Thyroid Cancer Awareness Month

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers
00:02 --> 00:05is provided by Smilow Cancer
00:05 --> 00:07Hospital and AstraZeneca.
00:07 --> 00:08Welcome to Yale Cancer
00:08 --> 00:09Answers with your host
00:09 --> 00:12Dr. Anees Chagpar. Yale Cancer Answers
00:12 --> 00:14features the latest information on
00:14 --> 00:17cancer care by welcoming oncologists and
00:17 --> 00:19specialists who are on the forefront of
00:19 --> 00:22the battle to fight cancer. This week,
00:22 --> 00:23it's a conversation about thyroid
00:23 --> 00:25cancer with Doctor Grace Lee.
00:25 --> 00:27Doctor Lee is an assistant professor
00:27 --> 00:29of surgery at the Yale School of
00:29 --> 00:31Medicine where Doctor Chagpar is
00:31 --> 00:33a professor of surgical oncology.
00:34 --> 00:36Grace, maybe we can start off by
00:36 --> 00:38you telling us a little bit about
00:38 --> 00:40yourself and about what you do.
00:40 --> 00:43As an endocrine surgeon I
00:43 --> 00:45remove the thyroid, parathyroid in
00:45 --> 00:48adrenal glands for various different
00:48 --> 00:50disorders including cancer.
00:50 --> 00:53My areas of clinical and research
00:53 --> 00:54interest include different
00:54 --> 00:56minimally invasive techniques
00:56 --> 00:59and new imaging techniques for
00:59 --> 01:01treatment of endocrine disorders.
01:01 --> 01:03So let's start off by talking a
01:03 --> 01:05little bit about thyroid cancer.
01:05 --> 01:07After all, it is thyroid
01:07 --> 01:08cancer awareness month.
01:08 --> 01:10So tell us a little bit more about
01:10 --> 01:12the epidemiology of thyroid cancer.
01:12 --> 01:14How many people get diagnosed?
01:14 --> 01:17How many people succumb to their disease?
01:17 --> 01:18How common is this?
01:19 --> 01:23So thyroid cancer is
01:23 --> 01:26number wise, about the eighth most
01:26 --> 01:28common cancer in the US, however,
01:28 --> 01:32it only accounts for about 4% of
01:32 --> 01:34all the new cancers being diagnosed,
01:34 --> 01:37and people who succumb to
01:37 --> 01:38thyroid cancer annually
01:38 --> 01:43we guesstimate at about 2000 so
01:43 --> 01:46it is not as prevalent as
01:46 --> 01:49breast cancer or colon cancer,
01:49 --> 01:52but what's interesting is that new
01:52 --> 01:55diagnoses of thyroid cancers have
01:55 --> 01:57tripled in the past three decades.
01:57 --> 02:00It is one of the most rapidly
02:00 --> 02:02increasing cancers in the US
02:02 --> 02:04but we believe that much of
02:04 --> 02:06the increase owes to the fact
02:06 --> 02:08that we're just catching them
02:08 --> 02:10earlier and more frequently,
02:10 --> 02:12as mentioned before,
02:12 --> 02:13we utilized
02:13 --> 02:17various diagnostic imaging to further
02:17 --> 02:21elucidate many conditions and we
02:21 --> 02:24just catch these incidental thyroid
02:24 --> 02:27nodules while we are just looking
02:27 --> 02:29into our body for different diseases.
02:29 --> 02:32So thyroid nodules are just
02:32 --> 02:34being caught earlier and more
02:34 --> 02:37frequently. Some of these imaging
02:37 --> 02:40studies that patients get include
02:40 --> 02:43CT scans after a car accident.
02:43 --> 02:46Pet CT to survey and other cancers
02:46 --> 02:48such as breast cancer or Melanoma
02:48 --> 02:50or even carotid ultrasound,
02:50 --> 02:52to examine narrowing of
02:52 --> 02:53the carotid arteries.
02:53 --> 02:56Let's dig a little bit more
02:56 --> 02:58into that because I find that statistic
02:58 --> 03:03of a tripling in the rate of thyroid
03:03 --> 03:06cancers to be really quite an awesome,
03:06 --> 03:10not in the sense of awesome 'awesome' but awesome
03:10 --> 03:14in the sense of a huge number deserving of awe.
