Med2Date — Clinical Guidelines
Home Oncology Thyroid Cancer

Thyroid Cancer

Last updated 31 May 2026 · Oncology clinical guideline

📋 Key Information Summary

📋
  • Thyroid cancer is the most common endocrine malignancy; Australia records ~3,800 new cases annually with age-standardised incidence rising ~3% per year, largely due to increased detection of small papillary cancers.
  • Four principal subtypes: papillary (PTC, ~80%), follicular (FTC, ~10%), medullary (MTC, ~5%), and anaplastic (ATC, ~2%); mixed differentiated thyroid cancers are classified as differentiated thyroid cancer (DTC).
  • Fine-needle aspiration (FNA) cytology is the diagnostic cornerstone; results are classified using the Bethesda System (Bethesda I–VI) to guide surgical decision-making.
  • High-resolution ultrasound is the first-line imaging for thyroid nodule characterisation, cervical lymph-node assessment and surveillance post-treatment.
  • Total thyroidectomy (± central compartment dissection) is the primary surgical treatment for DTC >1 cm, MTC, and ATC when feasible; lobectomy is appropriate for low-risk PTC ≤4 cm confined to one lobe.
  • Adjuvant radioactive iodine (RAI, I-131) remnant ablation is indicated for intermediate- and high-risk DTC per 2015 ATA risk stratification; low-risk patients may be managed without RAI.
  • TSH suppression therapy with levothyroxine targets TSH 0.1–0.5 mIU/L (intermediate risk) or <0.1 mIU/L (high risk) to reduce recurrence; over-suppression increases osteoporosis and atrial fibrillation risk.
  • MTC is not iodine-avid; management centres on total thyroidectomy with central ± lateral neck dissection; systemic options include tyrosine kinase inhibitors (selpercatinib, pralsetinib for RET-mutated disease).
  • ATC is one of the most aggressive human malignancies (median survival 3–6 months); BRAF V600E-targeted therapy (dabrafenib + trametinib) has improved outcomes when mutation is present.
  • All patients should be discussed at a multidisciplinary team (MDT) meeting including endocrinology, endocrine surgery, nuclear medicine, medical oncology, radiation oncology and pathology.
  • Thyroglobulin (Tg) and anti-thyroglobulin antibodies (TgAb) are essential surveillance markers for DTC after total thyroidectomy and RAI; rising Tg post-ablation signals possible recurrence.
  • Aboriginal and Torres Strait Islander peoples present with more advanced disease and have lower 5-year survival rates; culturally safe, community-based follow-up programmes are critical.

Introduction & Australian Epidemiology

Thyroid cancer encompasses a heterogeneous group of malignancies arising from thyroid follicular epithelial cells (papillary, follicular, anaplastic) and parafollicular C-cells (medullary). Surgery — typically total thyroidectomy — combined with adjuvant radioactive iodine (RAI, I-131) and long-term TSH suppression forms the therapeutic backbone for differentiated thyroid cancer (DTC), whereas medullary and anaplastic subtypes require distinct management paradigms.

Australian incidence and trends: According to the Australian Institute of Health and Welfare (AIHW), thyroid cancer was the 11th most commonly diagnosed cancer in Australia in 2023, with an estimated 3,800 new cases per year. The age-standardised incidence rate has risen from approximately 5 per 100,000 in the early 1990s to over 15 per 100,000, primarily reflecting increased detection of small (≤2 cm) papillary thyroid cancers through wider use of diagnostic ultrasound. Despite this, thyroid-cancer mortality has remained stable (~0.5 per 100,000), underscoring the indolent biology of most DTC.

Demographics: Thyroid cancer is 3 times more common in females than males, with a peak incidence in the 30–50 year age group for PTC. FTC is more common in older adults and in iodine-deficient regions (historically relevant in parts of inland Australia prior to iodised salt programmes). MTC occurs sporadically (~75%) or in the context of MEN2A/MEN2B syndromes (~25%). ATC typically presents in patients over 60 years of age.

Survival: Five-year relative survival for all thyroid cancers combined in Australia exceeds 95%. However, survival varies markedly by subtype: PTC 5-year survival >98%, FTC ~93%, MTC ~85%, and ATC <10%.

