I saw somebody today whose hair was getting thin, and her doctor decided to do an ultrasound to check her thyroid. Of course, they found a 5-mm papillary thyroid cancer that we are now going to follow with observation. In other cases, patients get carotid ultrasound , or chest or neck CT, and we find little changes in the thyroid, which usually leads to an ultrasound. Furthermore, we can now biopsy thyroid nodules as small as 2 and 3 mm. When I was a fellow, we would have never biopsied something smaller than 10 or 15 mm.
So we have excessive use of thyroid ultrasound that is being ordered for inappropriate reasons, combined with the ability to biopsy, very safely and very well, these really teeny tiny things. That sets the stage for a huge increase in small-volume thyroid cancer. Medscape: These are primarily incidental findings as a result of ultrasound for other causes?
Dr Tuttle: Most the time, they are. Thyroid cancer can sometimes be found by physical examination either as a thyroid nodule or as metastatic lymph nodes in the neck. Clearly, this is clinically significant thyroid cancer that needs to be diagnosed and treated. However, even incidental findings can be important. I have seen patients with thyroid nodules as large as cm that cannot be palpated on examination. So not every incidental finding should be ignored. By definition, these very small thyroid cancers are either being diagnosed because the ultrasound is being done for the wrong reasons, or to follow up a CT, MRI, or something else that was done for the right reason but accidently found a small thyroid nodule.
Medscape: What role do radiologists and oncologists play in overdiagnosis and presumably overtreatment, respectively, of thyroid cancer? Dr Tuttle: We are all to blame. Clearly, radiologists do not have much of a choice. If I request an ultrasound, then they are going to have to describe a small nodule—they can't ignore what they see.
Endocrinologists are the same way. If they see a nodule, then they usually feel that they should know what it is; they feel they should biopsy it. Patients are the same way.
Common sense says that the earlier that you find a thyroid cancer, the better, whether you are a radiologist, endocrinologist, oncologist, or a patient. Common sense says that if it is thyroid cancer, you should find that out. However, the new guidelines from the ATA, when they come out this fall, are going to specifically recommend against biopsying subcentimeter nodules even if they look suspicious.
It is the first time a group has made that strong a recommendation saying that even if a small thyroid nodule looks very suspicious for thyroid cancer, if it looks like it is confined to the thyroid, then the right thing to do is to repeat the ultrasound in months, not to stick a needle into it. Once you biopsy it, it is really hard for patients not to do anything about it.
The real issue is first, who is ordering that ultrasound to begin with, and second, who is insisting on having these small things biopsied. I think this is being driven by primary healthcare providers and endocrinologists and less so by radiologists and oncologists. Medscape: The guidelines are indeed becoming clearer about the subcentimeter nodules, with societies and organizations beginning to recognize nodules that should be left alone. Is there an issue with getting this guidance to primary care doctors and endocrinologists?
Dr Tuttle: Absolutely. We are fighting common sense. Nobody ever taught clinicians they were supposed to biopsy 5-mm thyroid nodules. You can't find that in any of the guidelines, yet you just kind of know that is the right thing to do. So we are fighting against what is a kind of common sense, and the recognition that we don't need to biopsy every subcentimeter nodule has really only gathered hold in the literature in the past several years. The recommendations from the ATA that specifically say not to biopsy nodules smaller than 1 cm are going to be pretty controversial when they come out, and there are going to be a lot of people who disagree with them.
We are only at the edge of the very senior thyroid specialists in the United States recognizing that immediate diagnosis and therapy are not required for every small papillary thyroid cancer. The challenge will be translating this information to endocrinologists, primary care doctors, family practice physicians, and patients and their families.
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Medscape: You used the phrase "common sense" to describe diagnosis, meaning that common sense says to look at a thyroid nodule early and find out what it is. However, there has also been this rise in ultrasound that has contributed to overdiagnosis. How does the US healthcare system, the reimbursement system, incentivize diagnosis and treatment of thyroid cancer? Does that contribute in any way? Dr Tuttle: No, honestly, I don't think so. You don't make a lot of money doing ultrasounds and biopsies.
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But there is no question that you get paid if you do that, and surgeons are going to be paid to do surgery. It just doesn't feel to me like monetary incentives are what is driving it. What's driving it is the desire to make a diagnosis of a cancer and to treat cancer. When I talk to doctors who are doing early diagnosis and treatment, they truly believe in their heart of hearts that they did a very good thing by finding a 5-mm papillary thyroid cancer.
See Drugs Approved for Thyroid Cancer for more information. Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing.
Available from ThyCa: Thyroid Cancer Survivors’ Association, Inc.
Hormones are substances made by glands in the body and circulated in the bloodstream. In the treatment of thyroid cancer, drugs may be given to prevent the body from making thyroid-stimulating hormone TSH , a hormone that can increase the chance that thyroid cancer will grow or recur. Also, because thyroid cancer treatment kills thyroid cells, the thyroid is not able to make enough thyroid hormone. Patients are given thyroid hormone replacement pills.
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Tyrosine kinase inhibitor TKI therapy is a type of targeted therapy that blocks signals needed for tumors to grow. Vandetanib is a TKI used to treat thyroid cancer. Information about clinical trials is available from the NCI Web site. For some patients, taking part in a clinical trial may be the best treatment choice.
Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
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Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment. Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward. Some clinical trials only include patients who have not yet received treatment.
Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring coming back or reduce the side effects of cancer treatment. Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials.
PDQ Cancer Information Summaries [Internet].
These have been retrieved from NCI's listing of clinical trials. Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated.
Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging. Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred come back.
These tests are sometimes called follow-up tests or check-ups. Check for U. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Treatment of stage III papillary and follicular thyroid cancer is usually total thyroidectomy. Cancer that has spread outside the thyroid, as well as any lymph nodes that have cancer in them, will also be removed.
Radioactive iodinetherapy or external radiation therapy may be given after surgery. Treatment of stage IV papillary and follicular thyroid cancer that has spread only to the lymph nodes can often be cured. When cancer has spread to other places in the body, such as the lungs and bone, treatment usually does not cure the cancer, but can relieve symptoms and improve the quality of life.
Treatment may include the following:. For more information from the National Cancer Institute about thyroid cancer, see the following:. The Thyroid Cancer Program aims to improve outcomes for the most acute thyroid cancer patients by targeting the unique genomics and biology of an individual's specific disease.
Panke is a pathologist in Ohio and a cancer patient.