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By Jeffrey Dach, MD
Originally published as "The Thyroid Nodule Epidemic by Jeffrey Dach, MD"
A 36 Year Old Female With Hypothyroidism After Thyroidectomy For Thyroid Cancer
Lisa, a 36-year-old model and actress, arrived in my office and told me her story. Ever since her thyroidectomy for cancer, she has had symptoms of severe fatigue, muscle pain, hair loss, and dry skin. The small dose of Synthroid prescribed by her endocrinologist didn't seem to be helping.
Four years ago, her family doctor palpated her thyroid gland, thought he felt a nodule and sent her for thyroid ultrasound, "just to be sure". The thyroid ultrasound images showed a small nodule about 9 mm in size, and the doctors recommended ultrasound guided needle biopsy, "just to be sure". About a week after the biopsy, the pathology report came back with a diagnosis of "papillary carcinoma of the thyroid."
Lisa is Told She Has Thyroid Cancer
As you can imagine, Lisa was very upset when the doctor informed her she had cancer. "Not to worry", said her doctor,"You have an excellent prognosis and a high likelihood for cure after surgery followed by radioactive iodine treatment."
Image: Video Assisted Thyroidectomy, courtesy of Wikimedia commons.
Lisa Undergoes Surgery and Radiation - Complete Thyroidectomy
Grateful that she had a treatable cancer with a good prognosis, Lisa underwent the surgery and radiation. Since the surgery completely removed her thyroid gland, she required thyroid medication every day. She also needed periodic screening tests to check for cancer recurrence.
Adverse Effects of Treatment
Unfortunately, Lisa was not spared the adverse effects of her treatment. The surgery had disturbed her recurrent laryngeal nerve leaving her with a chronic hoarseness, cough and voice change. The surgery also removed the parathyroid glands leaving her at risk for osteoporosis. The radioactive iodine treatment caused salivary gland damage, leaving her with a chronic dry mouth and bad taste. The radioactive iodine also carried an increased generalized cancer risk over her lifetime, and of course, a detrimental effect on fertility in the future when Lisa decides to have a family.
Switching from Synthroid to Natural Thyroid
I explained to Lisa that her symptoms of hypothyroidism were due to the small dose of Synthroid, which was not enough to relieve her symptoms. In addition, Synthroid, which contains only T4, does not completely replace the function of her missing thyroid gland. A natural thyroid medication from made from desiccated porcine thyroid gland containing T3, T4 and Calcitonin is a far better alternative. Lisa was switched over to her natural thyroid medication, called NatureThroid from RLC labs, along with iodine supplementation, and 3 weeks later called the office to report a dramatic improvement with relief of chronic fatigue and improved energy levels.
A Cancer with No Biological Significance
For twenty years as an interventional radiologist, my job was to perform ultrasound needle biopsies of small thyroid nodules sent into the hospital by primary care doctors. The vast majority of thyroid cancers found with ultrasound scanning and needle biopsy are the small papillary carcinoma, a relatively benign tumor with excellent prognosis (30 year survival rate 95% ).
image: Thyroid sonogram transverse image. 1=right carotid artery, 2=right thyroid gland, 3=trachea, 4=left thyroid gland, 5=left carotid artery. Courtesy of Wikimedia Commons.
A Frustrated Radiologist Says : Turn Off the Ultrasound Machines
An exasperated radiologist, John J. Cronan, MD says in the June 2008 issue of Radiology we should "turn off the ultrasound machines". Cronan questions this entire medical enterprise of detecting thyroid nodules, and small cancers with ultrasound guided biopsy. "From the patient perspective, we have hung the psychologic stigma of cancer on these patients and the dependency for daily thyroid supplementation...We accept all these consequences to control a cancer with a 99% 10-year survival."
A Normal Finding
Dr Harach says occult papillary carcinoma of the thyroid is a "normal" finding in Finland, and does not cause biologically significant disease. Dr. Louise Davies agrees with Dr Harach, and says in JAMA, "papillary cancers smaller than 1 cm could be classified as a normal finding"
Our Quixotic Approach to Thyroid Nodules
Keith Heller, MD, a neck surgeon who operated on 1,000 cases of thyroid cancer over a 28 year career, addressed his colleagues in a medical meeting saying:
"I do not believe that this epidemic of (thyroid cancer) is real. It is due to ...the increasing use of ultrasound-guided needle biopsy of thyroid nodules. We may be diagnosing and treating cancers that have no clinical significance...We have embarked on a quixotic quest to rid our patients of microscopic and probably clinically unimportant thyroid cancer.... We are performing far too many unnecessary thyroidectomies." [emphasis added]
Japan to the Rescue - Watchful Waiting - Just like the PSA Test
Since the invention of the PSA test for early detection of prostate cancer, we have seen evolution from aggressive medical treatment to "watchful waiting", with men with elevated PSA levels who have declined treatment with surgery and radiation, instead opting for "watchful waiting".
