You have been diagnosed with thyroid cancer, and choose no surgery.  Although thyroid cancer diagnosis has spiked around the world, a trend is to pass on surgery if the cancer is identified as low risk.  In doing so, mortality rate does not increase and it avoids unfavorable events sometimes related to surgery, such as vocal chord paralysis, hypothyroidsm, financial costs, and lifelong thyroid hormone treatment. 

In this episode, we visit with Dr. hypothyroidism, a pioneer in prescribing active surveillance in place of immediate surgery.    

Dr. Miyauchi is President and COO of Kuma Hospital, Center for Excellence in Thyroid Care, Kobe, Japan. He is an endocrine surgeon, especially interested in thyroid and parathyroid diseases. He earned his MD and PhD at Osaka University Medical School in 1970 and 1978, respectively. He was Associate Professor of Department of Surgery, Kagawa Medical University until he was appointed to Vice President of Kuma Hospital in 1998. Since 2001, he is at his present position. About 2,000 operations, including about 1,300 thyroid cancer cases, are done every year at Kuma Hospital. He is currently serving as Chairman of the Asian Association of Endocrine Surgeons. He also served as Council of the International Association of Endocrine Surgeons until August 2015.

Topics covered, include:

• Incidence versus mortality
• Worldwide trends related to thyroid cancer
• Papillary Microcarcinoma of the Thyroid (PMCT)
• Unfavorable events following immediate surgery
• Results of research which began in 1993
• The current trend in the incidence of thyroid cancer is expected to create an added cost of $3.5 billion by 2030, to the individual and as a society.

NOTES

Akira Miyauchi, MD, PhD (Kuma Hospital)

In this interview, items discussed include:

• the emotional burden of being diagnosed with cancer and the haste that sometimes follows
• the unnecessary damage of thyroid surgery, including the cutting of the laryngeal nerve resulting in vocal cord paralysis, low calcium levels and a need to supplement calcium and Vitamin D for life, and leaving residual disease behind
• knowing your risk factor and finding the right medical team to address it

Dr. Ralph P. Tufano is the Director of the Division of Head and Neck Endocrine Surgery at The Johns Hopkins School of Medicine, and conducts thyroid and parathyroid surgery with a focus on optimizing outcomes.  He is a recognized world authority on the management of thyroid cancer, thyroid nodules, benign thyroid diseases and parathyroid disease.  He has expertise in the management of thyroid cancer nodal metastases, advanced and invasive thyroid cancers as well as recurrent thyroid cancers.  His work in molecular markers, improving surgical outcomes, nerve monitoring and exploring novel treatment techniques for thyroid and parathyroid diseases has helped the medical field tailor and personalize treatment for patients with these conditions.  He is a Charles W. Cummings Professor, sits on the American Thyroid Association Board of Directors, is Director of the Division of Head and Neck Endocrine Surgery, and is a part of the Department of Otolaryngology-Head and Neck Surgery.  He conducts approximately 450 thyroid surgeries annually.  

NOTES:

American Thyroid Association

Dr. Ralph P. Tufano

Doctor Thyroid past episodes

In this interview, the following topics are discussed:

• Better treatment options for thyroid disease
• Better testing for thyroid disease
• Mental challenges
• Juggling career and Hashimoto's
• The word insignificant
• The role of T3 and biological connections
• Diagnosed at twelve years old
• Disappearing eyebrows
• You can’t have thyroid disease because you’re not overweight
• Always cold
• Depression and anxiety
• Integrative medicine
• High TSH levels
• The myth of fork to mouth disease
• Armour Thyroid
• Cold intolerance
• Saliva testing and cortisol levels
• Lyme disease
• The problem of testing TSH levels only

NOTES

Thyroid Change Resources

Website:  www.ThyroidChange.org Facebook:  www.facebook.com/ThyroidChange Twitter:   www.twitter.com/ThyroidChange

This episode details the medical approach to thyroid nodules.  Topics include:

• 60% of the U.S. population has thyroid nodules

• Discovered when evaluating other neck issues such as an unrelated pain

• What happens when you are told you have a thyroid nodule?

