Doctor Thyroid

Dr. Alan Farwell is an endocrinologist, Director of the Endocrine Clinics at Boston Medical Center, and Associate Professor of Medicine at Boston University School of Medicine, in Massachusetts.

In addition to his extensive academic and clinical activities, Dr. Farwell has been extremely active and served in multiple capacities in the ATA, including as Chair of the Education Committee and the Patient Education and Advocacy Committee, and as a member of the Program Committee and the Website Task Force Publications Committee. He has served two terms on the ATA Board of Directors, is the founding and current Chair of the ATA Alliance for Patient Education.

Dr. Farwell has been an Associate Editor and member of the Editorial Board of Thyroid, and since 2009 has been Editor-in-Chief of Clinical Thyroidology for the Public.

In this interview, we discuss the following topics:

• Thyroid surgery and RAI sometimes results in hypothyroidism
• Most common cause is Hashimoto's disease
• Explanation of overactive and underactive thyroid
• Weight gain, dry skin, constipation
• Very few symptoms unique to hypothyroidism
• Sleep apnea and being tired all of the time and weight gain.
• Brain fog and difficulty concentrating
• Blood tests diagnose hypothyroidism based on TSH levels, when elevated means it is not working too well.
• Explaining TSH in laymen's terms
• Normal TSH in the U.S. is .3 to 3.5
• Treating for feel rather than a number
• People with elevated TSH have many of the hypothyroid symptoms, but people with normal TSH levels may also have hypothyroid symptoms
• Sleep disturbances such as apnea and anemia can be disguised as hypothyroidism
• Historical explanation of hypothyroidism treatment
• About 10% of patients do not respond to Levothyroxin
• Explanation of desiccated thyroid, including pig and cow
• Dr. Jacqueline Jonklaas, PCORI Grant will look at a study, head to head, Levothyroxin versus desiccated
• Adding T3 to T4 treatment
• Discussing Dr. Bianco's research and deiodinases enzyme
• A discussion of celiac disease and gluten
• Explanation of auto-immune disorders, where the thyroid is attacked by the bodies own antibodies
• Physical symptoms of hypothyroidism are goiters, sluggishness, fatigue, dry skin, lateral eyebrows to disappear, the tongue can get thick, puffiness, swelling in legs, face, and around eyes. With proper treatment, these are reversible.

NOTES

Dr. Antonio Bianco

Dr. Jacqueline Jonklaas

American Thyroid Association

Dr. Bridget Brady is Austin's first fellowship trained endocrine surgeon. She has a passion for and expertise in disease of the thyroid, parathyroid, and adrenal glands. Since completing her endocrine surgery fellowship in 2006 under Matthias Rothmund, MD, an internationally acclaimed endocrine surgeon, she has performed thousands of thyroidectomies and parathyroidectomies here in Austin. Dr. Brady focuses on a variety of minimally invasive techniques to optimize patients' medical and cosmetic outcomes. Her fellowship training in Germany and experience in Austin have enabled her to specialize in patients with recurrent or persistent disease of the thyroid and parathyroid, including thyroid cancer. She offers complete diagnostic workups including in-office ultrasounds and FNA biopsies of thyroid nodules and lymph nodes.

Dr. Brady was named director of endocrine surgery for the new medical school in Austin. She was also recently chosen to teach general surgeons seeking additional training in endocrine surgery. Dr. Brady instructs these endocrine surgeons from the Baylor Scott and White fellowship program.

In this episode the following topics are discussed:

• Austin Thyroid Surgeons sees 30 patients per week with thyroid nodules
• Up to 80% of US population could have a thyroid nodule(s)
• less than 5% of Dr Brady's thyroid nodule patients test positive for cancer
• How relevant is what I don't know won't hurt me in thyroid cancer and biopsies of nodules?
• BETHESDA system or the middle category, also known as indeterminate
• For thyroid nodules that are indeterminate, historically a surgery would be performed
• With molecular testing, surgery can be decreased by up to 50%
• Afirma molecular testing uses messenger RNA
• If Afirma comes back suspicious it does NOT necessarily mean it is cancer
• Insurance covers molecular testing
• Nest steps for a doctor who would like to incorporate molecular testing
• Suspicious results with molecular testing can still be benign on final pathology
• How do you calmly tell a patient they have cancer?

NOTES

Dr. Bridget Brady

Veracyte

American Thyroid Association

Dr. Angela M. Leung is an Assistant Professor of Medicine at the UCLA David Geffen School of Medicine and an endocrinologist at both UCLA and the VA Greater Los Angeles Healthcare System.

After pursuing her undergraduate studies at Occidental College, Dr. Leung completed her internal medicine residency and endocrinology fellowship training at Boston University School of Medicine. She also studied at the Boston University School of Public Health and obtained a master's degree in Epidemiology.

