Sawka Anna M, Ghai Sangeet, Rotstein Lorne, Irish Jonathan C, Pasternak Jesse D, Monteiro Eric, Chung Janet, Su Jie, Xu Wei, Esemezie Alex O, Jones Jennifer M, Gafni Amiram, Baxter Nancy N, Goldstein David P
Division of Endocrinology, University Health Network and University of Toronto, Toronto, Ontario, Canada.
Joint Department of Medical Imaging, University Health Network-Mt Sinai Hospital-Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
JAMA Surg. 2025 Aug 20. doi: 10.1001/jamasurg.2025.2957.
In managing early-stage cancers, active surveillance (AS) may be preferentially favored by older individuals. In counseling patients, it is important to understand the durability of AS in the context of age.
To evaluate the durability of AS in patients with small, low-risk papillary thyroid cancer (PTC) according to age at the time of choosing AS.
DESIGN, SETTING, AND PARTICIPANTS: This single-center, prospective, long-term follow-up cohort study was conducted at a tertiary care hospital in Toronto, Ontario, Canada. Adult patients with small, localized, low-risk PTC less than 2 cm in maximal diameter were enrolled between May 2016 and February 2021. The clinical outcome data were analyzed up to the time point of May 25, 2025, and final data analysis was performed in June 2025.
All patients were offered the choice of AS or thyroid surgery.
The primary outcome was the overall rate of AS crossover to definitive treatment (treatment completed or recommended by an investigator) and the indications. Cumulative crossover incidence function curves were examined according to age, with death from other causes as the competing risk.
A total of 200 patients (155 patients under AS and 45 who had immediate surgery) were followed up for a median (IQR) duration of 71 (59-84) months. Overall mean (SD) age was 52.0 (14.9) years, and 153 patients (76.5%) were female. There were no observed thyroid cancer-related deaths or any distant metastatic disease. The overall crossover rate from AS was 23.9% (37/155; 32 completed treatment, 3 declined surgery for disease progression, and 2 awaiting treatment). Crossover reasons included disease progression (56.8% [21/37]), patient preference (40.5% [15/37]), and ultrasound imaging limitations precluding accurate tumor measurement under active surveillance (tumor border not clearly distinguishable from heterogeneous echotexture of the thyroid parenchyma in a patient with Hashimoto thyroiditis; 2.6% [1/37]). The 5-year age-stratified cumulative overall crossover incidence rates were 41.5% (95% CI, 25.6%-56.8%) in patients younger than 45 years, 20.9% (95% CI, 12.3%-31.1%) in those aged 45 to 64 years, and 5.1% (95% CI, 0.9%-15.2%) in those aged 65 years and older (P < .001).
This single-center Canadian cohort study found that AS is a durable long-term management strategy for small, low -risk PTC, particularly in older individuals. Older individuals may be less likely to cross over to surgery after choosing AS.
在早期癌症的管理中，主动监测（AS）可能更受老年人青睐。在为患者提供咨询时，了解年龄背景下AS的持续性很重要。
根据选择AS时的年龄，评估小的、低风险甲状腺乳头状癌（PTC）患者中AS的持续性。
设计、设置和参与者：这项单中心、前瞻性、长期随访队列研究在加拿大安大略省多伦多的一家三级护理医院进行。2016年5月至2021年2月期间纳入了最大直径小于2 cm的小的、局限性、低风险PTC成年患者。临床结局数据分析至2025年5月25日这个时间点，并于2025年6月进行最终数据分析。
所有患者都可选择AS或甲状腺手术。
主要结局是AS转为确定性治疗（研究者完成或推荐的治疗）的总体发生率及指征。根据年龄检查累积转换发生率函数曲线，将其他原因导致的死亡作为竞争风险。
共200例患者（155例接受AS，45例立即接受手术）接受了中位（IQR）71（59 - 84）个月的随访。总体平均（SD）年龄为52.0（14.9）岁，153例患者（76.5%）为女性。未观察到甲状腺癌相关死亡或任何远处转移疾病。AS的总体转换率为23.9%（37/155；32例完成治疗，3例因疾病进展拒绝手术，2例等待治疗）。转换原因包括疾病进展（56.8%[21/37]）、患者偏好（40.5%[15/37]）以及超声成像局限性导致在主动监测下无法准确测量肿瘤（在一名桥本甲状腺炎患者中，肿瘤边界无法与甲状腺实质的不均匀回声纹理清晰区分；2.6%[1/37]）。年龄分层的5年累积总体转换发生率在45岁以下患者中为41.5%（95%CI，25.6% - 56.8%），45至64岁患者中为20.9%（95%CI，12.3% - 31.1%），65岁及以上患者中为5.1%（95%CI，0.9% - 15.2%）（P < 0.001）。
这项加拿大单中心队列研究发现，AS是小的、低风险PTC的一种持久的长期管理策略，尤其是在老年人中。老年人在选择AS后转为手术的可能性可能较小。