• How to know if your thyroid nodule is cancerous?

• When is surgery done despite the nodule being benign?

• Decreasing patient anxiety with quick biopsy results

• The American Thyroid Association as a resource for patients and physicians

• A word of caution about sourcing medical information from online resources

Dr. M Regina Castro is an endocrinologist in Rochester, Minnesota and is affiliated with Mayo Clinic. She received her medical degree from Central University of Venezuela and has been in practice for more than 20 years. Dr. Castro accepts several types of health insurance, listed below. She is one of 78 doctors at Mayo Clinic who specialize in Endocrinology, Diabetes & Metabolism. She also speaks multiple languages, including Spanish and French.

NOTES:

M. Regina Castro, M.D.

THYROID NODULES —  Thyroid nodule size larger than 4 cm does not increase the risk of false negative biopsy results or the risk of cancer

American Thyroid Association 

Dr. Wartofsky is Professor of Medicine, Georgetown University School of Medicine and Chairman Emeritus, Department of Medicine, MedStar Washington Hospital Center.  He trained in internal medicine at Barnes Hospital, Washington University and in endocrinology with Dr. Sidney Ingbar, Harvard University Service, Thorndike Memorial Laboratory, Boston.   Dr. Wartofsky is past President of both the American Thyroid Association and The Endocrine Society.  He is the editor of books on thyroid cancer for both physicians and for patients, and thyroid cancer is his primary clinical focus.   He is the author or coauthor of over 350 articles and book chapters in the medical literature, is recent past Editor-in-Chief of the Journal of Clinical Endocrinology & Metabolism, and is the current Editor-in-Chief of Endocrine Reviews.

In this episode, Dr. Wartofsky discusses the following:

• Hypothyroidism causes
• When is replacement thyroid hormone necessary?
• The history of replacement thyroid hormone going back to 1891
• The early treatment included a chopped up sheep thyroid and served as a ‘tartar’, often resulting in vomiting
• Myxedema coma
• The danger of taking generic T4; are cheaper, larger profit margin, but the content varies.
• Synthroid versus generic
• Manufacturing plants in Italy, India, Puerto Rico are known to produce generics
• Content versus absorption when taking generic T4
• An explanation of TSH
• 1.39 is a healthy TSH level for women in the U.S.
• Symptoms of hypothyroidism, such as a slow mind, poor memory, dry skin, brittle hair, slow heart rate, problems with pregnancy, miscarriage, and hypertension.
• Screening TSH levels if contemplating pregnancy
• T4 is the most prescribed drug in the U.S.
• Hypothyroidism is common when there is a family history
• Auto-immune disease is often associated with hypothyroidism
• An explanation of T3
• An explanation of desiccated thyroid
• The T3 ‘buzz’
• Muhammed Ali’s overdose of T3
• Dangers of too much T3
• When to take T4 medication, and caution toward taking mediations that interfere with absorption
• Coffee and thyroid hormone absorption
• Losing muscle and bone by taking too much thyroid hormone
• Taking ownership of your disease

Related episodes:

37: Adding T3 to T4 Will Make You Feel Better? For Some the Answer is ‘Yes’ with Dr. Antonio Bianco from Rush University

NOTES

Leonard Wartofsky

American Thyroid Association

Andrew J. Bauer, MD is an Associate Professor of Pediatrics at the Perelman School of Medicine, University of Pennsylvania and serves as the Director of the Thyroid Center in the Division of Endocrinology and Diabetes at The Children’s Hospital of Philadelphia. Dr. Bauer maintains active membership as a fellow in the American Academy of Pediatrics (FAAP), the Endocrine Society, the Pediatric Endocrine Society, and the American Thyroid Association. He also volunteers as a consultant for the Thyroid Cancer Survivors Association and the Graves’ Disease and Thyroid Foundation. In the American Thyroid Association Dr. Bauer has recently served as a member of the pre-operative staging committee, the thyroid hormone replacement committee, and as a co-chair for the task force charged to author guidelines on the evaluation and treatment of pediatric thyroid nodules and differentiated thyroid cancer. His clinical and research areas of interest are focused on the study of pediatric thyroid disease, to include hyperthyroidism, thyroid nodular disease, thyroid cancer, and inherited syndromes associated with an increased risk of developing thyroid nodules and thyroid cancer.