Dr. Leung has particular clinical and research interests in thyroid disorders, and she also sees patients regarding parathyroid and adrenal disorders. She has published widely and lectures frequently on thyroid disease, including hyperthyroidism, hypothyroidism, thyroid nodules, thyroid cancer, and thyroid disease during pregnancy.

In this episode, the following topics are explained:

• Optimizing thyroid health prior to conception
• Thyroid issues that affect pregnancy
• Hypothyroid as result of surgery or Hashimotos
• Hyperthyroidism and pregnancy
• Adjusting current thyroid treatment, meaning optimizing thyroid levels by adjusting dosage of thyroid medication
• TSH levels in light of pregnancy
• Planned pregnancy usually means a dose increase
• What happens if someone does not get treatment during pregnancy?
• Hypothyroidism and the fetus
• Brain development for the fetus
• Lower IQ scores and hypothyroid in pregnancy
• CATS study from UK and Italy
• Iodine and pregnancy
• Iodine intake prior to pregnancy
• Armour thyroid and pregnancy
• Concerns regarding animal derived thyroid replacement TSH levels

NOTES

Dr. Angela Leung CATS study American Thyroid Association

49: Thyroid and Pregnancy⎥Why It Matters, with Dr. Elizabeth Pearce from Boston University

Dr. Amanda Laird, MD is an endocrine surgeon and Chief of Endocrine Surgery at the Rutgers Cancer Institute of New Jersey in New Brunswick, New Jersey. She is currently licensed to practice medicine in New Jersey and New York. She is affiliated with Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Hospital.

In this interview, Dr. Laird reflects on a decade of treating papillary thyroid cancer patients and reports none have died. In this interview we also explore these questions:

1. Prognosis and what will happen in the long run and quality of life.
2. Surgery complications.
3. Levothyroxine side-effects, including weight gain.
4. Life after surgery and RAI.
5. What causes thyroid cancer.
6. What time of day to take thyroid replacement medication.
7. What blood tests should be ordered and is fasting necessary prior to thyroid lab work.

NOTES

Amanda Laird, MD

American Thyroid Association

Dr. Danielle Ofri is a doctor at Bellevue Hospital in New York City. She is one of the foremost voices in the medical world today, shining an unflinching light on the realities of healthcare and speaking passionately about the doctor-patient relationship. Her newest book is "When We Do Harm: A Doctor Confronts Medical Error." Ofri is a regular contributor to the New York Times and is also the editor-in-chief of the Bellevue Literary Review. She lives in New York City and is determined to get through the Bach cello suites before she kicks the bucket.

In this episode:

• Medical error is the third leading cause of death? After heart disease and cancer.
• Intended audience for the book? A general audience; lay-public and medical professionals.
• It is difficult to define a medial error. Starting medication at wrong dose? What errors cause death? This can be vague.
• Hospitalized patients are different than the general public
• All sorts of patient harm should be brought to light — shift the medical field to "more safe" should be our goal.
• Once you are in the patient chair, one loses their strength and power.
• System flaws: more common error is a qualified professional who is burdened by design flaws — including false alarms.
• Collaboration and intellectual humility — recognizing we don't know.
• Patients are sicker and more chronic conditions, mean collaboration helps reduce error.
• Denmark as an example to error response: acknowledge and apologize.
• The U.S. malpractice system as part of the problem.
• Qualifiers of malpractice: harm occurred, doctor was the cause, and consequence was big enough to make the case worthwhile.
• Who is making the laws about malpractice? Could be an underlining agenda.
• Recourse for patients: 1. Talk with doctor or nurse. 2. The hospital's patient advocate. 3. Insurance patient advocates. 4. Local Board of Health. 5. Keep notes, and have a paper trail.
• The system is not designed to get information easy — take advantage of CARES Act.
• When transparency backfires; if a doctor is treating high risk patients, then their error will be higher.
• Doctors penalized for spending more time with a patient.
• The need for silence or time to think.
• The problem with the "reimbursement" model.
• Medical error, adverse events, and unintended consequences.
• Over-treating and over-diagnosis in regard to prostate or thyroid.
• Statute of limitations.
• Errors that don't cause harm.
• Wash your hands and stop and think.

Dr. Ofri's Links:

Bellevue Literary Review

www.danielleofri.com

"When We Do Harm: A Doctor Confronts Medical Error"

New Yorker Covid Diary

Recent events - Dr. Ofri:

tinyurl.com/BLRViral Covid Writing Goes Viral: How Literary and Social Media Writing Became a Lifeline during the Pandemic

tinyurl.com/ReadingTheBody Reading the Body: Poetry, Dance & Disability

Notes

CARES Act

Hardeep Singh, M.D., M.P.H.

