the 80 recommendations from the 2009 guidelines,” Dr Haugen, who is also head of the division of endocrinology, metabolism, and diabetes at the university, told Endocrinology Advisor.

The guidelines underwent 3 revisions before final acceptance.

Though previous versions have been relevant to patients of all ages, the new guidelines pertain only to adults, and a separate set of guidelines was also published in 2015 with recommendations for treating children with thyroid nodules and differentiated thyroid cancer.3 

“Our questions and recommendations were primarily driven by the facts that differentiated thyroid cancer is rapidly rising in incidence, many of these patients do well irrespective of our management approach, a significant minority of these patients have advanced disease and die from this disease, and this mortality rate is not falling like other cancers,” said Dr Haugen.

Differentiated thyroid cancer accounts for more than 90% of all thyroid cancer cases. While it was predicted that approximately 37 200 new cases would be diagnosed in the United States in 2009 when the previous version of the ATA guidelines was published, that estimate rose to approximately 63 000 new cases for 2014.4 The annual incidence almost tripled from 1975 to 2009, from 4.9 to 14.3 per 100 000 people.5 This change has been largely attributed to an increased incidence in papillary thyroid cancer, which researchers have predicted will become the third most common cancer in US women by 2019.6

“A recent population-based study . . . reported the doubling of thyroid cancer incidence from 2000 to 2012 compared with the prior decade as entirely attributable to clinically occult cancers detected incidentally on imaging or pathology,” the guideline authors wrote.

The purpose of the updated guidelines is to inform providers, patients, researchers, and policymakers about published evidence regarding the diagnosis and treatment of thyroid nodules and differentiated thyroid cancer.

“The recently published ATA guidelines represent an advance in our understanding and management of thyroid nodules and thyroid cancer, and the experts on the committee headed by Dr Haugen should be justifiably proud of their achievement,” Kenneth D. Burman, MD, director of the Endocrine Section at MedStar Washington Hospital Center in Washington, DC, and a professor of medicine at Georgetown University, told Endocrinology Advisor on behalf of the Endocrine Society.

Some specific updates that Dr Burman believes will likely change clinical practice and benefit patients are part of recommendation 48, which describes additional suggestions pertaining to the Initial Risk Stratification system to help predict the likelihood of disease recurrence or persistence in patients with differentiated thyroid cancer. This recommendation also recognizes that risk stratification is a continuum ranging from less than 1% in low-risk patients to more than 50% in high-risk patients.

Recommendation 49 contains another new, important aspect of the guidelines, according to Dr Burman. It indicates that “initial risk estimates should be modified over time depending on the clinical course and response to therapy,” he said. Such reassessments “should result in more individualized, personal treatment of patients and will likely decrease the use of unnecessary tests but will also support the use of more sophisticated radiologic tests and further treatment with 131-I, tyrosine kinase inhibitors, or focused radiologic treatments as indicated.”

Overall, some of the newest and most significantly changed recommendations include the following, according to Dr Haugen: 

  • The introduction of a new way to assess thyroid nodules by ultrasound based on the observed sonographic risk pattern;
  • The introduction of a series of recommendations on how best to approach patients with indeterminate fine-needle aspiration cytology and use of molecular markers;
  • The consideration of 2 different types of surgery for patients with papillary thyroid cancer smaller than 4 cm (lobectomy or thyroidectomy);
  • The introduction of a recommendation for standardized surgical pathology reporting;
  • A new section on surgical approaches to voice and parathyroid protection;
  • The refinement of risk stratification for patients with differentiated thyroid cancer and introduction of a common language to assess response to therapy, which is a more personalized way to guide long-term management;
  • A focus on who should receive radioiodine, for what reason, how much should be given, and how patients should be prepared for radioiodine treatment;
  • Personalized approaches to long-term management of these patients; and

The definition of patients who have recurrent or persistent differentiated thyroid cancer that is refractory to radioiodine and approaches to their care and the introduction of many new figures and tables that will hopefully help guide care for these patients.

“We need to be less aggressive with the majority of patients with differentiated thyroid cancer, while identifying and appropriately treating those at risk for more advanced cancer,” said Dr Haugen. “Hopefully these guidelines strike that fine balance.” 


  1. Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2009;19:1167–1214. doi:10.1089/thy.2009.0110.
  2. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1–133. doi:10.1089/thy.2015.0020.
  3. Francis GL, Waguespack SG, Bauer AJ, et al. Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Pediatric Thyroid Cancer. Thyroid. 2015;25:716–759. doi:10.1089/thy.2014.0460.
  4. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64:9–29. doi:10.3322/caac.21208.
  5. Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg. 2014;140:317–322. doi:10.1001/jamaoto.2014.1.
  6. Aschebrook-Kilfoy B, Schechter RB, Shih YCT, et al. The clinical and economic burden of a sustained increase in thyroid cancer incidence. Cancer Epidemiol Biomarkers Prev. 2013;22:1252–1259. doi:10.1158/1055-9965.EPI-13-0242.