03:17 --> 03:20What are the risk factors for thyroid cancer?
03:20 --> 03:23I appreciate that you said that
03:23 --> 03:26we think that a lot of this is just because
03:26 --> 03:30of an increasing rate of detection,
03:30 --> 03:33but help us to understand what are the
03:33 --> 03:36etiologic causes of thyroid cancer?
03:36 --> 03:38That's an excellent question,
03:38 --> 03:40if we can actually get down to
03:41 --> 03:43the bottom of why thyroid cancer happens
03:43 --> 03:46perhaps we can even prevent it,
03:46 --> 03:50so there have been many studies that have
03:50 --> 03:53been performed to characterize who are the
03:53 --> 03:56folks that are getting thyroid cancer.
03:56 --> 03:58Why we are catching
03:58 --> 04:00and detecting more of them.
04:00 --> 04:03Some of the risk factors for
04:03 --> 04:06thyroid cancer include being a woman
04:06 --> 04:10and of the Asian race and
04:10 --> 04:13age between 25 to 65 years old.
04:13 --> 04:15Although we do see some
04:15 --> 04:18extreme distribution of ages,
04:18 --> 04:22such as pediatric population versus
04:22 --> 04:25very advanced age population.
04:26 --> 04:27And also having had
04:27 --> 04:30prior radiation treatment to the
04:30 --> 04:34head and neck area as a child or
04:34 --> 04:36having had environmental radiation
04:36 --> 04:39exposure such as a nuclear accident.
04:39 --> 04:41And having a family member with
04:41 --> 04:44history of thyroid disease or
04:44 --> 04:46enlarged thyroid or thyroid cancer.
04:46 --> 04:49And again, the detection catches
04:49 --> 04:51incidental thyroid nodules.
04:51 --> 04:53Not necessarily thyroid cancer.
04:53 --> 04:57So most of these thyroid nodules
04:57 --> 04:59turn out to be benign nodules.
04:59 --> 05:01But because we're catching
05:01 --> 05:03benign nodules,
05:03 --> 05:05we are also seeing the increase
05:05 --> 05:06of thyroid cancer.
05:06 --> 05:08When you talk
05:08 --> 05:09about the risk factors,
05:09 --> 05:11a lot of the things you mentioned
05:11 --> 05:13are things that we cannot change.
05:13 --> 05:16Being a woman, your age,
05:16 --> 05:18your race or ethnicity,
05:18 --> 05:21your family history.
05:21 --> 05:25And the things that are other
05:25 --> 05:28risk factors, exposure to radiation,
05:28 --> 05:31nuclear accidents,
05:31 --> 05:33thankfully, not many of us, I think,
05:33 --> 05:36can claim to have that,
05:36 --> 05:38and certainly sometimes when
05:38 --> 05:40we're exposed to radiation due
05:40 --> 05:42to CT scans or other things,
05:42 --> 05:44those may be beyond
05:44 --> 05:47our control as well.
05:47 --> 05:50Are there any factors that our audience
05:50 --> 05:53might be interested in that increase
05:53 --> 05:56or decrease your risk of thyroid
05:56 --> 05:58cancer that you can control?
05:58 --> 06:00And so I'm thinking here about
06:00 --> 06:02things like an iodine deficiency
06:02 --> 06:06that we know can have a role to
06:06 --> 06:09play in benign thyroid conditions.
06:09 --> 06:12Any role for that in terms of cancers?
06:12 --> 06:16Any other factors that
06:16 --> 06:19people could potentially control?
06:20 --> 06:22That's very interesting question.
06:22 --> 06:26I do occasionally have a patient
06:26 --> 06:30who's interested in modifying their diet
06:30 --> 06:33to either combat the existing thyroid
06:33 --> 06:37cancer or help their family members
06:37 --> 06:40prevent from getting thyroid cancer.
06:40 --> 06:42Iodine deficiency certainly
06:42 --> 06:47can be the cause of a goiter,
06:47 --> 06:48an enlarged thyroid gland.