⚠️
Rising incidence: The rapid increase in thyroid cancer incidence in Australia largely reflects over-diagnosis of small papillary cancers. Active surveillance protocols for papillary microcarcinoma (≤1 cm, low-risk) are under evaluation in Australian centres, following Japanese and Korean models.

Epidemiology & Classification

Thyroid cancers are classified according to the WHO Classification of Endocrine and Neuroendocrine Tumours (5th edition, 2022). The four main histological subtypes differ dramatically in cell of origin, molecular drivers, clinical behaviour and management.

Subtype Cell of Origin Frequency Key Molecular Alterations Iodine Avid
Papillary (PTC) Follicular epithelium ~80% BRAF V600E (60%), RAS, RET/PTC fusions, NTRK fusions, TERT promoter Yes
Follicular (FTC) Follicular epithelium ~10% RAS, PIK3CA, PTEN, PAX8-PPARγ Yes
Medullary (MTC) Parafollicular C-cells ~5% RET (M918T in MEN2B, C634R in MEN2A), somatic RET/RAS No
Anaplastic (ATC) Follicular epithelium (dedifferentiated) ~2% BRAF V600E (often co-existing with PTC), TP53, TERT, PIK3CA No

Risk factors: Ionising radiation exposure (especially childhood), family history of thyroid cancer or MEN2 syndromes, iodine deficiency (FTC), Cowden syndrome, familial adenomatous polyposis (FAP/Gardner syndrome), and obesity (modest association).

Australian patterns: PTC accounts for ~85% of thyroid cancers in Australia, with the highest rates in metropolitan areas correlating with greater access to diagnostic imaging. FTC remains proportionally higher in remote and regional communities. MTC genetic screening (RET proto-oncogene testing) is available through Australian public genetics services and is recommended for all first-degree relatives of index MTC cases.

Pathology — Papillary, Follicular, Medullary & Anaplastic

Papillary Thyroid Carcinoma (PTC)

PTC is the most common subtype. Histologically it is characterised by papillary architecture, overlapping ground-glass (Orphan Annie eye) nuclei with nuclear grooves, and psammoma bodies. Classic PTC, follicular variant PTC, tall-cell variant, and hobnail variant are recognised; tall-cell and hobnail variants carry a worse prognosis. PTC commonly metastasises to cervical lymph nodes (up to 60% on central compartment dissection) and is generally indolent, with distant metastases (lung, bone) occurring in ~5–10% of cases.

Follicular Thyroid Carcinoma (FTC)

FTC is distinguished from follicular adenoma by capsular or vascular invasion — a distinction that cannot be made on FNA cytology and requires histological examination of the excised specimen. FTC tends to spread haematogenously, with lung and bone metastases more common than nodal disease. Hurthle cell (oncocytic) carcinoma is now classified separately by WHO but is managed similarly to FTC. FTC has a slightly worse prognosis than PTC, particularly in patients over 45 years.

Medullary Thyroid Carcinoma (MTC)

MTC arises from parafollicular C-cells and secretes calcitonin and carcinoembryonic antigen (CEA). Approximately 25% are hereditary (MEN2A, MEN2B, or familial MTC) due to germline RET mutations. Hereditary MTC is often bilateral and multicentric. Sporadic MTC commonly presents with a palpable thyroid nodule and elevated serum calcitonin. MTC does not concentrate iodine, rendering RAI therapy ineffective.

🚨
RET testing mandatory: All patients with confirmed MTC must undergo germline RET proto-oncogene testing. First-degree relatives of RET-positive patients require genetic counselling and cascade screening. Children with RET M918T mutation (MEN2B) should undergo prophylactic thyroidectomy by 6 months of age.

Anaplastic Thyroid Carcinoma (ATC)

ATC is a highly aggressive undifferentiated malignancy, usually arising in the context of pre-existing DTC through progressive dedifferentiation. Histology shows pleomorphic giant cells, spindle cells, or mixed patterns with brisk mitotic activity and necrosis. ATC often presents as a rapidly enlarging neck mass with compressive symptoms (dysphagia, stridor, voice change). Distant metastases to lungs, bone and brain are present at diagnosis in ~50% of patients. Median overall survival is 3–6 months, though targeted therapy has improved outcomes in BRAF V600E-mutated tumours.

