Thyroid Cancer Awareness Month

September 27, 2021

Information

September 26, 2021

Yale Cancer Center

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00:00Funding for Yale Cancer Answers
00:03is provided by Smilow Cancer
00:05Hospital and AstraZeneca.
00:07Welcome to Yale Cancer
00:09Answers with your host
00:10Dr. Anees Chagpar. Yale Cancer Answers
00:12features the latest information on
00:14cancer care by welcoming oncologists and
00:17specialists who are on the forefront of
00:20the battle to fight cancer. This week,
00:22it's a conversation about thyroid
00:24cancer with Doctor Grace Lee.
00:26Doctor Lee is an assistant professor
00:27of surgery at the Yale School of
00:30Medicine where Doctor Chagpar is
00:31a professor of surgical oncology.
00:34Grace, maybe we can start off by
00:36you telling us a little bit about
00:38yourself and about what you do.
00:40As an endocrine surgeon I
00:43remove the thyroid, parathyroid in
00:45adrenal glands for various different
00:48disorders including cancer.
00:50My areas of clinical and research
00:53interest include different
00:55minimally invasive techniques
00:57and new imaging techniques for
00:59treatment of endocrine disorders.
01:02So let's start off by talking a
01:04little bit about thyroid cancer.
01:05After all, it is thyroid
01:07cancer awareness month.
01:09So tell us a little bit more about
01:11the epidemiology of thyroid cancer.
01:13How many people get diagnosed?
01:15How many people succumb to their disease?
01:17How common is this?
01:19So thyroid cancer is
01:23number wise, about the eighth most
01:26common cancer in the US, however,
01:29it only accounts for about 4% of
01:32all the new cancers being diagnosed,
01:35and people who succumb to
01:37thyroid cancer annually
01:39we guesstimate at about 2000 so
01:43it is not as prevalent as
01:46breast cancer or colon cancer,
01:50but what's interesting is that new
01:53diagnoses of thyroid cancers have
01:55tripled in the past three decades.
01:58It is one of the most rapidly
02:01increasing cancers in the US
02:03but we believe that much of
02:05the increase owes to the fact
02:07that we're just catching them
02:09earlier and more frequently,
02:11as mentioned before,
02:13we utilized
02:14various diagnostic imaging to further
02:18elucidate many conditions and we
02:21just catch these incidental thyroid
02:24nodules while we are just looking
02:27into our body for different diseases.
02:30So thyroid nodules are just
02:32being caught earlier and more
02:35frequently. Some of these imaging
02:38studies that patients get include
02:40CT scans after a car accident.
02:43Pet CT to survey and other cancers
02:46such as breast cancer or Melanoma
02:49or even carotid ultrasound,
02:51to examine narrowing of
02:52the carotid arteries.
02:54Let's dig a little bit more
02:56into that because I find that statistic
02:59of a tripling in the rate of thyroid
03:03cancers to be really quite an awesome,
03:07not in the sense of awesome 'awesome' but awesome
03:11in the sense of a huge number deserving of awe.
03:17What are the risk factors for thyroid cancer?
03:20I appreciate that you said that
03:24we think that a lot of this is just because
03:27of an increasing rate of detection,
03:31but help us to understand what are the
03:34etiologic causes of thyroid cancer?
03:36That's an excellent question,
03:38if we can actually get down to
03:41the bottom of why thyroid cancer happens
03:44perhaps we can even prevent it,
03:46so there have been many studies that have
03:50been performed to characterize who are the
03:54folks that are getting thyroid cancer.
03:57Why we are catching
03:59and detecting more of them.
04:01Some of the risk factors for
04:04thyroid cancer include being a woman
04:07and of the Asian race and
04:10age between 25 to 65 years old.
04:14Although we do see some
04:16extreme distribution of ages,
04:19such as pediatric population versus
04:22very advanced age population.
04:26And also having had
04:28prior radiation treatment to the
04:30head and neck area as a child or
04:34having had environmental radiation
04:36exposure such as a nuclear accident.
04:39And having a family member with
04:42history of thyroid disease or
04:44enlarged thyroid or thyroid cancer.
04:47And again, the detection catches
04:50incidental thyroid nodules.
04:51Not necessarily thyroid cancer.
04:54So most of these thyroid nodules
04:57turn out to be benign nodules.
05:00But because we're catching
05:02benign nodules,
05:04we are also seeing the increase
05:05of thyroid cancer.
05:07When you talk
05:09about the risk factors,
05:10a lot of the things you mentioned
05:12are things that we cannot change.
05:13Being a woman, your age,
05:16your race or ethnicity,
05:18your family history.
05:22And the things that are other
05:26risk factors, exposure to radiation,
05:29nuclear accidents,
05:31thankfully, not many of us, I think,
05:34can claim to have that,
05:36and certainly sometimes when
05:38we're exposed to radiation due
05:40to CT scans or other things,
05:43those may be beyond
05:45our control as well.
05:47Are there any factors that our audience
05:51might be interested in that increase
05:54or decrease your risk of thyroid
05:56cancer that you can control?
05:58And so I'm thinking here about
06:01things like an iodine deficiency
06:03that we know can have a role to
06:07play in benign thyroid conditions.
06:09Any role for that in terms of cancers?
06:12Any other factors that
06:16people could potentially control?
06:20That's very interesting question.
06:22I do occasionally have a patient
06:27who's interested in modifying their diet
06:30to either combat the existing thyroid
06:34cancer or help their family members
06:37prevent from getting thyroid cancer.
06:41Iodine deficiency certainly
06:43can be the cause of a goiter,
06:47an enlarged thyroid gland.
06:49But I do not believe there has
06:52been an established linkage
06:55between iodine supplementation and
06:57decreased rate of thyroid cancer.
07:00So at the current time point,
07:03I think detection and appropriate treatment
07:06will be the best course of action
07:09once one is found to have thyroid cancer.
07:16Getting back to that original statistic,
07:18this tripling of thyroid cancers,
07:21it doesn't seem that there has been
07:23a tripling of nuclear accidents.
07:26If anything, I think our nuclear
07:29exposures have generally declined,
07:31as safety protocols have improved,
07:35one wouldn't think that there
07:37would have been a difference in terms of
07:40age or gender or race over the last
07:44few decades where we've seen this
07:47tripling and so that brings us to
07:49this whole area of of detection,
07:52which you surmise is really the
07:55thing at the driving seat of
07:58this tripling of thyroid cancer.
08:01Has anybody looked at that?
08:02Has the rate at which we are imaging
08:06people increased at that same proportion?
08:09So in other words we all know that
08:12there's been this burgeoning of technology.
08:16And we seem to do more imaging
08:18nowadays than we used to.
08:20At least that's how it feels anecdotally.
08:23But has anybody looked at that to see
08:25whether these two trends are parallel?
08:28Yeah, I believe so.
08:29So in much of thyroid cancer literature,
08:32we always attribute the partial rapid
08:38increase in thyroid cancer being
08:42prevalent to essentially the detection,
08:46in leading to earlier diagnosis,
08:49not necessarily more aggressive treatment,
08:52we have been scaling back down on the
08:57resection of these thyroid cancers.
09:00So not all thyroid cancers lead to surgery,
09:03but it is certainly true that there
09:07is clear correlation between the
09:10utilization of imaging studies
09:13in multiple different aspects.
09:16And also perhaps patient awareness
09:20in clinician exam skills being
09:23improved lead to detection of the
09:28thyroid nodules and go down the
09:31pathway of thyroid cancer detection.
09:33Let's talk a little bit
09:35about that because as you say,
09:36not all thyroid nodules that
09:37may be picked up incidentally,
09:39either on imaging or on physical
09:42exam are actually a cancer.
09:44So let's suppose somebody does have
09:47a scan done for whatever reason
09:50and the thyroid nodule is found.
09:52How do we get from incidental thyroid
09:55nodule to making a diagnosis of cancer?
09:58How does that work?
10:00Yeah, so as we mentioned,
10:02it is not uncommon that we just
10:05stumble upon a thyroid nodule being
10:08mentioned on a CT scan that a patient
10:12may have gotten for neck pain or
10:15just to rule out lung nodules etc.
10:20So after initial detection of the
10:24thyroid nodule on a different modality,
10:28we do a comprehensive neck
10:31ultrasound as the gold standard exam.
10:37If the patient does not have recent
10:40thyroid function that was drawn
10:42with a routine yearly checkup.
10:46So after the ultrasound is obtained,
10:50we can then
10:52detect whether the thyroid nodule
10:55is of the appropriate size and if
10:59that nodule has specific ultrasound
11:02characteristics that make us worried
11:05about that thyroid nodule being cancerous.
11:08And if we
11:11give that thyroid nodule appropriate
11:14numbers and if we surmise that the
11:18nodule is meeting the biopsy criteria,
11:21then what we usually do is
11:24a fine needle aspiration biopsy
11:27under the guidance of ultrasound
11:31to have our pathologists then take
11:33a look at some of the cell samples
11:36obtained from their thyroid nodule.
11:38So let's flush that out a little bit.
11:41You mentioned that
11:42there are some size criteria,
11:44some morphologic criteria that you
11:46look at in terms of a thyroid nodule
11:49to kind of gauge your suspicion as to
11:52whether this could be malignant or not,
11:54tell us a little bit more
11:56about what those criteria are.
11:58What are the things that make you worried
12:00that a thyroid nodule could be cancer?
12:03Yeah, so generally speaking we
12:07worry about bigger thyroid nodules.
12:11That's generally speaking.
12:15And how big is big grade?
12:18We consider anything less than
12:211 centimeter as kind of
12:25microterritory and 1 centimeter or greater
12:28at least meets the size criteria.
12:31If the thyroid nodule looks worrisome
12:35enough on the ultrasound and some of the
12:39worrisome features are the thyroid nodule
12:42being solid rather than mostly fluid,
12:48or mixed solid and fluid,
12:51what we call cystic and it has what
12:54we call hypoechoic characteristic
12:57onto ultrasound microcalcifications
12:59irregular borders taller than wide, etc.
13:04So we radiologists are very familiar
13:08with assigning certain
13:11points to these thyroid nodules
13:14to see if this is thyroid nodule
13:18should then proceed to the
13:21biopsy stage or
13:23this thyroid nodule looks
13:26to be pretty innocuous.
13:28Although it is 2 centimeters
13:30or three centimeters,
13:31and perhaps we can watch it.
13:34And so we're going to pick up on
13:37this conversation about what happens
13:39once that diagnosis of thyroid
13:41cancer is made right after we take
13:43a short break for a medical minute.
13:45Please stay tuned to learn more about
13:48the care of patients with thyroid
13:49cancer with my guest doctor Grace Lee.
13:52Support for Yale Cancer Answers
13:54comes from Smilow Cancer Hospital,
13:56where an individualized approach to
13:58prostate cancer screening is used
14:00to determine which men are eligible
14:02and would benefit from screening.
14:04To learn more, visit Yale Cancer
14:08Center dot org slash screening.
14:10Genetic testing can be useful for
14:12people with certain types of cancer
14:14that seem to run in their families.
14:16Genetic counseling is a process that
14:18includes collecting a detailed personal
14:20and family history or risk assessment and
14:23a discussion of genetic testing options.
14:25Only about 5 to 10% of all
14:28cancers are inherited,
14:29and genetic testing is not
14:31recommended for everyone.
14:32Individuals who have a personal and
14:34or family history that includes
14:37cancer at unusually early ages,
14:39multiple relatives
14:39on the same side of the family
14:42with the same cancer,
14:43more than one diagnosis of
14:45cancer in the same individual,
14:47rare cancers or family history of a
14:50known altered cancer predisposing gene
14:52could be candidates for genetic testing.
14:55Resources for genetic counseling and
14:57testing are available at federally
14:59designated comprehensive cancer
15:01centers such as Yale Cancer Center
15:03and Smilow Cancer Hospital.
15:05More information is available at
15:08yalecancercenter.org. You're listening
15:09to Connecticut Public Radio.
15:12Welcome back to Yale Cancer Answers.
15:14This is doctor Anees Chagpar and I'm
15:17joined tonight by my guest Doctor Grace Lee.
15:19We're talking about the care of
15:22patients with thyroid cancer in
15:24honor of Thyroid Cancer Awareness
15:26Month and right before the break,
15:28Grace was telling us this amazing
15:31statistic that thyroid cancers have
15:33actually tripled in recent history
15:35in large part due to an increase
15:38in standard imaging.
15:39So we're stumbling upon these
15:42incidental thyroid nodules,
15:44which, if they're large enough,
15:46and if they have certain
15:49morphologic features on ultrasound,
15:51are warranting a biopsy and that biopsy
15:55can sometimes reveal thyroid cancers.
15:58So Grace,
16:00before the break you were mentioning that
16:03thyroid cancer is not a uniform disease.
16:07It's not homogeneous.
16:08Not all thyroid cancers are treated the same.
16:12So tell us a little bit more about that.
16:15First of all,
16:16are there different kinds of thyroid cancer?
16:19And second of all,
16:21how does that impact what you do next?
16:25There are
16:26about four different major
16:29types of thyroid cancers.
16:32The good news is that the most
16:35common thyroid cancer known as
16:38papillary thyroid cancer actually
16:41carries the best prognosis.
16:43So most people, about 90% of the
16:48patients that I treat come in
16:51with papillary thyroid cancer,
16:54and the rest, 10% comprise of
16:58other follicular medullary or
17:01anaplastic thyroid cancers.
17:03And other good news is that seven
17:06out of those ten patients recently
17:09diagnosed with thyroid cancer come in
17:13with the cancer that is well behaving,
17:16meaning their cancer has not actually
17:19spread outside of the thyroid.
17:22So most of the people who get
17:25the diagnosis of thyroid cancer,
17:28although it is quite terrifying,
17:30should be reassured that as
17:33long as we treat them
17:36the right way they're going to
17:39be enjoying excellent prognosis.
17:43Tell us a little bit
17:45more about that, I mean
17:4790% of patients have papillary
17:50cancers which have a good prognosis.
17:52Of those, 70% are well behaved,
17:57but these patients still
17:59require treatment, right?
18:01Or is it that thyroid cancer has
18:04now gone the way of other cancers
18:06in terms of watchful waiting?
18:09That's a hotly debated
18:13very individualized choice, but the
18:18mainstay treatment for thyroid cancer,
18:22first and foremost is surgical,
18:25or if the cancer has gone
18:28outside of the thyroid,
18:30then we would treat by removing the entire
18:34thyroid as well as the involved lymph nodes.
18:39Watchful waiting in the thyroid world,
18:43we call that active surveillance.
18:46We can sometimes employ that approach,
18:51which is another right answer to
18:54this thyroid cancer management.
18:55We can go active surveillance route
18:59if the papillary thyroid cancer,
19:02the well behaving thyroid cancer
19:03happens to be less than one centimeter.
19:06So if there is no risk of this
19:10cancer invading into the nerve or
19:13the cancer going outside of the
19:16thyroid is well cushioned by normal
19:19thyroid and the patient is very
19:22motivated and reliable to comply with
19:26this active surveillance program.
19:29We can certainly go that route,
19:32but any thyroid cancer that is between
19:36one centimeter to 4 centimeter
19:39can go either half of the thyroid
19:42that's containing that cancer or the
19:46entire thyroid to be removed.
19:49So there are multiple right answers.
20:03Let me just pick up
20:04on a couple of things there.
20:05So the first thing is in
20:08terms of active surveillance.
20:09This is for people who have papillary
20:12cancers that are well differentiated
20:14that are less than one centimeter.
20:20What does active surveillance
20:23actually entail?
20:24I mean, is this an ultrasound
20:26every six months to make sure that
20:29this thyroid nodule isn't growing?
20:31Is it blood work?
20:33Is it CT scans?
20:35What exactly does that entail?
20:38Great question. Yes,
20:40it would mean actively monitoring the size
20:49or the growth changes of that biopsy
20:53known micro papillary thyroid cancer
20:56and is some clinician dependent,
20:59but usually about every six months
21:02to a year ultrasound exam and the
21:06thyroid cancer is not something that
21:11we follow on laboratory values.
21:14So it's heavily
21:16image independent and sometimes even a
21:20neck CT is utilized to pick up on lymph
21:25node spread a little bit more closely.
21:30It is what's called a wolf in sheep
21:33clothing by one of my mentors because
21:37even micro papillary cancer can spread to
21:40nearby lymph nodes in the thyroid cancer world,
21:43even the lymphatic spread does not
21:47necessarily mean worse prognosis.
21:49However, it is more advanced
21:52or at least local,
21:54regionally advanced disease.
21:56So we treat those folks
22:00almost as equally as someone who has
22:03bigger cancer and the folks that I'm
22:06talking about are patients under active
22:09surveillance and by watching them carefully,
22:14it may earn them,
22:16or it may buy them an extra five years
22:19extra 10 years with their own thyroid.
22:23And surgical
22:26treatment always is an option.
22:30But generally speaking,
22:31if the size of that micro cancer
22:34changes by about 3 millimeters,
22:36we say, well, OK.
22:38I think it's time to intervene,
22:41and most of the studies on
22:44active surveillance comes out of
22:46Japan and their long term result
22:49is actually quite excellent.
22:51So you really are watching
22:53these people very closely.
22:54I mean, even 3 millimeters doesn't sound
22:57like a whole lot to the people
22:59who are listening to our show today,
23:01I'm sure, but really
23:04that is going to trigger you moving to
23:08a more aggressive surgical approach
23:10as opposed to active surveillance.
23:13My next question has to do
23:15with that surgical approach.
23:16You mentioned that for people who have
23:18larger tumors, so larger than one centimeter,
23:21you could do a partial thyroidectomy,
23:25take out just that part of the
23:27thyroid that had the cancer.
23:29Or you could take out the whole
23:31thyroid and you said this
23:34is really a decision that's made by
23:37the team and is personalized
23:39what factors go into deciding what kind
23:44of an operation a patient should have?
23:47One would think that it's a big
23:49difference between having only part of your
23:51thyroid removed and having your
23:53whole thyroid removed?
23:55Yes, this is a discussion
23:58that I get to have multiple times a week,
24:01so I usually talk about the benefits first
24:05of only removing half of the thyroid and
24:09this is a change that the American
24:13Thyroid Association instituted
24:15in 2015 because there is such a
24:18increase in the prevalence of
24:21thyroid cancers, so perhaps a less
24:24aggressive approach is warranted,
24:27as I think what the experts were thinking,
24:30so the benefit of only removing half
24:33of the thyroid that contains cancer
24:35is that there is a pretty good chance
24:38that the remaining thyroid may be
24:40able to pick up the missing half and
24:45still give you enough thyroid hormone.
24:50So if you lose the entire thyroid,
24:53you will have to take a thyroid
24:57hormone supplementation pill everyday.
24:59But if you have at least half of a thyroid,
25:03that is normal
25:04remaining in you,
25:05there is a pretty good chance that you
25:08may be able to avoid the medication aspect,
25:11so that's one plus.
25:14And although the thyroid surgery is
25:18very safe when done in expert hands and
25:22known to have very low complication rate it
25:27will double the amount of thyroid
25:30resection and obviously put you at
25:33double the risk of complications,
25:37so those are some of the things
25:40that we discuss.
25:41Obviously if one thyroid nodule
25:45was biopsied
25:48happens to have some genetic mutations,
25:51such as a brief V600 E mutation.
25:56Or if the patient has
25:59Hashimoto's thyroiditis,
26:00has a family history of thyroid cancer,
26:03or has another sizable nodule
26:06on the other side,
26:08then maybe it's better for us
26:11to do an up front
26:14total removal of the thyroid so
26:17we can catch perhaps multiple
26:20spots of thyroid cancer,
26:22which is a pretty well known
26:25phenomenon in thyroid cancer patients.
26:28So those are some of the considerations
26:31when we discuss should we take
26:34out half or the entire thyroid?
26:37And of course,
26:38if the patient happens to have
26:42the lymph node spread
26:43already outside the thyroid
26:45and then the discussion is OK,
26:48we should just go ahead and remove the
26:51entire thyroid and the compartments
26:54where the diseased lymph nodes are and
26:57so it sounds like if the thyroid
27:00is otherwise pretty healthy,
27:02no Hashimoto's, no other nodules
27:05and the thyroid cancer itself has
27:10not spread to lymph nodes.
27:13But still is more than one centimeter.
27:16It sounds like your general
27:17recommendation is a partial thyroidectomy.
27:19Is that right?
27:20That's right.
27:25So far we've been
27:27talking about papillary cancers,
27:28if it was one of the other kinds,
27:30the follicular, the medullary,
27:32the anaplastic,
27:33that 10% that we were talking
27:35about at the top of the show,
27:37does that change your mind?
27:39Yes, so in the case of medullary thyroid
27:43cancer, thank goodness is pretty rare,
27:45but there is a genetic disposition and the
27:50cancer itself portends to worse prognosis.
27:54We would be doing at minimum total thyroid
27:57surgery and what's called central neck
28:01lymph node dissection from the get go.
28:04So the extent that we talk
28:07about for different types of
28:09thyroid cancer very drastically.
28:12And of course in the case of
28:14anaplastic thyroid cancer,
28:15if the patient is a surgical candidate,
28:19then we can certainly attempt to reset
28:23or debulk the bulk of the disease.
28:26But the unfortunate part is that anaplastic
28:29thyroid cancer is often incurable.
28:33Doctor Grace Lee is an assistant professor
28:35of surgery at the Yale School of Medicine.
28:38If you have questions,
28:39the addresses cancer answers at
28:41yale.edu and past editions of the
28:44program are available in audio and
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28:48We hope you'll join us next week to
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