Abstract
IMPORTANCE: Given the favorable prognosis of papillary thyroid microcarcinoma (PTMC), treatment decisions increasingly rely on patient-reported outcomes (PROs), such as health-related quality of life (HRQOL). Comparative HRQOL data between active surveillance, thermal ablation, and surgery remain limited. OBJECTIVE: To compare HRQOL among adults with PTMC undergoing active surveillance, thermal ablation, or surgery to inform shared decision-making. DATA SOURCES: Embase, MEDLINE via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched from inception to June 17, 2025. STUDY SELECTION: Eligible studies included adult patients with PTMC and compared at least 2 relevant interventions while reporting PROs. Studies restricted to noncomparative designs or non-PTMC populations were excluded. Two reviewers independently screened titles, abstracts, and full texts, resolving discrepancies with a third reviewer. DATA EXTRACTION AND SYNTHESIS: This systematic review followed PRISMA 2020 and PRISMA-S guidelines; the meta-analysis adhered to MOOSE guidelines. Data were extracted by 1 reviewer and independently verified by a second. Study quality was assessed using established critical appraisal checklists. Random-effects models were applied to obtain mean differences with 95% CIs. MAIN OUTCOMES AND MEASURES: The primary outcome was domain-specific HRQOL (eg, voice problems, neuromuscular symptoms, psychological distress), as measured using the Thyroid Cancer Quality of Life (THYCA-QOL), Korean Thyroid-specific Quality of Life (KT-QOL), and other validated instruments. RESULTS: Of 988 retrieved records, 13 studies comprising 5793 patients were included: 2356 underwent active surveillance, 242 received thermal ablation (211 radiofrequency, 31 laser), and 3195 underwent surgery (2350 lobectomy, 833 total thyroidectomy, 12 unspecified). Active surveillance was consistently associated with better PROs compared with surgery across thyroid-specific domains, including neuromuscular symptoms, voice problems, concentration issues, psychological distress, sympathetic complaints, feelings of being chilly, and scar-related concerns. Generic instruments (eg, 36-item Short Form Health Survey, version 2) supported these findings. Low-certainty evidence indicated that thermal ablation was associated with better HRQOL than surgery after 3 to 6 months, although these differences diminished by 12 months. Across studies, heterogeneity arose from differences in treatment strategies and comparators, outcome instruments and duration of follow-up. CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found that patients whose PTMC was managed with active surveillance reported equal or better HRQOL than those undergoing surgery. These findings support the importance of incorporating PROs into shared decision-making for low-risk thyroid cancer.