06:48 --> 06:52But I do not believe there has
06:52 --> 06:54been an established linkage
06:54 --> 06:57between iodine supplementation and
06:57 --> 06:59decreased rate of thyroid cancer.
06:59 --> 07:03So at the current time point,
07:03 --> 07:05I think detection and appropriate treatment
07:05 --> 07:09will be the best course of action
07:09 --> 07:12once one is found to have thyroid cancer.
07:16 --> 07:18Getting back to that original statistic,
07:18 --> 07:20this tripling of thyroid cancers,
07:20 --> 07:23it doesn't seem that there has been
07:23 --> 07:25a tripling of nuclear accidents.
07:25 --> 07:28If anything, I think our nuclear
07:28 --> 07:30exposures have generally declined,
07:30 --> 07:34as safety protocols have improved,
07:34 --> 07:37one wouldn't think that there
07:37 --> 07:40would have been a difference in terms of
07:40 --> 07:44age or gender or race over the last
07:44 --> 07:46few decades where we've seen this
07:46 --> 07:49tripling and so that brings us to
07:49 --> 07:51this whole area of of detection,
07:51 --> 07:54which you surmise is really the
07:54 --> 07:58thing at the driving seat of
07:58 --> 08:00this tripling of thyroid cancer.
08:00 --> 08:02Has anybody looked at that?
08:02 --> 08:05Has the rate at which we are imaging
08:05 --> 08:09people increased at that same proportion?
08:09 --> 08:12So in other words we all know that
08:12 --> 08:15there's been this burgeoning of technology.
08:15 --> 08:18And we seem to do more imaging
08:18 --> 08:20nowadays than we used to.
08:20 --> 08:22At least that's how it feels anecdotally.
08:22 --> 08:24But has anybody looked at that to see
08:24 --> 08:26whether these two trends are parallel?
08:27 --> 08:29Yeah, I believe so.
08:29 --> 08:32So in much of thyroid cancer literature,
08:32 --> 08:37we always attribute the partial rapid
08:37 --> 08:42increase in thyroid cancer being
08:42 --> 08:45prevalent to essentially the detection,
08:45 --> 08:48in leading to earlier diagnosis,
08:48 --> 08:52not necessarily more aggressive treatment,
08:52 --> 08:56we have been scaling back down on the
08:56 --> 09:00resection of these thyroid cancers.
09:00 --> 09:03So not all thyroid cancers lead to surgery,
09:03 --> 09:07but it is certainly true that there
09:07 --> 09:10is clear correlation between the
09:10 --> 09:13utilization of imaging studies
09:13 --> 09:16in multiple different aspects.
09:16 --> 09:19And also perhaps patient awareness
09:19 --> 09:23in clinician exam skills being
09:23 --> 09:27improved lead to detection of the
09:27 --> 09:31thyroid nodules and go down the
09:31 --> 09:32pathway of thyroid cancer detection.
09:33 --> 09:34Let's talk a little bit
09:34 --> 09:35about that because as you say,
09:35 --> 09:37not all thyroid nodules that
09:37 --> 09:38may be picked up incidentally,
09:38 --> 09:41either on imaging or on physical
09:41 --> 09:43exam are actually a cancer.
09:43 --> 09:46So let's suppose somebody does have
09:46 --> 09:49a scan done for whatever reason
09:49 --> 09:51and the thyroid nodule is found.
09:51 --> 09:54How do we get from incidental thyroid
09:54 --> 09:58nodule to making a diagnosis of cancer?
09:58 --> 09:59How does that work?
09:59 --> 10:02Yeah, so as we mentioned,
10:02 --> 10:05it is not uncommon that we just
10:05 --> 10:07stumble upon a thyroid nodule being
10:07 --> 10:11mentioned on a CT scan that a patient
10:11 --> 10:15may have gotten for neck pain or
10:15 --> 10:20just to rule out lung nodules etc.
10:20 --> 10:23So after initial detection of the
10:23 --> 10:27thyroid nodule on a different modality,
10:27 --> 10:30we do a comprehensive neck
10:30 --> 10:34ultrasound as the gold standard exam.
10:36 --> 10:39If the patient does not have recent
10:39 --> 10:42thyroid function that was drawn
10:42 --> 10:45with a routine yearly checkup.