Doctor Thyroid Facebook

Doctor Thyroid with Philip James

Twitter

[email protected]

In this episode, topics include:

• Hypothyroidism and hyperthyroidism during pregnancy
• Pregnant and without a thyroid
• Avoiding T3 during pregnancy, including concerns with desiccated thyroid
• If being treated for hypothyroidism already, the importance of upping dose while pregnant
• Pregnant with auto-immunity
• Pregnant with Graves' disease
• The dangers of pregnancy and overt hypothyroidism or hyperthyroidism
• Three-percent of pregnancies are affected
• The importance of iodine during pregnancy

Dr. Pearce received her undergraduate and medical degrees from Harvard and a masters' degree in epidemiology from the Boston University School of Public Health. She completed her residency in internal medicine at Beth Israel Deaconess Medical Center, and her fellowship in endocrinology at the Boston University Medical Center. She is currently an Associate Professor of Medicine at Boston University School of Medicine. She has served as a member of the board of directors of the American Thyroid Association and is currently on the management council of the Iodine Global Network. She recently co-chaired the ATA's Thyroid in Pregnancy Guidelines Task Force. She was the 2011 recipient of the ATA's Van Meter Award for outstanding contributions to research on the thyroid gland.

NOTES

Elizabeth Pearce

American Thyroid Association

Dr. Shaha specializes in head and neck surgery, with a particular interest in thyroid and parathyroid surgery. He uses an algorithm of selective thyroid tumor criteria (the size, location, stage and type of cancer, along with the patient's age), to tailor therapy to each individual's circumstances. This can help thyroid cancer patients avoid unnecessary and potentially damaging over-treatment, while still providing the best option for control of their cancer and better quality of life after treatment. Dr. Shaha works very closely with Memorial Sloan Ketterings' endocrinologists to monitor the careful post-treatment hormone balancing necessary for thyroid cancer patients. Many academic hospitals and medical societies worldwide have invited Dr. Shaha to speak on the principles of targeted thyroid surgery and to share his expertise in the treatment of head and neck cancers.

In this interview, topics include:

• The first question a surgeon should ask and why.
• When talking active surveillance or observation, changing the language to deferred intervention, 'we are going to defer'.
• Understanding the biology of the cancer
• The biology of thyroid cancer is a friendly cancer.
• Anxiety when diagnosed with cancer.
• Medical legalities — spend a lot of time with patient — and empower patient.
• Let the treatment not be worse than the disease.
• Large tumors, more than 4 cm, bulky nodes, voice hoarseness, vocal cord is paralyzed. All circumstances where surgery maybe advocated.
• If a tumor is benign but there is presence of compressive goiters, or deviation of trachea or swallowing difficulty.
• Considering the condition of the patient, age, cardiac issues.
• When voice is critical to the patients livelihood, such as teachers, politicians, and singers.
• Main three complications of surgery include bleeding, change of voice, calcium problems.
• Non-academic surgeons.
• Cancer treatment requires a team: surgeons, anesthesiologist, pre-op, radiologist, pathologist, endocrinologists, oncologists.
• When wind pipe is involved with tumor.
• When in surgical business a long time, you become humble no matter how good you are.
• Family present during consultation.
• God gave you an organ — you took it away — now you are on a pill — since the surgery its 'just' not the same.
• When treatment is out of the box — many will not agree with you.
• How to develop a scale to measure quality of life.
• To avoid scarring, surgery maybe conducted through the armpit in Korea and Japan.
• Fibrosis
• Progress in understanding biology of thyroid cancer only cancer, that there is 98% survival.

NOTES:

Dr. Ashok R. Shaha

RELATED EPISODES:

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

40: New Research Reveals Thyroid Surgery Errors 5x More Frequent Than Reported with Dr. Maria Papaleontiou from Michigan Medicine

42: Flame Retardants Connected to Thyroid Cancer, with Dr. Julie Ann Sosa from Duke University

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

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

09: Thyroid Cancer Patients Experience Quality of Life Downgrade with Dr. Raymon Grogan and Dr. Briseis Aschebrook from the University of Chicago Medicine

36: 1 in 3 People Die With Thyroid Cancer — Not From with Dr. Seth Landefeld from UAB

American Thyroid Association

During this interview, Dr. Tuttle discusses the following points:

• Challenges of managing thyroid cancer as outlined by the guidelines
• Scaling back care for insurance-challenged patients, and adopting a plan that gets the same result without needing the expensive tests
• Desired outcome is survival and no recurrence, a third is for no harm that would be caused by an unnecessary surgery
• Unwanted side affects of thyroid cancer include nerve damage, parathyroid damage, and infections
• RAI sometimes has unwanted side affects
• With technology, ultrasounds and biopsies, we know some cancers do not need to be treated, as they are now being found very early
• Change in ATA guidelines, low risk cancers can be considered for observation
• Two different kinds of patient profiles: Minimalist and Maximalist
• 1cm or 1.5cm?
• Patient characteristic, ultra sound characteristics, and the medical team characteristics weighs who is the most appropriate for observation
• 400 active surveillance patients currently at MSKCC
• Certain parts of the world are harder to offer observation as a treatment due to practicality, examples include Latina America where multi-nodular goiters are common, and Germany still is iodine deficient