In this episode Dr. Bauer shares the complexities of managing children with thyroid nodules, and differentiated thyroid cancer.  This is a must listen interview for parents whose child has a thyroid nodule or thyroid cancer diagnosis. 

There are a several important differences in how pediatric thyroid nodules and differentiated thyroid cancer (DTC) present and respond to therapy. Kids are less frequently diagnosed with a thyroid nodule; however, the risk for malignancy is four- to fivefold higher compared with an adult thyroid nodule. For DTC (specifically papillary thyroid cancer), more than 50% of pediatric-aged patients will have metastases to cervical lymph nodes at the time of diagnosis, but because the tumors typically retain the ability to absorb iodine (retain differentiation), disease-specific mortality is very low, with > 95% of pediatric patients surviving from the disease. This is true even for children with pulmonary metastases, which occur in approximately 15% of patients who present with lateral neck disease.

With the high risk for malignancy and the invasive potential of the cancer, there has been a stronger tendency to take kids with thyroid nodules to the operating room (OR) and to administer RAI to those found to have DTC. With a greater realization of the increased risk for surgical complications as well as the short- and long-term complications of RAI treatment, the guidelines emphasize the need for appropriate preoperative assessment of nodules, and the approach to surgical resection, and they provide a stratification system and guidance for surveillance to identify which patients may benefit from RAI. The stratification system, called the "ATA pediatric risk classification," is not designed to identify patients at risk of dying of disease; it is designed to identify patients at increased likelihood of having persistent disease.

We have known about these differences for years, but the approach to evaluation and care has never been summarized into a pediatric-specific guideline. The adult guidelines aren't organized to address the differences in presentation, and the adult staging systems are targeted to identify patients at increased risk for disease-specific mortality. So, the adult guidelines are not transferable to the pediatric population.

NOTES:

Dr. Andrew Bauer

American Thyroid Association

Not all thyroid cancer patients who receive a thyroidectomy require radioactive iodine, but for those whose cancer maybe more aggressive and spread beyond the thyroid area, often radioactive iodine (RAI) is protocol. 

RAI treatment may vary depending on the hospital.   For example, in this interview you hear protocol for RAI at Cedars Sinai. 

In this interviews, Dr. Alan Waxman explains what occurs leading up to, during, and after RAI.   Topics discussed include:

• If staying at the hospital after taking RAI, how long is the stay required?
• Should you go home after RAI?
• What is the benefit of staying overnight at the hospital when receiving RAI?
• Worldwide trends toward prescribing lower doses of RAI.
• Is there risk in RAI causing leukemia?
• The importance of ultrasound prior to administering RAI of done.
• The need to stimulate TSH prior to administering RAI.
• Withdrawal versus injections in raising TSH levels.
• Damage to salivary glands. 

Alan D. Waxman, MD is Director of Nuclear Medicine at the S. Mark Taper Foundation Imaging Center at Cedars Sinai. He is also a member of the Saul and Joyce Brandman Breast Center – A Project of Women’s Guild and the Thyroid Cancer Center at Cedars-Sinai Medical Center. He is a clinical professor of radiology at Los Angeles County + University of Southern California (USC) Medical Center. Dr. Waxman’s participation in research has led to the development of many new imaging techniques and equipment adaptations. A leading expert in nuclear medicine imaging, Dr. Waxman has directed efforts to develop innovations in whole-body tumor imaging using new and existing radiolable compounds. Dr. Waxman is an active member and officer of the Society of Nuclear Medicine. He has authored numerous publications and lectured extensively throughout the world. Dr. Waxman is a graduate of the USC Medical School, where he completed his postgraduate training. He also completed a clinical research fellowship at the National Institutes of Health.

