**11. Future Considerations**

Impalpable thyroid cancers detected by ultrasound have almost always an excellent prognosis. The precursor lesions of DTC are not well-established and recognised pathology lesions, but there is no clear demarcation that differentiates precancerous from cancerous lesions. If these were to be reclassified as an indolent lesion of epithelial origin (IDLE), the need for aggressive therapy and screening would be mitigated [102]. Therefore, the redefinition of these lesions as "papillary lesions in situ" as precursors of malignant tumours might be beneficial in reducing the overdiagnosis and overtreatment of patients with thyroid nodules [103]. Being able to select which patients would develop more aggressive disease will have huge impact on healthcare costs for DTC.

Surgical complications from an often-unnecessary operation, the emotional distress linked to the diagnosis of 'cancer', and the stress of follow-up, as well as the financial burden to the individual and society, should not be ignored. The problem affects wealthy countries where the steep rise in thyroid ultrasound and FNA has been driven by access to diagnostic imaging. The reversal or slowing down of this trend requires an understanding of the pathology at all medical levels but is not easy to solve [104]. Education whilst helpful clashes with the realities of defensive medicine where the fear of litigation can intimidate doctors towards more investigations, more interventions, and endless follow-up that transforms every person into a lifelong patient. Future research should be directed towards micro-cost analyses to identify potential factors associated with the increased costs. Cost-effectiveness studies with QALY and ICER calculations should be implemented in future guidelines on treatment, surgical, and follow-up strategy.

Some ground-breaking work in health economics has been undertaken, but more needs to be done on to stem the tide and avert medical bankruptcy. Some changes that have been shown to help are the centralisation of cancer care for an economy of scale and quality assurance that comes from group practice and a multidisciplinary environment.

However, a broader, international approach is required to address the problem of overdiagnosis and overtreatment of thyroid cancer, facilitated by data collection, health economic assessment, subspecialisation, and international health policy that together may find a balance between expenses and clinical benefit for the patient. International societies will have to incorporate health economic considerations into their guidelines. The revised 2015 ATA guidelines stated several research questions that remain unanswered to date: optimising molecular markers for diagnosis, AS of DTC primary tumours, and improved risk stratification and survivorship care. Potential answers could all influence future healthcare expenditures.
