Table 6.

Representative Comments from the Responders

		Number of comments
A. Regarding the diagnosis of nodules ≤10 mm suspected of PTC
1	The standardization of ultrasound diagnosis and improving its accuracy are important, including the measurement of tumor size, evaluation of extrathyroidal extension, and lymph node metastases.	8
2	The indication of FNAC should be clarified. The discrepancy between the Japanese “Guidebook for ultrasound diagnosis of thyroid diseases” and the ATA guidelines 2015 limits accurate diagnosis and treatment.	2
B. Regarding the indications and contraindications of AS
1	Clear presentation about indications other than tumor size is requested.	2
2	Clarify how to manage PTMCs with multiplicity and/or family history.	2
3	Clarify how to manage PTMCs with high serum thyroglobulin levels and low TSH levels.	2
4	Clarify how to manage when high-grade malignancy such as tall cell valiant is suspected on cytology.	1
C. Regarding implementing AS
1	Define how long or until what age AS should be continued?	8
2	The appropriate frequency of surveillance is unknown.	6
3	Guidelines about examination, particularly evaluation of distant metastasis and its frequency are needed.	5
4	Features of PTMC that indicate a need to convert from AS to surgery should be clarified.	4
D. Regarding education for patients and physicians
1	It is important to form a consensus, and JAES/JSTS should establish management guidelines and disseminate the information to physicians, primary care doctors, patients, and the general public.	20
2	It is difficult to refuse surgery for patients who were cytologically diagnosed with PTMC and were referred for surgery by primary care doctors.	6
3	Information should be carefully constructed to avoid misunderstanding such as that all PTCs are harmless and can be observed, and that none of the nodules measuring 10 mm or smaller requires close examination.	3
E. Suggestions for improvement of the sociomedical environment to implement AS
1	Recruitment and education of staff, medical specialists, and ultrasound technicians are urgently needed.	9
2	Immediate surgery is more economically beneficial for hospital management, precluding implementation of AS. Compensation through an “active surveillance management fee” should be considered.	4
3	Countermeasures to avoid loss to follow-up is important.	2
F. Regarding future research agenda
1	The establishment of a nationwide, long-term continuous case accumulation survey system for assessing outcomes of AS.	11
2	Further studies on PTMC with poor outcomes.	7
3	Methods for the early identification of PTMC progression (molecular markers etc.).	4
4	Studies on the patient perspective.	3
5	Significance of TSH suppression for patients who undergo AS.	2
6	Comparison of lifetime cost between AS and immediate surgery.	2

AS, active surveillance; ATA, American Thyroid Association; FNAC, fine-needle aspiration cytology; JAES, Japan Association of Endocrine Surgery; JSTS, Japanese Society of Thyroid Surgery; PTC, papillary thyroid carcinoma; PTMC, papillary thyroid microcarcinoma; TSH, thyrotropin.