NOTES:

Dr. Alan Waxman

Salivary gland toxicity after radioiodine therapy for thyroid cancer.

Blog by Philip James

American Thyroid Association

RELATED EPISODES

34: What Happens When Thyroid Cancer Travels to the Lungs? with Dr. Fabian Pitoia from the Hospital of University of Buenos Aires

30: Thyroid Cancer and Children with Dr. Andrew Bauer from the Perelman School of Medicine, U of Pennsylvania

Dr. Aime Franco is professor at the University of Arkansas.  She leads a research group investigating the role of thyroid hormones in tumorigenesis.  She is also actively involved, both locally and nationally, advocating for the importance of biomedical research and the importance of engaging patients and survivors in cancer research.

After, completing her Ph.D. in Cancer Biology, she became a thyroid cancer research fellow at Memorial Sloan-Kettering Cancer Center in the Human Oncology and Pathogenesis Program.

Dr. Franco is a survivor of thyroid cancer, and balances her research as a mom and competitive triathlete. 

in this interview we explore the following:

Does thyroid cancer have a good prognosis compared to other cancers because its different or because we are aggressive with surgery and radiation therapy?

What were some personal insecurities when facing thyroid cancer surgery?

What are the questions in regard to TSH that the medical community is overlooking? Which prescription medication works best?

How often and when should thyroid blood markers be tested?

You may find Dr. Franco here, http://physiology.uams.edu/faculty/aime-franco/

In this interview, some of the key points include:

• Self-discovered thyroid nodule
• Diagnosed thyroid nodule
• FNA and biopsy
• 5 cm nodule
• Juice cleanse and no more red meat
• 3 hour surgery
• Regret about a Friday afternoon surgery
• Outpatient surgery
• Vocal cord paralysis
• Impact of vocal cord paralysis
• RAI six weeks post surgery - 176 mc
• RAI diet
• A positive and optimistic approach to the disease
• Surgeon did not present consequences of thyroid surgery
• Ran cross-country in high school

Jody Gelb is a Broadway singer and actress.   Six months ago she was diagnosed with papillary thyroid cancer, during a doctor's visit for an unrelated issue.  This news sparked immediate research and discovering an alternate path that does not include surgery.

In this episode, the following topics are discussed:

• Broadway musical and tour
• Voice used during work as a performer, singing and acting
• Diagnosed with thyroid cancer while going to the doctor for a minor back strain
• MRI on back lead to discovery of thyroid nodules
• A scare, at one point being told cancer could be medullary
• BETHESDA scale
• Book by Dr. Gilbert Welch
• Incidental findings
• Watch and wait or active surveillance as an option to removing your thyroid
• Conflicting and inconsistent information from healthcare professionals to the patient
• Maximilaist or minimalist
• Cultivating a wherewithal to ask questions, even when being told something by a healthcare professional
• Dr. Atul Gawande
• Dr. Henry Marsh
• Choosing active surveillance and then feeling isolated or alienated
• Sharing selectively
• The importance of Google and Twitter and searching ‘papillary thyroid cancer’

NOTES

Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering

Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

Avoiding Thyroid Cancer Surgery, Depending on the Size with Dr. Miyauchi from Kuma Hospital in Kobe, Japan

1 in 3 People Die With Thyroid Cancer — Not From with Dr. Seth Landefeld from UAB

Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles

American Thyroid Association

Overdiagnosed: Making People Sick in the Pursuit of Health

Best Time of Day to Take Your Thyroid Medication and Other Questions for the Endocrinologist with Wendy Sacks, M.D. from Cedars Sinai

Jody Gelb

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