BACKGROUND: Despite guidelines that recommend total thyroidectomy for papillary thyroid cancer (PTC) greater than or equal to 1 cm, the extent of surgery remains controversial. We examined surgical practice patterns for PTC greater than or equal to 1 cm and identified factors that predict the use of total thyroidectomy. METHODS: Of 90,382 patients in the National Cancer Center Data Base (NCDB) with PTC from 1985 to 2003, 57,243 patients had tumors greater than or equal to 1 cm and underwent total thyroidectomy or lobectomy. Trends in extent of surgery for PTC were examined over 2 decades. Logistic regression was used to identify factors that predict use of total thyroidectomy compared with lobectomy. RESULTS: Use of total thyroidectomy increased from 70.8% in 1985 to 90.4% in 2003 (P < .0001). Patients were less likely to undergo total thyroidectomy if they were black, older than 45 years, had Medicare, had lower household incomes, or had less education (P < .0001). Moreover, patients treated at high-volume or academic centers were more likely to undergo total thyroidectomy than were patients examined at low-volume or community hospitals (P < .0001). CONCLUSIONS: Use of total thyroidectomy for PTC greater than or equal to 1 cm increased over time. Differences in use of total thyroidectomy are related to patient, tumor, and hospital factors and likely reflect disparities in access to care.