Interviewer: Advances in recent years have changed how doctors diagnose and treat thyroid cancer.
Dr. Jason Hunt is the Clinical Director of Head and Neck Surgical Oncology at University of Utah Health and Huntsman Cancer Institute. And today he's going to talk us through how he works with patients to ensure an accurate thyroid cancer diagnosis, and how he determines if the appropriate treatment is a half or full thyroid gland removal or if a wait-and-see approach is more appropriate.
Dr. Hunt, the first question somebody might ask when they receive a thyroid cancer diagnosis or it's noticed that they have nodules on their thyroid, "Is this really cancer?" So how can a person feel confident that they got a reliable diagnosis?
Diagnosing Thyroid Cancer
Dr. Hunt: This is the first step. There is oftentimes some confusion. Most patients don't show up with something that is causing a lot of difficulties with their quality of life. They show up with a lump in the neck. Sometimes they don't even show up with a lump in the neck. They got a CT scan for something totally different. Maybe they fell and hit their head, went and got a scan in the emergency room, and said, "You have a nodule on your thyroid gland." And that kind of leads this series of events. They go and see someone and get an ultrasound. Ultrasound says, "Well, we need to stick a needle in it." The interesting thing about the biopsies for these nodules is that oftentimes they are indeterminate. So oftentimes they'll come back and it'll say something such as, "Atypia of undetermined significance," kind of leaving the patient, leaving you like, "Well, what is this? And what do I do next?"
The Evolution of Genetic Testing in Thyroid Cancer Diagnosis
Over the past 5 to 10 years, we've actually changed a little bit on how we manage these situations. Previously, if you had that type of diagnosis that was inconclusive, we would tell you, "You have a 10% risk of cancer. But the only way we're going to know for sure is by doing a surgery, by taking out half of your thyroid gland." And we don't have to do that anymore. We've now kind of honed in more... The world has moved a lot more towards the genetics of it, so looking at the mutations, looking at specific markers. And what a marker is, a marker is something, oftentimes it's a protein or something that's produced by the tumor that may give you a hint or a sign that it's cancer.
And so now instead of going straight to surgery to take out half your thyroid gland, we actually talk to you about, "Let's do some more tests. We may be able to actually downgrade this to a completely benign nodule so that you do not need any surgery. You don't need anything for." And that I think is one of the biggest things that people need to know even before they get a diagnosis of cancer or not cancer is really how you even get to the diagnosis.
Interviewer: Right. So it used to be that . . . like this is just development, the genetic testing is just a development in the past few years too, isn't it? This is relatively new. It used to be it was always just a biopsy and then you had to make a guess, right?
Dr. Hunt: That's exactly right, because while sometimes that biopsy may say cancer or may say benign, a lot of those end up into this middle ground where we just say, we scratch our heads and tell the patient we don't really know. And so that made up a large portion of surgeries for thyroid that ended up really didn't need to happen.
Interviewer: Yeah. Let me jump on the other side of that. If somebody gets a diagnosis and they're like, "Yep, this is cancerous," are those generally pretty accurate?
Dr. Hunt: Yeah, if you get that and it says cancer, that's about a 97% to 98% accuracy. So if you get that diagnosis, you can feel pretty comfortable that, yeah, there's now a pathway and you're going to make that pathway based on that diagnosis of cancer.
The "Wait-and-See Approach" for Inconclusive Thyroid Cancer Diagnoses
Interviewer: And if it's one of the more kind of nebulous in the gray area diagnosis, the inconclusive one, is it okay to adopt a wait-and-see approach? Or what would you counsel a patient to do at that point?
Dr. Hunt: You know, one of the options that we discuss is a wait-and-see or a repeat biopsy. I would say most patients though, leaving that as an unknown, most patients don't feel quite comfortable with that, right? And so telling you, "Well, you may have cancer. I don't know. Should we just watch it, come back and see?" Even though that's a completely safe approach, most patients, want to know. And so that's when we talk about these genetic testing. We call it molecular diagnostics, which kind of encompasses genetics and also looks at other kinds of markers within the nodule or the tumor.
Interviewer: Can some of those genetic tests come back then inconclusive as well? Like you had mentioned it could come back that, yeah, this is not a problem. Are those pretty accurate, first of all, if it does say genetically this is not a problem.
Dr. Hunt: Yeah, yeah. It's almost like the corollary to what we talked about with cancer, meaning that if it comes back and says, "There are no adverse markers, there's no adverse genetics," you got about a 97% assurance that this is going to be a benign nodule and you're good.
Interviewer: Sure. All right.
Dr. Hunt: But kind of to your point, sometimes that test also comes back as inconclusive because there are some markers that are associated with cancer but are not diagnostic. All of them don't end up being cancer. And so there's one specific mutation, and it's called a RAS. It's one of the pathways that you can develop cancer, but it may not be all the way to cancer. It could be a pre-malignant or a pre-cancer nodule. And unfortunately, when we get those, a lot of times we're back stuck in the same situation of, "Well, we're going to have to do surgery to take it out to know for sure."
Interviewer: Sure. So if a patient chooses a wait-and-see approach, I mean generally thyroid cancer is pretty slow growing and doesn't generally spread, at least the common one that most people get. Is that accurate? I mean, this is where the diagnosis is so important, right, because there are some that are a little bit more aggressive. So talk me through that as a patient.
Dr. Hunt: So you're right. I mean, the wait-and-see, if we are concerned about kind of what we call the well-differentiated, so people may have heard of papillary thyroid cancer or follicular carcinoma. Those are the ones that tend to be slow-growing and tend to have very good survival. Those are things that you don't have to feel like you're in a rush to get done. You've got time. You've got time to think about it. You have time to make sure you've got an accurate diagnosis.
There are some others that we are a little bit more aggressive in treating. There's one called medullary. Medullary tends to run in families a little bit more, and tends to be a little bit more aggressive. And we try to take care of those in a little bit more of a time-sensitive fashion.
There's another one that's really rare called anaplastic. And anaplastic is one of those that really want to get on top of really quickly, because time makes a huge difference. Now, fortunately, it's not very common that one, and a lot of patients will read and are concerned about the anaplastic, but it almost always affects older people, and it's just not very common.
Differentiating Thyroid Cancer Types
Interviewer: And are you pretty good at identifying the type of cancer it is pretty accurately?
Dr. Hunt: We are. Yeah, the needle biopsy, taking the biopsy plus taking kind of how the patient is presenting, we can get a pretty accurate diagnosis of which flavor, if you will, of thyroid cancer that it is.
Interviewer: Okay. Say a patient now has been diagnosed with thyroid cancer, what would kind of be the treatment options if that patient decided to pursue treatment? And again, the diagnosis is so important because it would depend on the type of cancer they have. So let's go through that list again.
Dr. Hunt: If we could step back a minute to one of the things you mentioned, you talked a little bit about that wait-and-see approach. Sometimes we even take a wait-and-see approach for actual cancers. There's really good data out there that very small, well-differentiated cancers, like if you had a papillary thyroid cancer and it's small, let's say it's less than one centimeter, we would give the option of observation. And a lot of those would actually never grow to cause a problem. Now some patients, once they hear the word "cancer," a lot of patients don't feel comfortable with that approach, as you can imagine. Once you hear the word "cancer," a lot of patients say, "I want it out ASAP, tomorrow."
Surgical Treatment Options for Thyroid Cancer
Interviewer: So then generally, if somebody does want to get treatment, is surgery the first thing? Are there some drugs that somebody could take? Like what does that look like?
Dr. Hunt: Yeah, surgery, thyroid cancer is primarily a surgical disease. So surgery is our best option. There are some drugs that can be used, but primarily we're going to recommend surgery to remove the cancer.
Interviewer: Okay. For all four types?
Dr. Hunt: You know, for all four types, if we can remove it with reasonable quality of life. And there are four types, but I lump two of those together. So the follicular and the papillary, we just call those well-differentiated thyroid cancers, and those get surgery. The middle one, the medullary gets surgery.
Targeted Drugs and Advances in Anaplastic Thyroid Cancer Treatment
The last one, the anaplastic, the one that tends to be very aggressive, a lot of those when they present, we can't even remove them because they're into structures that you can't live without. But kind of the cool thing that's happened in the past, gosh, really the past three to five years with anaplastic, it used to be that patients would die within a couple of months with that. But we've actually had new targeted drugs that for some of those we can actually shrink the tumor down, then go in to remove it. And the cancer may . . . You may still end up succumbing to cancer down the road, but we can add . . . We've added years onto patients' lives where previously it was months of survival. And that's been really cool. And this has been based on kind of the genetics of the disease and new drugs that actually target those genes.