A thyroid cancer expert, Dr. Yasuhiro Ito of Kobe, Japan, has come up with a similar approach for papillary thyroid cancer, and has a number of studies to back up his statements.
Dr Ito published this in the 2003 Thyroid Journal:
"Our preliminary data suggest that papillary microcarcinomas do not frequently become clinically apparent, and that patients can choose observation while their tumors are not progressing, although they are pathologically multifocal and involve lymph nodes in high incidence."
Dr. Ito observed 162 patients with papillary thyroid microcarcinoma (< 10 mm) over 8 years. 70% of tumors either remained stable or decreased in size. Only 10% enlarged by more than 10 mm. Only 1.2% of patients developed neck node metastasis over the 8 years observation. Because of this study, Dr. Ito says the patient can opt for watchful waiting with serial ultrasound follow up studies. Dr. Ito says that if follow up ultrasound shows enlarging tumor, or enlarging metastatic neck nodes, then more aggressive surgical treatment is indicated with an excellent prognosis.
In another study of 52 cases, Dr Ito found when the papillary thyroid cancer is resected as a benign nodule (by mistake), even this is sufficient treatment and no further immediate surgery is needed.
It's the Pathologist's Fault - Just Stop Calling It Cancer
Left Image: Lymph node with metastasis of papillary thyroid carcinoma (middle/bottom of image). The papillary thyroid carcinoma (thyroid cancer) shown here has the classically described appearance (papillary architecture -- papillae with fibrovascular cores). The lymph node has several germinal centers (left, top/right of image). Adipose tissue (fat) is seen at the edge of the image (bottom and left). Courtesy of Wikimedia Commons
Perhaps this whole problem is caused by incorrect terminology used by the pathologist who reviews the biopsy slide and uses the word "cancer", a word that strikes fear and creates undue stress. Once a pathology report with the word "cancer" is placed on the desk, rationality gets thrown out the window, and the patient demands aggressive treatment, usually out of proportion to the actual pathology.
In the 2003 issue of the International Journal of Surgical Pathology, Dr Rosai presented the Porto Proposal , in which he proposed a change in terminology. Instead of CANCER, he suggested the terminology, papillary microtumor. Others (Hazard et al.) proposed "nonencapsulated thyroid tumor" because "the surgeon may become unduly alarmed when the pathologist reports the presence of carcinoma." Harach et al. proposed the term occult papillary tumor, "in order to avoid unnecessary operations and serious psychologic effects on patients."
Is Treatment of Papillary Micro-Carcinoma Overly Aggressive?
Over the years, we have seen surgical treatment for breast cancer evolve from the overly aggressive and debilitating radical mastectomy procedure, to the current day simple lumpectomy for many small breast cancers. Perhaps treatment for thyroid cancer is going in this same direction, and is playing "catch-up" with the more limited breast cancer treatments.
Dr Ian Hay's 2008 study published in Endocrine Abstracts followed 900 patients with papillary thyroid microcarcinoma over 54 years. Dr Ian Hay, "neither total thyroidectomy, nor Postoperative Radioactive Iodine Ablation, improved long term outcome during 40 years, in terms of either tumor recurrence or cause-specific mortality." Dr Hay advocates removal of the tumor with unilateral lobectomy, saying that it was unnecessary to perform total thyroidectomy or radioactive iodine treatment, since they did not improve prognosis compared to unilateral thyroid lobectomy alone.
The Role of Iodine Supplementation
You might ask the obvious question, "Thyroid nodules are found in 67% of the population. What is causing this?" I would suggest that the most likely explanation is subclinical iodine deficiency in the population. Iodine deficiency causes thyroid enlargement (goiter), thyroid nodules, and thyroid cancer.
Thyroid cancer appears linked to Iodine deficiency in both animal models and humans. Studies have shown that iodine deficiency is associated with increased anaplastic thyroid cancer, the aggressive type unresponsive to treatment and associated with high mortality rate. Population studies in which iodine supplementation was given showed reduced mortality from thyroid cancer. Incidentally, this reduced mortality was also associated with an increase in well differentiated papillary cancers, again suggesting the papillary type to be associated with a better outcome. Make sure to take Iodine supplements to reduce the risk of dangerous types of thyroid cancer. For more on Iodine and cancer prevention, click here.
References can be found at the original source for this article.
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Jeffrey Dach MD
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