Investigations — Ultrasound, FNA & TFTs

Thyroid Function Tests (TFTs)

TFTs (TSH, free T4, free T3) are essential initial investigations. Most patients with thyroid cancer are euthyroid. A suppressed TSH may suggest a benign autonomously functioning nodule (though follicular carcinoma cannot be excluded). Elevated calcitonin on a stimulated assay is highly suggestive of MTC.

✔ Available
Serum TSH, free T4, free T3
MBS item 66716. All Australian pathology labs. Fasting not required.
✔ Available
Serum calcitonin
MBS item 66814. Specialist-initiated (endocrinology). Measure if MTC suspected or confirmed. Basal and stimulated (pentagastrin) assays available at major centres.
✔ Available
Serum CEA
MBS item 66818. Useful for MTC staging and surveillance.

High-Resolution Neck Ultrasound

Ultrasound is the single most important imaging investigation for thyroid nodules. It assesses nodule size, composition (solid, cystic, mixed), echogenicity, margins, calcifications (microcalcifications are suspicious), shape (taller-than-wide is suspicious), and vascularity. The ACR Thyroid Imaging Reporting and Data System (TI-RADS) stratifies malignancy risk and guides FNA indication.

TI-RADS Category Risk of Malignancy FNA Threshold Surveillance
1 (Normal) ~0% Not indicated N/A
2 (Benign) <2% Not indicated Repeat US at 12–24 months
3 (Probably benign) ~5% ≥2.5 cm Repeat US at 12 months
4 (Suspicious) 5–20% ≥1.5 cm Repeat US at 6–12 months
5 (Highly suspicious) >20% ≥1.0 cm FNA or surgical excision

Ultrasound is also performed for cervical lymph-node mapping (levels II–VI) to detect metastatic lymphadenopathy, which influences surgical extent.

Fine-Needle Aspiration (FNA) Cytology

Ultrasound-guided FNA is the gold-standard diagnostic investigation for thyroid nodules. Results are reported using the Bethesda System for Reporting Thyroid Cytopathology.

Bethesda Category Risk of Malignancy Recommended Management
I — Non-diagnostic 5–10% Repeat FNA with ultrasound guidance (≥6 weeks later); consider molecular testing or core biopsy
II — Benign 0–3% Clinical and ultrasound surveillance; repeat US at 12–24 months
III — Atypia of Undetermined Significance (AUS/FLUS) 10–30% Repeat FNA, molecular testing (ThyGeNEXT/ThyraMIR if available), or diagnostic lobectomy
IV — Follicular Neoplasm 25–40% Diagnostic lobectomy; molecular testing may guide decision
V — Suspicious for Malignancy 50–75% Total thyroidectomy (or lobectomy if low-risk features); surgery recommended
VI — Malignant 97–99% Total thyroidectomy ± lymph-node dissection; MDT discussion

Additional Investigations

✔ Available
Thyroglobulin (Tg) & anti-Tg antibodies (TgAb)
MBS item 66823. Post-surgical surveillance for DTC. TgAb can interfere with Tg assay; serial monitoring of TgAb trend is informative.
Referral
Diagnostic CT/MRI neck and chest
For staging of locally advanced or metastatic disease. Avoid IV iodinated contrast before planned RAI (delays therapy by 2–3 months).
Specialist
PET-CT (18F-FDG)
Not routinely indicated for DTC. Useful for radioiodine-refractory DTC, staging of ATC, and elevated Tg with negative diagnostic whole-body scan.
Specialist
RET proto-oncogene genetic testing
All MTC patients; available through public genetics services (e.g., SA Pathology, VCGS, NSW Health Pathology). Medicare rebate under MBS item 73289.
Specialist
BRAF V600E mutation testing
Immunohistochemistry or molecular (PCR/NGS) on FNA or surgical specimen. Relevant for PTC prognosis and ATC targeted therapy eligibility (dabrafenib + trametinib).

Management — Thyroidectomy, Radioiodine & TSH Suppression

Surgery

Surgery is the primary treatment for all thyroid cancer subtypes. The extent of resection depends on tumour size, histology, risk stratification and presence of nodal or distant metastases.

Procedure Indication Key Considerations
Thyroid lobectomy (isthmusectomy) Low-risk PTC ≤4 cm, unifocal, no ETE, no LN metastases; Bethesda III/IV (diagnostic) Avoids lifelong levothyroxine in ~75% of patients; completion thyroidectomy if adverse features on final histology
Total thyroidectomy PTC >4 cm, bilateral/multifocal disease, ETE, clinical LN metastases, prior head/neck radiation, familial disease; all FTC, MTC, ATC Performed by high-volume endocrine surgeon (>25 thyroidectomies/year); RLN injury rate <2%, hypoparathyroidism <5% with experienced surgeon
Central compartment dissection (level VI) Clinically positive central LNs (PTC, MTC); prophylactic for MTC and for lateral LN-positive PTC Increases transient hypoparathyroidism risk; permanent hypopara ~2%
Lateral neck dissection (levels II–V) Clinically positive lateral cervical LNs (PTC, MTC) Selective (not radical) dissection of involved levels preferred
⚠️
Surgical expertise matters: Nerve injury (recurrent laryngeal nerve, superior laryngeal nerve) and hypoparathyroidism rates are significantly lower when thyroidectomy is performed by a high-volume surgeon. All thyroid cancer patients in Australia should be referred to an endocrine surgeon experienced in thyroid cancer surgery.

Radioactive Iodine (RAI / I-131) Therapy

RAI is used post-thyroidectomy for remnant ablation and/or adjuvant therapy in DTC. MTC and ATC do not concentrate iodine and are not amenable to RAI.

Indications per ATA risk stratification:

  • Low risk: Unifocal PTC ≤2 cm, no ETE, no LN metastases, no angioinvasion — RAI generally NOT recommended; TSH-stimulated Tg <1 ng/mL post-thyroidectomy supports omission.
  • Intermediate risk: Tumour 2–4 cm, microscopic ETE, <5 metastatic LN (<3 cm), vascular invasion — RAI recommended (activity typically 1.1–3.7 GBq).
  • High risk: Gross ETE, incomplete resection, >5 metastatic LN (>3 cm), distant metastases, aggressive histology — RAI indicated (activity 3.7–7.4 GBq).

Preparation for RAI: Thyroid hormone withdrawal (levothyroxine cessation for 4 weeks, or switch to liothyronine for 2 weeks then stop for 2 weeks) to achieve TSH >30 mIU/L. Alternatively, recombinant human TSH (Thyrogen®, rhTSH) injection avoids hypothyroid symptoms and is now PBS-subsidised for ablation preparation (Authority Required).

☢️
Recombinant human TSH (rhTSH)
Thyrogen® · Thyrotropin alfa · TSH agonist
Dose 0.9 mg IM × 2 doses (Day 1 and Day 2); I-131 administered on Day 3
Route Intramuscular (gluteal)
Renal adjustment Caution in severe renal impairment (reduced clearance)
PBS status ⚡ Authority Required

TSH Suppression Therapy

After thyroidectomy, patients with DTC receive levothyroxine at doses sufficient to suppress TSH below the normal range, as TSH is a growth factor for differentiated thyroid cancer cells. The degree of suppression is tailored to recurrence risk.

💊
Levothyroxine
Oroxine® · Eutroxsig® · Thyroxine sodium
Adult dose 1.5–2.0 μg/kg/day PO (post-thyroidectomy); titrate to target TSH
TSH target — Low risk 0.5–2.0 mIU/L (normal range)
TSH target — Intermediate risk 0.1–0.5 mIU/L for 5–10 years, then reassess
TSH target — High risk <0.1 mIU/L; continue indefinitely if disease persists
Route Oral, 30–60 min before breakfast, on empty stomach
Renal/hepatic No specific adjustment; monitor free T4 to avoid excess
Key interactions Calcium, iron, PPIs reduce absorption — separate by ≥4 hours
PBS status ✔ PBS General Benefit
🚨
TSH over-suppression risks: Chronic TSH <0.1 mIU/L increases the risk of atrial fibrillation (especially in patients >60 years), reduced bone mineral density and osteoporosis (particularly post-menopausal women). Balance recurrence risk against treatment morbidity at each follow-up.

Systemic Therapy for Advanced / Radioiodine-Refractory DTC

For progressive, radioiodine-refractory (RAIR) DTC, multi-kinase inhibitors have demonstrated progression-free survival benefit in randomised trials.

💊
Lenvatinib
Lenvima® · Multi-kinase inhibitor
Dose 24 mg PO daily (continuous); reduce to 20 mg → 14 mg → 10 mg for toxicity
Key toxicities Hypertension (73%), diarrhoea, proteinuria, hand-foot syndrome, fatigue, QTc prolongation
Monitoring BP weekly for 6 weeks, then monthly; LFTs, TFTs, urine protein, ECG
PBS status ⚡ Authority Required (RAIR DTC)
💊
Sorafenib
Nexavar® · Multi-kinase inhibitor
Dose 400 mg PO BD (continuous); dose reduce for hand-foot, diarrhoea, hypertension
PBS status ⚡ Authority Required (RAIR DTC)

Systemic Therapy for Advanced MTC

💊
Selpercatinib
Retevmo® · RET-selective inhibitor
Dose 160 mg PO BD; reduce to 120 mg BD → 80 mg BD for toxicity
Indication Advanced or metastatic RET-mutant MTC with progressive disease
Key toxicities Hypertension, hepatotoxicity (LFT monitoring required), QTc prolongation, dry mouth
PBS status ⚡ Authority Required
💊
Pralsetinib
Gavreto® · RET-selective inhibitor
Dose 400 mg PO daily (fasting); reduce to 300 mg → 200 mg for toxicity
PBS status ⚡ Authority Required

Management of Anaplastic Thyroid Carcinoma

ATC requires urgent MDT involvement. Surgery is usually limited to debulking or tracheostomy for airway protection. Targeted therapy has transformed outcomes for BRAF V600E-mutated ATC.

💊
Dabrafenib + Trametinib
Tafinlar® + Mekinist® · BRAF + MEK inhibitor combination
Dose Dabrafenib 150 mg PO BD + Trametinib 2 mg PO daily
Indication BRAF V600E-mutated locally advanced or metastatic ATC (TGA-approved)
Key toxicities Pyrexia, fatigue, nausea, skin rash, retinal vein occlusion (ophthalmology review baseline)
PBS status ⚡ Authority Required

External Beam Radiation Therapy (EBRT)

EBRT is not routinely used for DTC but may be considered for: incomplete surgical margins with residual macroscopic disease, unresectable locoregional recurrence, bone metastases requiring palliative radiotherapy, and ATC (concurrent chemoradiation with paclitaxel/doxorubicin ± radiotherapy if performance status permits).

Risk Stratification

The 2015 American Thyroid Association (ATA) risk stratification system guides initial treatment intensity, RAI indication, TSH target and surveillance strategy.

Low Risk
Favourable DTC
Intrathyroidal PTC without vascular invasion; no LN metastases or ≤5 micrometastases (<0.2 cm); no aggressive histology; no RAI-avid distant metastases; complete tumour resection.
TSH 0.5–2.0 mIU/L · RAI usually not required · Surveillance: US + Tg q6–12 months × 5 years
Intermediate Risk
Moderate Features
Microscopic ETE; vascular invasion (FTC); cervical LN metastases (≥5, <3 cm); aggressive histology (tall-cell, hobnail, columnar); multifocal PTC with ETE and BRAF V600E.
TSH 0.1–0.5 mIU/L · RAI recommended (1.1–3.7 GBq) · Surveillance: stimulated Tg + diagnostic WBS at 6–12 months
High Risk
Aggressive Disease
Gross ETE; incomplete tumour resection; distant metastases; post-operative serum Tg suggestive of distant metastases; cervical LN metastases ≥3 cm or >5 metastatic LNs.
TSH <0.1 mIU/L · RAI (3.7–7.4 GBq) · Surveillance: stimulated Tg + diagnostic WBS at 6–12 months, then annual for ≥5 years

Dynamic risk assessment: The ATA recommends re-stratifying patients at 6–12 months post-initial therapy based on response to treatment (excellent response: undetectable Tg, negative imaging; incomplete response: persistent structural or biochemical disease). This dynamic approach guides ongoing surveillance intensity and TSH targets.

Special Populations

🤰 Pregnancy
Diagnosis
FNA is safe in pregnancy. Ultrasound is the preferred imaging (no radiation). Avoid CT. MTC calcitonin levels rise physiologically in pregnancy — interpret with caution.
Surgery
If surgery is required, the second trimester (weeks 13–27) is the safest window. For low-risk PTC diagnosed in the second half of pregnancy, surgery may be deferred to post-partum without adverse oncological outcomes.
RAI (I-131)
Absolutely contraindicated in pregnancy. Pregnancy must be excluded before RAI administration. Avoid pregnancy for ≥6 months after RAI (ATA recommendation).
Levothyroxine
Continue levothyroxine; dose increase typically required by 30–50% in early pregnancy. Monitor TSH every 4 weeks; target TSH per trimester-specific ranges (T1: <2.5, T2: <3.0, T3: <3.5 mIU/L).
👶 Paediatrics
Epidemiology
Paediatric thyroid cancer is rare (~1% of childhood cancers) but tends to present at more advanced stage with higher rates of LN metastases and distant metastases (lung). However, prognosis remains excellent (>95% 20-year survival).
Surgery
Total thyroidectomy is generally recommended for PTC >1 cm in children due to high rates of multifocality and bilateral disease. Lobectomy may be appropriate for unifocal PTC ≤1 cm in a single lobe.
RAI
Lower activity doses are used (weight-based or BSA-based dosing). Long-term risks include second primary malignancies and reduced fertility; discuss with nuclear medicine paediatric specialist.
Levothyroxine
Weight-based dosing: 2–3 μg/kg/day (infants), 2–4 μg/kg/day (children). Monitor growth, bone age and TSH/free T4.
MEN2 screening
Children from MEN2 families: prophylactic thyroidectomy timing guided by RET mutation codon (highest risk M918T: thyroidectomy by 6 months; high risk C634R: by age 5).
👴 Elderly
Surgical risk
Increased surgical morbidity (cardiovascular, pulmonary). Pre-operative optimisation essential. ATC is more common in elderly patients.
TSH suppression
Atrial fibrillation risk increases with TSH <0.1 mIU/L in patients >60 years. Use least suppressive dose consistent with adequate cancer control.
Bone health
TSH suppression accelerates bone loss in post-menopausal women. DEXA scan at initiation and q1–2 years; consider bisphosphonate if T-score ≤ −2.0.
🫘 Renal Impairment
RAI
I-131 is renally cleared. Patients with eGFR <30 mL/min require dose reduction and extended radiation safety precautions. Dialysis patients: RAI administered after dialysis session.
Levothyroxine
Hypothyroidism is common in CKD. Dose requirements may be altered; monitor TSH and free T4 closely.
rhTSH (Thyrogen)
Reduced clearance in severe renal impairment; use with caution.
🫁 Hepatic Impairment
Levothyroxine
No dose adjustment required; hepatic impairment does not significantly affect T4 metabolism. Monitor free T4.
Lenvatinib / Sorafenib
Both are hepatically metabolised. Avoid in severe hepatic impairment (Child-Pugh C). Dose reduce for moderate impairment.
Selpercatinib / Pralsetinib
Hepatotoxicity risk; baseline and fortnightly LFTs for first 3 months.
🛡️ Immunocompromised
Considerations
Thyroid cancer management is not significantly altered by immunosuppression. However, RAI patients on immunosuppressive therapy may have blunted immune response post-ablation. Ensure up-to-date vaccinations before RAI hospital admission.
Lenvatinib / Sorafenib
Risk of impaired wound healing — hold for 1 week pre- and post-surgery. Risk of infection; monitor closely.

Monitoring & Surveillance

Post-treatment surveillance for DTC is guided by dynamic risk stratification and involves biochemical (Tg, TgAb, TSH) and structural (ultrasound, diagnostic whole-body scan) assessments.

6–12 weeks post-surgery
First endocrinology review. Check calcium, PTH, voice assessment. TSH, free T4. Commence or adjust levothyroxine. Refer for RAI if indicated.
6–12 months post-RAI
Stimulated Tg (on T4 withdrawal or rhTSH) ± diagnostic whole-body scan. Neck ultrasound. Dynamic risk re-stratification.
Annually (years 1–5)
TSH, Tg (on T4), TgAb, neck ultrasound annually. Low-risk patients with excellent response may transition to less frequent surveillance (q1–2 years).
Years 5–10
Annual or biennial TSH, Tg. Ultrasound per risk category. Consider TSH relaxation if excellent response maintained ≥5 years.
>10 years
Late recurrences possible (especially FTC, tall-cell PTC). Annual TSH, Tg. Low-threshold for imaging if Tg rises.