About Dr. Tuttle, in his words:

I am a board-certified endocrinologist who specializes in caring for patients with advanced thyroid cancer. I work as part of a multidisciplinary team including surgeons, pathologists, radiologists, nuclear medicine specialists, and radiation oncologists that provides individualized care to patients treated at Memorial Sloan Kettering for thyroid cancer.

In addition to treating patients I am also actively researching new treatments for advanced thyroid cancer. I am a professor of medicine at the Joan and Sanford I. Weill Medical College of Cornell University and travel extensively both in the US and abroad, lecturing on the difficult issues that sometimes arise in the management of patients with thyroid cancer. My research projects in radiation-induced thyroid cancer have taken me from Kwajalein Atoll in the Marshall Islands to the Hanford Nuclear power-plant in Washington State to regions in Russia that were exposed to fallout from the Chernobyl accident.

I am an active member of the American Thyroid Association (ATA) and the Endocrine Society. In addition to serving on the ATA committee that produced the current guidelines for the management of benign and malignant nodules, I am also a Chairman of the National Comprehensive Cancer Network Thyroid Cancer Panel, a consultant to the Endocrinologic and Metabolic Drugs Advisory Committee of the FDA, and a consultant to the Chernobyl Tissue Bank.

NOTES

Listen to Doctor Thyroid American Thyroid Association Dr. Michael Tuttle

RELATED EPISODES

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

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

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

The USPSTF upholds its 1996 recommendation against screening for thyroid cancer among asymptomatic adults.

The USPSTF commissioned the systematic review due to the rising incidence of thyroid cancers against a background of stable mortality, which is suggestive of over-treatment. And in view of the results, the task force concluded with "moderate certainty" that the harms outweigh the benefits of screening.

The USPSTF emphasizes, however, that this recommendation pertains only to the general asymptomatic adult population, and not to individuals who present with throat symptoms, lumps or swelling, or those at high risk for thyroid cancer.

A global problem

The over-diagnosis of thyroid cancer is worldwide.

South Korean doctors treated these newly diagnosed thyroid cancers by completely removing the thyroid—a thyroidectomy. People who undergo these surgeries require thyroid replacement hormones for the rest of their lives. And adjusting the dose can be difficult. Patients suffer from too much thyroid replacement hormone (sweating, heart palpitations, and weight loss) or too little (sleepiness, depression, constipation, and weight gain). Worse, because of nerves that travel close to the thyroid, some patients suffer vocal-cord paralysis, which affects speech.

Over-diagnosis and over-treatment of thyroid cancer hasn't been limited to South Korea. In France, Italy, Croatia, Israel, China, Australia, Canada, and the Czech Republic, the rates of thyroid cancer have more than doubled. In the United States, they've tripled. In all of these countries, as had been the case in South Korea, the incidence of death from thyroid cancer has remained the same.

1 in 3 people die with thyroid cancer, not of.

NOTES

As heard on NPR

Dr. Seth Landefeld

American Thyroid Association

RELATED DOCTOR THYROID INTERVIEWS

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

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

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

www.docthyroid.com

Antonio Bianco, MD, PhD, is head of the division of Endocrinology and Metabolism at Rush University Medical Center. Dr. Bianco also co-chaired an American Thyroid Association task force that updated the guidelines for treating hypothyroidism.

Dr. Bianco's research has revealed the connection between thyroidectomy, hypothyroidism symptoms, and T4-only therapy. Although T4-only therapy works for the majority, others report serious symptoms. Listen to this segment to hear greater detail in regard to the following topics:

• Combination therapy of adding T3 to T4
• 85% of patients on Synthroid feel fine.
• Nearly 5% of the U.S. population takes T4 or Levothyroxine, as revealed by the NHANE survey. This means 10 - 15 million Americans.
• Residual symptoms of thyroidectomy include depression, difficulty losing weight, poor motivation, sluggishness, and lack of motivation. For some, there is no remedy to these symptoms. For others, adding T3 to T4 shows immediate improvement.
• The importance of physical activity and its benefit in treating depression
• If we normalize T3 does it get rid of hypothyroid symptoms?
• Overlap between menopause and hypothyroid symptoms

Notes:

American Thyroid Association

Bianco Lab

Bianco Lab on Facebook

NHANES Survey

The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations.