Introduction
1. Background
In clinical practice, countless decisions must be made in response to diverse circumstances. Historically, these decisions were made predominantly by clinicians, who held superior knowledge and information. However, the growing emphasis on patient autonomy has led to patients being recognized as active participants in medical decision-making. Incorporating patient perspectives is particularly critical in situations where the clinical effectiveness and safety of available options are comparable (clinical equipoise) or when the choice depends primarily on patient values, even if differences in clinical outcomes exist (value–option incongruence) [1–3].
Shared decision-making (SDM) is a process in which patients and clinicians exchange medical information on treatment options and, by reflecting on the patient’s values and preferences, jointly determine the most appropriate choice [4,5]. Unlike the traditional model, where clinicians unilaterally decide, SDM requires equal participation, open discussion, and shared responsibility between both parties. It also differs fundamentally from simple consent or informed consent because it actively incorporates patient values and preferences [1,6]. For example, when a patient with chronic kidney disease must choose between hemodialysis and peritoneal dialysis, both are effective renal replacement therapies. However, the treatment decision may vary depending on the patient’s health status, lifestyle, perceptions of dialysis, and personal values [7]. Thus, in situations where patient values and preferences shape medical choices, SDM is the ideal approach.
Low-risk papillary thyroid microcarcinoma (PTMC) is also a clinical scenario well-suited for SDM [3]. Historically, surgery was recommended for most patients diagnosed with thyroid cancer. However, recent evidence demonstrates that delaying surgery for small thyroid cancers does not increase the risk of distant metastasis or mortality. Therefore, active surveillance, which refers to close monitoring of tumor progression with regular ultrasound examinations without immediate surgery, has been proposed as a viable alternative [8,9]. Because the final treatment decision depends on patient values and preferences, such as their views on cancer therapy, perception of current health, and expectations for quality of life (value–option incongruence), the choice between surgery and surveillance in low-risk thyroid cancer is ideally approached through SDM. In this process, patients must receive comprehensive, objective medical information, including not only recurrence and progression rates but also potential surgical complications and the likelihood of long-term medication use.
Necessity of SDM in low-Risk Thyroid Cancer
Papillary thyroid carcinoma (PTC) is the most common histological type of thyroid cancer. Low-risk thyroid cancer is defined as PTMC with a maximum tumor diameter of 1 cm or less that meets all three of the following criteria: (1) no evidence of lymph node or distant metastasis, (2) no extrathyroidal extension into adjacent structures such as the strap muscles, trachea, or recurrent laryngeal nerve, and (3) absence of aggressive histological subtypes of PTC [8,9]. Low-risk thyroid cancer, as defined, carries an excellent long-term prognosis, even without surgery [10]. To date, no deaths have been reported among patients who opted for active surveillance. Moreover, recurrence rates do not significantly differ between patients who underwent surgery after cancer progression during surveillance and those who received immediate surgery following diagnosis [10]. On the basis of this evidence, both Korean and international guidelines recommend immediate surgery and active surveillance as valid treatment options for patients with low-risk thyroid cancer [11].
However, because active surveillance is not suitable for all thyroid cancers, clinicians must carefully assess whether a patient is an appropriate candidate for choosing between surgery and surveillance. For this reason, the Korean Thyroid Association (KTA) and the Korean Society of Thyroid Radiology have published active surveillance guidelines [8,9,12], which detail tumor and patient characteristics for which this approach is appropriate. The SDM process between surgery and active surveillance should therefore only be initiated for patients who meet all established criteria for low-risk thyroid cancer.
Advantages and Disadvantages of Surgical and Active Surveillance Approaches
Both surgery and active surveillance carry distinct advantages and disadvantages. Surgery provides the benefit of removing the cancer entirely, thereby offering a high probability of cure and psychological reassurance. However, it is associated with unavoidable hospitalization, high costs, surgical scars, the potential need for lifelong medication, and the risk of surgical complications. Should complications occur, patients may regret their choice, raising concerns about overtreatment.
In contrast, active surveillance avoids the immediate physical burden, surgical risks, and high upfront costs of surgery. It also spares patients from undergoing unnecessary surgery if the cancer does not progress. Yet, long-term repeated follow-up examinations may eventually lead to higher cumulative costs than surgery. Furthermore, the psychological burden of “living with cancer and watching it” can induce anxiety or depression in some patients. If the cancer progresses during surveillance, surgery ultimately becomes unavoidable.
Role of SDM
Although both treatment strategies yield favorable prognoses, their respective advantages and disadvantages are not objectively superior to one another. Instead, the preferred option often depends on subjective factors such as the patient’s values and preferences. No single treatment can be universally considered superior, and how an individual patient weighs the benefits and trade-offs ultimately determines their satisfaction. Patients who are uncertain about their choice or dissatisfied with the decision-making process may seek repeated consultations or engage in “doctor shopping,” visiting multiple clinicians and institutions. By employing SDM to select a treatment plan that reflects the patient’s values and preferences, patients can gain greater confidence in their decision and report higher satisfaction.
Clinicians, however, have noted that fear of potential legal disputes in cases where cancer progresses during active surveillance remains a barrier to implementing this strategy [13]. Conversely, patients who face lifelong medication or complications after surgery, or who experience cancer progression during surveillance, may regret their choice and develop distrust or negative attitudes toward their medical team. SDM mitigates this risk by engaging patients as active participants in the decision-making process, thereby increasing both satisfaction and personal responsibility for the outcome. Applying SDM to the treatment of low-risk thyroid cancer enables clinicians to reduce uncertainty by providing accurate and comprehensive information about the pros and cons of both surgery and surveillance. It also helps patients clarify their values and priorities, actively participate in the decision-making process, and enhance overall satisfaction. At a broader level, this approach may reduce the unnecessary consumption of healthcare resources.
Components of SDM in Low-Risk Thyroid Cancer
SDM consists of four essential components [4,14]: (1) active participation by both the patient and clinician, (2) exchange of information and mutual understanding of treatment options and patient preferences, (3) integration of the patient’s values and preferences into the discussion, and (4) decision-making based on mutual agreement. The following section will examine these elements in the context of treatment decisions for low-risk thyroid cancer.
1. Participation by the patient and the clinician
At least two participants—the patient and the clinician—must be actively involved in the decision-making process. The patient should not remain a passive recipient but should instead take an active role by expressing their values and preferences, based on a clear understanding of the treatment options. The clinician, in turn, should respect the patient’s opinions and foster two-way communication rather than relying solely on one-sided recommendations. In some cases, the patient’s spouse, children, or acquaintances may also participate in the process, and their views can strongly influence the patient’s decision. One study reported that patients who chose surgery were significantly more likely to have been influenced by family members than those who opted for active surveillance [15]. This finding suggests that the involvement of family or others who influence the decision-making process can contribute to achieving a more satisfactory decision.
2. Exchange of information and mutual understanding of treatment options and patient preferences
For SDM to occur, there must be a process of reciprocal communication in which adequate information is provided about the benefits and risks of both surgery and active surveillance, while also confirming the patient’s comprehension. This should not be a one-way transfer of information from clinician to patient but rather an interactive dialogue that helps the patient interpret the information in their own words and apply it to their personal circumstances.
1) Information on surgical approaches
Patients must be informed of the specific surgical methods as well as their advantages and disadvantages. Surgery aims to achieve a cure by completely removing the thyroid cancer. Reported outcomes include a 5-year recurrence rate of less than 3% and a 10-year survival rate exceeding 99.9% [16]. However, surgery requires hospitalization and general anesthesia. Depending on the extent and type of surgery, complications such as surgical scarring, recurrent laryngeal nerve palsy, and hypoparathyroidism may occur. For example, total thyroidectomy carries a permanent recurrent laryngeal nerve palsy rate of 0.9% and a permanent hypoparathyroidism rate of 1.8% [17]. Moreover, patients undergoing total thyroidectomy must take lifelong thyroid hormone replacement therapy, and even after lobectomy, 50% to 70% of patients require thyroid hormone supplementation [8].
2) Information on active surveillance
Active surveillance, in contrast, is based on evidence that the natural course of low-risk thyroid cancer is generally favorable. For many patients, the tumor remains stable and does not progress over extended periods. However, in some cases, tumor enlargement or lymph node metastasis may occur. A meta-analysis reported a progression rate of approximately 14.5% (range, 4.6%–29.2%) during active surveillance [10], while a Korean prospective study found that about 10% of patients experienced disease progression over 5 years [18]. When progression occurs, surgery is performed, and some patients may require more extensive surgery or additional treatment such as radioactive iodine therapy. Nevertheless, even in these cases, the disease remains highly treatable, and the 10-year survival rate exceeds 99.9%, equivalent to that of patients who underwent immediate surgery [10].
3) Customized information and communication
Beyond clinical outcomes, patients should be informed that healthcare costs, quality of life, and psychological well-being can also vary depending on the treatment choice. Quality of life and emotional health, in particular, are influenced when patients make decisions after fully understanding their options and reflecting on their values. Therefore, providing tailored information that addresses not only recurrence rates and potential complications but also expected healthcare costs and long-term treatment implications can enhance patient satisfaction with the decision-making process [8].
It is important to note that even when given the same information, patients may differ in their interpretation and understanding. Factors such as age, illness perception, and psychological state can shape how information is received. Clinicians must therefore assist patients in understanding the personal significance of each treatment option and actively verify their comprehension. This requires a communication strategy tailored to the patient’s individual characteristics. Ultimately, a high-quality understanding of the options—not simply the delivery of large amounts of information—is a prerequisite for effective SDM.
3. Reflection of the patient's values and preferences
A central element of SDM is thoroughly exploring the patient’s values and preferences and incorporating them into the treatment decision. In cases of low-risk thyroid cancer, since both surgery and active surveillance are clinically valid options, patient values and preferences play an especially critical role in determining the treatment plan. While both strategies yield excellent long-term prognoses, their physical, psychological, and social impacts differ, and the perception and acceptance of these impacts can vary significantly across individuals. Because patients often do not initially have a clear understanding of their own values or preferences, clinicians must go beyond simply presenting information. They must assist patients in identifying and articulating their concerns, expectations, and life priorities.
Previous studies indicate that patients who chose immediate surgery frequently cited anxiety about the mere presence of cancer or fear of its potential future progression as key reasons for their decision [15,19]. Some patients who initially selected active surveillance later switched to surgery because of persistent or worsening anxiety. A Korean prospective study found that 55.5% of patients who underwent delayed surgery during surveillance did so primarily due to psychological anxiety, not because of objective disease progression [18]. Research on psychological traits shows that patients with high levels of anxiety are more likely to choose surgery, and some continue to experience anxiety even after the operation [20,21]. Furthermore, individuals with an “active coping” style—those who actively attempt to manage challenging situations—demonstrated a stronger preference for surgery [19].
In contrast, patients who opted for active surveillance tended to avoid concerns about surgical complications, lifelong thyroid hormone replacement, and potential declines in postoperative quality of life [15,19]. They were also more accepting of surveillance when they believed that, even if the cancer progressed in the future, it could still be adequately treated with surgery at that time [15].
Thus, the decision between surgery and active surveillance is not determined solely by clinical evidence but involves a complex value judgment shaped by cognitive and emotional factors, personal priorities, and personality traits. For example, surgery may be more suitable for patients with significant anxiety about harboring cancer or fears of progression, while active surveillance may be preferable for those more concerned about surgical complications or long-term medication use.
Accordingly, clinicians should actively explore each patient’s inclinations, values, and priorities during consultations and explain treatment options within that framework. Maintaining a supportive and empathetic attitude enables patients to reflect on their concerns and expectations. This process helps patients select the treatment most compatible with their circumstances, thereby increasing satisfaction and acceptance of the chosen plan.
4. Decision-making based on mutual agreement
The final component of SDM is reaching a treatment decision through mutual agreement between the patient and the clinician. This process is not unilateral, in which the clinician merely provides information and the patient chooses. Rather, it is collaborative: the clinician supplies sufficient evidence-based information about prognosis and risks, while the patient interprets this information in light of their personal context. Both parties, with an understanding of the advantages and disadvantages of each treatment option and the patient’s values and preferences, engage equally in the decision-making process.
The ultimate aim of SDM is to arrive at a “customized treatment strategy” that balances medical validity with the patient’s circumstances. Thus, the decision should not be seen as a simple choice but as a shared conclusion founded on mutual trust and respect.
When decisions are made without adequate information or without incorporating the patient’s values, the result may be regret, dissatisfaction, and emotional distress, which can undermine quality of life after treatment and weaken trust in the medical team. Conversely, decisions made through mutual agreement enhance acceptance of and satisfaction with the outcome. They also reinforce patient confidence and responsibility for the decision, even if complications occur or the disease progresses, thereby reducing unnecessary visits and reliance on healthcare facilities.
SDM Model for Low-Risk PTMC
Various structured SDM models have been proposed to effectively implement SDM in clinical practice. These include the three-talk model [22], the SEED model [23], the SHARE approach model [24], and the more recently published six-step model by Clayman et al. [25]. While all these frameworks incorporate the four core components of SDM (participation, information exchange, value reflection, and mutual agreement), they differ in the number of steps, their sequence, and the specific strategies they employ.
We determined that the six-step model is most appropriate for low-risk PTMC, given the clinical workflow from diagnosis to treatment and the specific characteristics of both patients and clinical practice environments. Based on this framework, we constructed a PTMC-specific SDM model (Figure 1) and are currently conducting a prospective cluster randomized controlled trial to verify its effectiveness (MAeSTro-SDM study; ClinicalTrials.gov ID: NCT06730893). The steps of the PTMC-specific SDM model are as follows [25].
1. Step 1: define the goal of the consultation
Inform the patient that they have been diagnosed with low-risk thyroid cancer and that there are two treatment options: surgery and active surveillance. Emphasize that the decision is not about determining a single “correct answer,” but about choosing an approach that best aligns with the patient’s values and preferences. Clearly state that the goal of the consultation is for the patient and clinician to reach this decision together.
2. Step 2: explain the necessity for patient participation in the decision-making process
Explain that both surgery and active surveillance for low-risk PTMC have advantages and disadvantages, and that the most suitable strategy depends on the patient’s personal circumstances and values. Stress the importance of the patient’s active participation by encouraging them to fully understand the clinician’s explanations and openly share their values, preferences, and concerns.
3. Step 3: explain the prognosis, advantages, and disadvantages of surgery and active surveillance
Provide patients with up-to-date information on the prognosis, benefits, and drawbacks of both treatment options. This information can be communicated verbally or through written materials, but visual aids such as charts, diagrams, or videos may improve comprehension.
4. Step 4: explore the patient's values and preferences
Engage the patient in a discussion about their concerns, expectations, and anxieties regarding treatment. For example, assess whether the patient feels greater anxiety about harboring cancer or about the risk of progression, or whether they are more concerned about surgical complications, lifelong thyroid hormone therapy, or potential changes in quality of life. Help the patient recognize their own values and priorities and support them in incorporating these into the treatment decision.
5. Step 5: joint decision-making
Work with the patient to arrive at a joint decision, confirming whether they prefer surgery or active surveillance. Ensure that any outstanding questions, concerns, or information needs are addressed. If the patient remains uncertain, the process may be repeated, or a follow-up consultation can be scheduled to allow further deliberation.
6. Step 6: put the decision into action
Develop a concrete implementation plan based on the agreed treatment. If surgery is chosen, establish the surgery date and provide preoperative guidance. If the consulting clinician is not the surgeon, refer the patient to the appropriate surgeon. If active surveillance is chosen, outline the follow-up plan, including the schedule for ultrasound examinations and other monitoring.
The SDM model we developed enables structured consultations for patients with low-risk PTMC in real-world clinical settings. It provides a practical framework for developing individualized treatment plans that reflect both medical appropriateness and patient values. Successful implementation requires clear, accurate, and accessible delivery of medical information, as well as sufficient consultation time to explore patient priorities. Our research team also developed the decision support tool “NAVI: A Guide to Thyroid Treatment” (Figure 2A), which helps patients understand the necessity of SDM, review information on treatment options, and organize their values and preferences according to the six steps. In addition, we produced three educational videos outlining the pros and cons of treatment strategies and 15 card-news posts addressing frequently asked questions (Figure 2). These resources are being validated through an ongoing clinical trial launched in May 2025 (ClinicalTrials.gov ID: NCT06730893) and will later be made available on the KTA website. To further assist clinicians in applying this model, we plan to develop and distribute a standard operating procedure and a user manual for SDM. We expect these resources to help both patients and clinicians intuitively follow the SDM process, establish a practical foundation for its implementation in low-risk PTMC treatment decisions, and reduce the time and psychological burden in routine clinical care.
Conclusion
Low-risk thyroid cancer is a condition with an excellent long-term prognosis, and both surgery and active surveillance are clinically recognized treatment strategies. In such situations, not only medical evidence but also patient values and preferences significantly influence treatment decisions and satisfaction with outcomes. SDM—a process in which patients and clinicians exchange sufficient information and jointly determine a treatment plan by incorporating the patient’s values and preferences—is therefore a particularly appropriate approach for the management of low-risk thyroid cancer. The six-step PTMC-specific SDM model developed by our research team is designed to help patients and clinicians facing the choice between surgery and active surveillance fully share clinical information and enhance patient self-understanding to support effective decision-making. We anticipate that this will promote faithful adherence to the chosen treatment plan.
However, even with the development of a robust SDM model, successful implementation in clinical practice requires clinicians to be familiar with the model and capable of applying it within the limited time available for consultation. In South Korea, where the clinical environment is often constrained by low fees and typical consultation times of only about three minutes, the efforts of individual clinicians or institutions alone are insufficient to achieve widespread SDM. Therefore, governmental support and policy-level interventions are urgently needed, including appropriate reimbursement for the SDM process and institutional infrastructure to facilitate its practice. For SDM to become widely adopted in the management of low-risk thyroid cancer, active discussions and systemic improvements at both medical and healthcare policy levels will be necessary to overcome these practical constraints.
We hope that the adoption of SDM in the treatment of low-risk thyroid cancer will expand, thereby improving patient satisfaction with both the decision-making process and treatment outcomes, and ultimately advancing patient-centered care that minimizes unnecessary treatment and decisional regret.
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