10:45 --> 10:49So after the ultrasound is obtained,
10:49 --> 10:52we can then
10:52 --> 10:54detect whether the thyroid nodule
10:54 --> 10:58is of the appropriate size and if
10:58 --> 11:01that nodule has specific ultrasound
11:01 --> 11:04characteristics that make us worried
11:04 --> 11:08about that thyroid nodule being cancerous.
11:08 --> 11:10And if we
11:10 --> 11:13give that thyroid nodule appropriate
11:13 --> 11:18numbers and if we surmise that the
11:18 --> 11:21nodule is meeting the biopsy criteria,
11:21 --> 11:24then what we usually do is
11:24 --> 11:27a fine needle aspiration biopsy
11:27 --> 11:30under the guidance of ultrasound
11:30 --> 11:32to have our pathologists then take
11:32 --> 11:35a look at some of the cell samples
11:35 --> 11:37obtained from their thyroid nodule.
11:38 --> 11:40So let's flush that out a little bit.
11:40 --> 11:41You mentioned that
11:41 --> 11:43there are some size criteria,
11:43 --> 11:45some morphologic criteria that you
11:45 --> 11:48look at in terms of a thyroid nodule
11:48 --> 11:51to kind of gauge your suspicion as to
11:51 --> 11:54whether this could be malignant or not,
11:54 --> 11:56tell us a little bit more
11:56 --> 11:57about what those criteria are.
11:57 --> 11:59What are the things that make you worried
11:59 --> 12:02that a thyroid nodule could be cancer?
12:02 --> 12:06Yeah, so generally speaking we
12:06 --> 12:10worry about bigger thyroid nodules.
12:10 --> 12:14That's generally speaking.
12:14 --> 12:16And how big is big grade?
12:17 --> 12:20We consider anything less than
12:20 --> 12:241 centimeter as kind of
12:24 --> 12:28microterritory and 1 centimeter or greater
12:28 --> 12:31at least meets the size criteria.
12:31 --> 12:35If the thyroid nodule looks worrisome
12:35 --> 12:39enough on the ultrasound and some of the
12:39 --> 12:42worrisome features are the thyroid nodule
12:42 --> 12:48being solid rather than mostly fluid,
12:48 --> 12:50or mixed solid and fluid,
12:50 --> 12:54what we call cystic and it has what
12:54 --> 12:56we call hypoechoic characteristic
12:56 --> 12:59onto ultrasound microcalcifications
12:59 --> 13:04irregular borders taller than wide, etc.
13:04 --> 13:08So we radiologists are very familiar
13:08 --> 13:11with assigning certain
13:11 --> 13:13points to these thyroid nodules
13:13 --> 13:18to see if this is thyroid nodule
13:18 --> 13:21should then proceed to the
13:21 --> 13:23biopsy stage or
13:23 --> 13:25this thyroid nodule looks
13:25 --> 13:28to be pretty innocuous.
13:28 --> 13:29Although it is 2 centimeters
13:29 --> 13:31or three centimeters,
13:31 --> 13:33and perhaps we can watch it.
13:34 --> 13:37And so we're going to pick up on
13:37 --> 13:38this conversation about what happens
13:38 --> 13:40once that diagnosis of thyroid
13:40 --> 13:43cancer is made right after we take
13:43 --> 13:45a short break for a medical minute.
13:45 --> 13:47Please stay tuned to learn more about
13:47 --> 13:49the care of patients with thyroid
13:49 --> 13:51cancer with my guest doctor Grace Lee.
13:52 --> 13:54Support for Yale Cancer Answers
13:54 --> 13:56comes from Smilow Cancer Hospital,
13:56 --> 13:58where an individualized approach to
13:58 --> 13:59prostate cancer screening is used
14:00 --> 14:02to determine which men are eligible
14:02 --> 14:03and would benefit from screening.
14:03 --> 14:07To learn more, visit Yale Cancer
14:07 --> 14:09Center dot org slash screening.
14:09 --> 14:11Genetic testing can be useful for
14:11 --> 14:13people with certain types of cancer
14:13 --> 14:15that seem to run in their families.
14:15 --> 14:18Genetic counseling is a process that
14:18 --> 14:20includes collecting a detailed personal
14:20 --> 14:22and family history or risk assessment and
14:22 --> 14:25a discussion of genetic testing options.
14:25 --> 14:27Only about 5 to 10% of all
14:27 --> 14:28cancers are inherited,
14:28 --> 14:30and genetic testing is not
14:30 --> 14:32recommended for everyone.
14:32 --> 14:34Individuals who have a personal and
14:34 --> 14:36or family history that includes
14:36 --> 14:38cancer at unusually early ages,
14:38 --> 14:39multiple relatives
14:39 --> 14:41on the same side of the family
14:41 --> 14:43with the same cancer,
14:43 --> 14:45more than one diagnosis of
14:45 --> 14:46cancer in the same individual,
14:46 --> 14:49rare cancers or family history of a
14:49 --> 14:51known altered cancer predisposing gene
14:51 --> 14:55could be candidates for genetic testing.
14:55 --> 14:57Resources for genetic counseling and
14:57 --> 14:59testing are available at federally
14:59 --> 15:00designated comprehensive cancer
15:00 --> 15:03centers such as Yale Cancer Center
15:03 --> 15:04and Smilow Cancer Hospital.
15:04 --> 15:08More information is available at
15:08 --> 15:09yalecancercenter.org. You're listening
15:09 --> 15:11to Connecticut Public Radio.
15:11 --> 15:14Welcome back to Yale Cancer Answers.
15:14 --> 15:16This is doctor Anees Chagpar and I'm
15:16 --> 15:19joined tonight by my guest Doctor Grace Lee.
15:19 --> 15:21We're talking about the care of
15:21 --> 15:23patients with thyroid cancer in
15:23 --> 15:26honor of Thyroid Cancer Awareness
15:26 --> 15:27Month and right before the break,
15:27 --> 15:30Grace was telling us this amazing
15:30 --> 15:32statistic that thyroid cancers have
15:32 --> 15:35actually tripled in recent history
15:35 --> 15:38in large part due to an increase
15:38 --> 15:39in standard imaging.
15:39 --> 15:41So we're stumbling upon these
15:41 --> 15:43incidental thyroid nodules,
15:43 --> 15:46which, if they're large enough,
15:46 --> 15:49and if they have certain
15:49 --> 15:51morphologic features on ultrasound,
15:51 --> 15:55are warranting a biopsy and that biopsy
15:55 --> 15:58can sometimes reveal thyroid cancers.
15:58 --> 15:59So Grace,
15:59 --> 16:03before the break you were mentioning that
16:03 --> 16:06thyroid cancer is not a uniform disease.
16:06 --> 16:08It's not homogeneous.
16:08 --> 16:12Not all thyroid cancers are treated the same.
16:12 --> 16:14So tell us a little bit more about that.
16:14 --> 16:16First of all,
16:16 --> 16:19are there different kinds of thyroid cancer?
16:19 --> 16:21And second of all,
16:21 --> 16:24how does that impact what you do next?
16:24 --> 16:25There are
16:25 --> 16:28about four different major
16:28 --> 16:31types of thyroid cancers.
16:31 --> 16:35The good news is that the most
16:35 --> 16:38common thyroid cancer known as
16:38 --> 16:40papillary thyroid cancer actually
16:40 --> 16:43carries the best prognosis.
16:43 --> 16:48So most people, about 90% of the
16:48 --> 16:50patients that I treat come in
16:50 --> 16:53with papillary thyroid cancer,
16:53 --> 16:58and the rest, 10% comprise of
16:58 --> 17:01other follicular medullary or
17:01 --> 17:03anaplastic thyroid cancers.
17:03 --> 17:06And other good news is that seven
17:06 --> 17:09out of those ten patients recently
17:09 --> 17:12diagnosed with thyroid cancer come in
17:12 --> 17:15with the cancer that is well behaving,
17:15 --> 17:19meaning their cancer has not actually
17:19 --> 17:22spread outside of the thyroid.
17:22 --> 17:25So most of the people who get
17:25 --> 17:27the diagnosis of thyroid cancer,
17:27 --> 17:30although it is quite terrifying,
17:30 --> 17:33should be reassured that as
17:33 --> 17:35long as we treat them
17:35 --> 17:39the right way they're going to
17:39 --> 17:42be enjoying excellent prognosis.
17:42 --> 17:44Tell us a little bit
17:44 --> 17:47more about that, I mean
17:47 --> 17:4990% of patients have papillary
17:49 --> 17:52cancers which have a good prognosis.
17:52 --> 17:57Of those, 70% are well behaved,
17:57 --> 17:59but these patients still
17:59 --> 18:00require treatment, right?
18:00 --> 18:03Or is it that thyroid cancer has
18:03 --> 18:05now gone the way of other cancers
18:06 --> 18:07in terms of watchful waiting?
18:08 --> 18:13That's a hotly debated
18:13 --> 18:17very individualized choice, but the
18:17 --> 18:22mainstay treatment for thyroid cancer,
18:22 --> 18:25first and foremost is surgical,
18:25 --> 18:28or if the cancer has gone
18:28 --> 18:29outside of the thyroid,
18:29 --> 18:34then we would treat by removing the entire
18:34 --> 18:39thyroid as well as the involved lymph nodes.
18:39 --> 18:42Watchful waiting in the thyroid world,
18:42 --> 18:45we call that active surveillance.
18:45 --> 18:51We can sometimes employ that approach,
18:51 --> 18:53which is another right answer to
18:53 --> 18:55this thyroid cancer management.
18:55 --> 18:58We can go active surveillance route
18:58 --> 19:01if the papillary thyroid cancer,
19:01 --> 19:03the well behaving thyroid cancer
19:03 --> 19:06happens to be less than one centimeter.
19:06 --> 19:09So if there is no risk of this
19:09 --> 19:12cancer invading into the nerve or
19:12 --> 19:16the cancer going outside of the
19:16 --> 19:19thyroid is well cushioned by normal
19:19 --> 19:22thyroid and the patient is very
19:22 --> 19:25motivated and reliable to comply with
19:25 --> 19:28this active surveillance program.
19:28 --> 19:32We can certainly go that route,
19:32 --> 19:35but any thyroid cancer that is between
19:35 --> 19:38one centimeter to 4 centimeter
19:39 --> 19:42can go either half of the thyroid
19:42 --> 19:45that's containing that cancer or the
19:45 --> 19:48entire thyroid to be removed.
19:48 --> 19:51So there are multiple right answers.
20:02 --> 20:03Let me just pick up
20:03 --> 20:05on a couple of things there.
20:05 --> 20:07So the first thing is in
20:07 --> 20:09terms of active surveillance.
20:09 --> 20:11This is for people who have papillary
20:11 --> 20:13cancers that are well differentiated
20:13 --> 20:16that are less than one centimeter.
20:20 --> 20:22What does active surveillance
20:22 --> 20:23actually entail?
20:23 --> 20:26I mean, is this an ultrasound
20:26 --> 20:29every six months to make sure that
20:29 --> 20:31this thyroid nodule isn't growing?
20:31 --> 20:33Is it blood work?
20:33 --> 20:35Is it CT scans?
20:35 --> 20:37What exactly does that entail?
20:37 --> 20:40Great question. Yes,
20:40 --> 20:48it would mean actively monitoring the size
20:48 --> 20:52or the growth changes of that biopsy
20:52 --> 20:55known micro papillary thyroid cancer
20:55 --> 20:59and is some clinician dependent,
20:59 --> 21:02but usually about every six months
21:02 --> 21:06to a year ultrasound exam and the
21:06 --> 21:10thyroid cancer is not something that
21:10 --> 21:13we follow on laboratory values.
21:13 --> 21:15So it's heavily
21:15 --> 21:19image independent and sometimes even a
21:19 --> 21:24neck CT is utilized to pick up on lymph
21:24 --> 21:29node spread a little bit more closely.
21:29 --> 21:33It is what's called a wolf in sheep
21:33 --> 21:36clothing by one of my mentors because
21:36 --> 21:40even micro papillary cancer can spread to
21:40 --> 21:43nearby lymph nodes in the thyroid cancer world,
21:43 --> 21:46even the lymphatic spread does not
21:46 --> 21:49necessarily mean worse prognosis.
21:49 --> 21:51However, it is more advanced
21:51 --> 21:54or at least local,
21:54 --> 21:56regionally advanced disease.
21:56 --> 21:59So we treat those folks
21:59 --> 22:02almost as equally as someone who has
22:02 --> 22:06bigger cancer and the folks that I'm
22:06 --> 22:09talking about are patients under active
22:09 --> 22:13surveillance and by watching them carefully,
22:13 --> 22:15it may earn them,
22:15 --> 22:18or it may buy them an extra five years
22:18 --> 22:22extra 10 years with their own thyroid.
22:22 --> 22:26And surgical
22:26 --> 22:29treatment always is an option.
22:29 --> 22:31But generally speaking,
22:31 --> 22:33if the size of that micro cancer
22:34 --> 22:36changes by about 3 millimeters,
22:36 --> 22:38we say, well, OK.
22:38 --> 22:41I think it's time to intervene,
22:41 --> 22:43and most of the studies on
22:43 --> 22:45active surveillance comes out of
22:45 --> 22:48Japan and their long term result
22:48 --> 22:50is actually quite excellent.
22:51 --> 22:52So you really are watching
22:52 --> 22:53these people very closely.
22:53 --> 22:56I mean, even 3 millimeters doesn't sound
22:56 --> 22:59like a whole lot to the people
22:59 --> 23:00who are listening to our show today,
23:00 --> 23:03I'm sure, but really
23:03 --> 23:07that is going to trigger you moving to
23:07 --> 23:10a more aggressive surgical approach
23:10 --> 23:12as opposed to active surveillance.
23:12 --> 23:14My next question has to do
23:14 --> 23:15with that surgical approach.
23:15 --> 23:18You mentioned that for people who have
23:18 --> 23:21larger tumors, so larger than one centimeter,
23:21 --> 23:24you could do a partial thyroidectomy,
23:24 --> 23:27take out just that part of the
23:27 --> 23:28thyroid that had the cancer.
23:28 --> 23:31Or you could take out the whole
23:31 --> 23:33thyroid and you said this
23:33 --> 23:36is really a decision that's made by
23:36 --> 23:38the team and is personalized
23:38 --> 23:43what factors go into deciding what kind
23:43 --> 23:46of an operation a patient should have?
23:47 --> 23:49One would think that it's a big
23:49 --> 23:51difference between having only part of your
23:51 --> 23:53thyroid removed and having your
23:53 --> 23:54whole thyroid removed?
23:54 --> 23:57Yes, this is a discussion
23:57 --> 24:00that I get to have multiple times a week,
24:00 --> 24:04so I usually talk about the benefits first
24:04 --> 24:08of only removing half of the thyroid and
24:08 --> 24:12this is a change that the American
24:12 --> 24:14Thyroid Association instituted
24:14 --> 24:18in 2015 because there is such a
24:18 --> 24:20increase in the prevalence of
24:20 --> 24:24thyroid cancers, so perhaps a less
24:24 --> 24:26aggressive approach is warranted,
24:26 --> 24:29as I think what the experts were thinking,
24:29 --> 24:32so the benefit of only removing half
24:32 --> 24:34of the thyroid that contains cancer
24:34 --> 24:38is that there is a pretty good chance
24:38 --> 24:40that the remaining thyroid may be
24:40 --> 24:44able to pick up the missing half and
24:44 --> 24:48still give you enough thyroid hormone.
24:50 --> 24:53So if you lose the entire thyroid,
24:53 --> 24:56you will have to take a thyroid
24:56 --> 24:59hormone supplementation pill everyday.
24:59 --> 25:03But if you have at least half of a thyroid,
25:03 --> 25:04that is normal
25:04 --> 25:05remaining in you,
25:05 --> 25:07there is a pretty good chance that you
25:07 --> 25:11may be able to avoid the medication aspect,
25:11 --> 25:13so that's one plus.
25:13 --> 25:18And although the thyroid surgery is
25:18 --> 25:22very safe when done in expert hands and
25:22 --> 25:26known to have very low complication rate it
25:26 --> 25:29will double the amount of thyroid
25:29 --> 25:32resection and obviously put you at
25:32 --> 25:36double the risk of complications,
25:36 --> 25:39so those are some of the things
25:39 --> 25:40that we discuss.
25:40 --> 25:45Obviously if one thyroid nodule
25:45 --> 25:47was biopsied
25:47 --> 25:51happens to have some genetic mutations,
25:51 --> 25:55such as a brief V600 E mutation.
25:55 --> 25:58Or if the patient has
25:58 --> 25:59Hashimoto's thyroiditis,
25:59 --> 26:02has a family history of thyroid cancer,
26:02 --> 26:05or has another sizable nodule
26:05 --> 26:08on the other side,
26:08 --> 26:10then maybe it's better for us
26:10 --> 26:13to do an up front
26:13 --> 26:16total removal of the thyroid so
26:16 --> 26:19we can catch perhaps multiple
26:19 --> 26:22spots of thyroid cancer,
26:22 --> 26:25which is a pretty well known
26:25 --> 26:28phenomenon in thyroid cancer patients.
26:28 --> 26:31So those are some of the considerations
26:31 --> 26:33when we discuss should we take
26:33 --> 26:36out half or the entire thyroid?
26:36 --> 26:38And of course,
26:38 --> 26:41if the patient happens to have
26:41 --> 26:43the lymph node spread
26:43 --> 26:45already outside the thyroid
26:45 --> 26:48and then the discussion is OK,
26:48 --> 26:51we should just go ahead and remove the
26:51 --> 26:53entire thyroid and the compartments
26:53 --> 26:56where the diseased lymph nodes are and
26:56 --> 26:59so it sounds like if the thyroid
26:59 --> 27:01is otherwise pretty healthy,
27:01 --> 27:05no Hashimoto's, no other nodules
27:05 --> 27:09and the thyroid cancer itself has
27:09 --> 27:13not spread to lymph nodes.
27:13 --> 27:15But still is more than one centimeter.
27:15 --> 27:17It sounds like your general
27:17 --> 27:19recommendation is a partial thyroidectomy.
27:19 --> 27:19Is that right?
27:20 --> 27:21That's right.
27:24 --> 27:26So far we've been
27:26 --> 27:28talking about papillary cancers,
27:28 --> 27:29if it was one of the other kinds,
27:29 --> 27:31the follicular, the medullary,
27:31 --> 27:32the anaplastic,
27:32 --> 27:34that 10% that we were talking
27:34 --> 27:36about at the top of the show,
27:37 --> 27:38does that change your mind?
27:38 --> 27:42Yes, so in the case of medullary thyroid
27:42 --> 27:44cancer, thank goodness is pretty rare,
27:44 --> 27:50but there is a genetic disposition and the
27:50 --> 27:53cancer itself portends to worse prognosis.
27:53 --> 27:57We would be doing at minimum total thyroid
27:57 --> 28:00surgery and what's called central neck
28:00 --> 28:03lymph node dissection from the get go.
28:03 --> 28:06So the extent that we talk
28:06 --> 28:09about for different types of
28:09 --> 28:11thyroid cancer very drastically.
28:11 --> 28:14And of course in the case of
28:14 --> 28:15anaplastic thyroid cancer,
28:15 --> 28:19if the patient is a surgical candidate,
28:19 --> 28:22then we can certainly attempt to reset
28:22 --> 28:26or debulk the bulk of the disease.
28:26 --> 28:29But the unfortunate part is that anaplastic
28:29 --> 28:31thyroid cancer is often incurable.
28:32 --> 28:34Doctor Grace Lee is an assistant professor
28:34 --> 28:37of surgery at the Yale School of Medicine.
28:37 --> 28:39If you have questions,
28:39 --> 28:41the addresses cancer answers at
28:41 --> 28:43yale.edu and past editions of the
28:43 --> 28:46program are available in audio and
28:46 --> 28:47written form at yalecancercenter.org.
28:47 --> 28:50We hope you'll join us next week to
28:50 --> 28:52learn more about the fight against
28:52 --> 28:53cancer here on Connecticut Public
28:53 --> 28:55radio funding for Yale Cancer
28:55 --> 28:57Answers is provided by Smilow
28:57 --> 29:00Cancer Hospital and AstraZeneca.

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September 26, 2021

Yale Cancer Center

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