MTC Surveillance

MTC does not produce thyroglobulin. Surveillance is based on calcitonin and CEA levels:

  • Calcitonin and CEA at 3 months post-surgery, then every 6 months for 2 years, then annually.
  • Doubling time of calcitonin is the most important prognostic marker: <6 months doubling time = poor prognosis, consider systemic therapy.
  • Cross-sectional imaging (CT chest/abdomen or MRI) if calcitonin >150 pg/mL or rising.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health
Disparity in outcomes
Aboriginal and Torres Strait Islander Australians with thyroid cancer present at later stages and have lower 5-year survival compared to non-Indigenous Australians. AIHW data shows significant gaps in cancer outcomes driven by delayed diagnosis, reduced access to specialist services, and systemic barriers to timely care.
Access to surgery & nuclear medicine
High-volume endocrine surgery and nuclear medicine facilities are concentrated in metropolitan centres. Patients in remote and very remote communities face significant travel burdens (often >1,000 km). Telehealth endocrinology consultations, patient-assisted travel schemes (PATS), and Aboriginal Liaison Officers are essential facilitators.
Cultural safety
Cancer diagnosis carries particular cultural significance. Health services must provide culturally safe care, including access to Aboriginal Health Workers / Practitioners, acknowledgement of sorry business and kinship obligations, and gender-sensitive care where requested. Cancer care pathways should be co-designed with local Aboriginal Community Controlled Health Organisations (ACCHOs).
Follow-up adherence
Long-term endocrine follow-up for TSH monitoring and surveillance is challenging in remote settings. Strategies include: local blood collection with electronic result forwarding, shared-care models with ACCHOs, and dedicated recall systems managed by cancer care coordinators.
Health literacy
Patient education materials should be available in plain English and, where possible, in relevant Aboriginal and Torres Strait Islander languages. Explain the rationale for lifelong thyroid hormone replacement and the importance of regular blood tests using visual aids and teach-back methods.
Iodine status
Although Australia is generally iodine-replete due to mandatory iodised salt in bread, some remote Aboriginal and Torres Strait Islander communities may have suboptimal iodine intake. Iodine deficiency is a risk factor for FTC. Urinary iodine testing may be considered in high-risk communities.

📚 References

  1. 1. 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):1–133.
  2. 2. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia. Canberra: AIHW; 2024. Cat. no. CAN 140.
  3. 3. Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association Guidelines for the Management of Medullary Thyroid Carcinoma. Thyroid. 2015;25(6):567–610.
  4. 4. Bible KC, Kebebew E, Brierley J, et al. 2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer. Thyroid. 2021;31(3):337–386.
  5. 5. Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. Am J Clin Pathol. 2009;132(5):658–665.
  6. 6. Schlumberger M, Tahara M, Wirth LJ, et al. Lenvatinib versus placebo in radioiodine-refractory thyroid cancer. N Engl J Med. 2015;372(7):621–630.
  7. 7. Wirth LJ, Sherman E, Robinson B, et al. Efficacy of selpercatinib in RET-altered thyroid cancers. N Engl J Med. 2020;383(9):825–835.
  8. 8. Subbiah V, Kreitner MJ, Gainor JF, et al. Dabrafenib plus trametinib in patients with BRAF V600E-mutated anaplastic thyroid cancer (ROAR). J Clin Oncol. 2022;40(suppl):6015.
  9. 9. Cancer Council Australia. Thyroid Cancer — Guidelines for the Management of Thyroid Cancer. 2nd ed. Sydney: Cancer Council Australia; 2022.
  10. 10. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
  11. 11. Royal Australasian College of Surgeons (RACS). Position Paper on Thyroid Surgery. Melbourne: RACS; 2023.
  12. 12. National Health and Medical Research Council (NHMRC). Clinical Practice Guidelines for the Management of Thyroid Cancer. Canberra: NHMRC; 2020.
  13. 13. AIHW. Aboriginal and Torres Strait Islander Health Performance Framework 2020 — Summary report. Canberra: AIHW; 2020.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).