Surgical Decision-Making: Partial vs. Total Thyroid Removal
Interviewer: So if a patient does decide to go have surgery, you've mentioned that sometimes you remove half the thyroid, sometimes you remove all of the thyroid. How is that decision made?
Dr. Hunt: You know, if we were to look back at what we've done in the past, we mentioned before we overtreated a lot of thyroid cancers. So 15, 10, 15 years ago, if you had a diagnosis of thyroid cancer, for the most part, they removed all your thyroid gland. And then they gave you a relatively high dose of radioactive iodine, which is a treatment that gets concentrated in thyroid tissue and essentially is a way to deliver radiation to the thyroid cells. So over time, we've realized we don't need to do that. We actually don't need to take out all the thyroid on patients, and we don't need to give radioactive iodine, because a lot of patients were overtreated. It didn't help them live longer. It didn't help them have a decreased chance of it coming back.
And so I would say probably in the past 5 to 10 years, we've adopted a much less aggressive approach. And for most thyroid cancers that are well differentiated, we would offer taking out half the thyroid, a hemithyroidectomy we call it. So we just take one half out.
Now, when would we take out all of it? Well, I think that comes down to kind of the chances that the cancer is going to come back. And there are some signs that we can predict cancers that are more likely to come back. If it's spread to other areas. We have these little glands in our neck called lymph nodes, and these lymph nodes drain fluid. And so if the cancer has drained from the thyroid gland to a lymph node, that's a sign that it's a little bit more aggressive. If that cancer has grown outside the thyroid gland and let's say it's actually stuck to some of the muscles or other structures, it's more aggressive. And those patients are going to need to be treated in the kind of more classic way we did 10, 15 years ago, meaning we have to take all the thyroid gland out, and we need to give radioactive iodine.
And the reason you have to take all the thyroid gland out is that the iodine is taken up into thyroid cells. And if we've left . . . Let's just say we took the bad half, the cancer half of the thyroid out and left the normal half, then all that radioactive iodine would just go to that normal half and would not go to any microscopic cells, the cancer cells where we would want to treat, if that kind of makes sense.
Interviewer: What's the upside to leaving part of the thyroid gland in place as opposed to just removing the entire thing and just being sure that it's all gone?
Dr. Hunt: There's two things, aspects of it. It does decrease your risk of surgery a little bit. But I think even the bigger part is we can keep patients off of medication. So if you don't have a thyroid, you have to take thyroid hormone replacement. If you leave half, about 70% of those patients will not need to take thyroid hormone medication. And I don't know about you Scot, but if I can decrease one pill to take in a day, that's a big win for me.
Interviewer: Right. So it sounds like as a patient, again, another one of these points of conversation I'd really want to be sure about is if I'm being told I need to have my whole thyroid removed, really start to ask some questions, "Are we positive about that?" Because it sounds like there's a big advantage to being able to leave half of it there.
Exploring Second Opinions in Thyroid Cancer Treatment
Dr. Hunt: And we actually get patients that come in for second opinions where they've been recommended to have all of it removed. And it's a big question. Matter of fact, actually I just saw someone yesterday that that was kind of what they were being recommended outside, and the patient, the big thing that they wanted was to not have to be on medications because they don't take any medications otherwise. And those are situations where a lot of times, if it's appropriate from a medical standpoint, if it's appropriate, we offer them a hemithyroidectomy. We just take half, try to leave a normal half of the gland, and try to keep them off of medications.
Interviewer: What would you say to somebody who's listening to this conversation that we're having right now? Obviously, they've been diagnosed or there's a concern that they might have thyroid cancer, they're investigating some of their treatments and some of their options, some of their upsides, and some of their downsides. What didn't we address that a lot of patients would ask you about?
Dr. Hunt: You know, I think some of the things are, well, number one, I think if you have a thyroid nodule or even a diagnosis of thyroid cancer, it's a slow-growing disease in most all the cases, and you have time to actually do your homework. You have time to think about it and make sure that you're actually getting the appropriate treatment that's going to lead to kind of your best quality of life afterward. Because we really are shifted a little bit because the patients do well. Survival is good, and we want to make sure that your quality of life in the long term is good as well.
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