Brittany Henderson, MD, ECNU is board-certified in internal medicine and endocrinology, with advanced training in thyroid disorders, including Hashimoto’s thyroiditis, Graves Disease, thyroid nodules, and thyroid cancer. Originally from Cleveland, Ohio, she graduated in the top 10% of at her class at Northeastern Ohio Medical University, where she received the honor of Alpha Omega Alpha (AOA). She completed her endocrinology fellowship training under a National Institutes of Health (NIH) research-training grant at Duke University Medical Center. She then served as Medical Director for the Thyroid and Endocrine Tumor Board at Duke University Medical Center and as Clinical Director for the Thyroid and Endocrine Neoplasia Clinic at Wake Forest University Baptist Medical Center. Topics discussed in this episode include: How to interpret my thyroid results? Why did I get this? Is it something I did? Thyroid controls nearly all body systems: heart, weight, brain, bowel. Testing and diagnosis: beyond blood-work TSH is the most common check TSH is like the reading of your electric meter: it tells you big picture for a month, not daily — it is not a fluid system, it changes by the hour TSH is not the cure all for reading thyroid health Full thyroid panel: Free T4 and Free T3 is important — highest in morning, lowest around 2p or 3p in the afternoon There is no one size fits all to Hashimoto’s — there are different types Blood tests: preparing for lab tests ‘Normal’ TSH but a patient does not feel normal Normal TSH range is controversial — .5 to 3 TSH is normal — if on thyroid replacement target 1.5 Suppressed TSH Dangers of suppressed TSH for thyroid cancer replacement or those on too much on thyroid replacement — heart failure, osteoporosis T3 symptoms of TSH is kept too low for too long The T4 — T3 relationship T4 is money in savings account — but you cant use it now — T3 is money in your pocket and available now Preferred thyroid replacement — but, issues with synthetic and desiccated The goal — T4 and T3 as stable as possible throughout the day — in light of absorption and interfering food Compounded medications A doctor must listen to the patient Generic levothyroxine and fillers — who is the manufacturer What is better, Nature or Armour? Why do some people do better on various thyroid replacement formulations? Gut biome The environment and thyroid disease Defining leaky gut Avoid foods that gut inflammation thereby worsening auto-immune disease Three food foes: processed foods, sugar, and iodine disruptors Is adrenal fatigue real? Supplements: vitamins and Hashimoto’s Nutrients needed to produce thyroid hormone, such as optimizing iron and selenium Anti-inflammatory vitamins and Vitamin A and Vitamin D Anti-oxidant vitamins — Vitamin B1, Vitamin C, and Glutathione What time of day to take to thyroid replacement medication What happens if you miss a day of thyroid replacement hormone? What does an endocrinologist feel about a patient seeing a Naturopath or an integrative medicine specialist? NOTES 57: The Gut⎥Antibiotics Danger, Fixing Inflammation, and Thyroid Health, with Dr. Lisa Sardinia 42: Flame Retardants Connected to Thyroid Cancer, with Dr. Julie Ann Sosa from Duke University Exposure to flame retardant chemicals and occurrence and severity of papillary thyroid cancer: A case-control study.  LGR5 is associated with tumor aggressiveness in papillary thyroid cancer. Hedgehog signaling in medullary thyroid cancer: a novel signaling pathway.  Dr. Brittany Henderson Facebook, Instagram, and Twitter: @DrHendersonMD, @charlestonthyroid, @hashimotosbook Websites: www.charlestonthyroid.com and www.drhendersonmd.com    

Doctor Thyroid

97: What You Must Know About Hashimoto's Disease with Dr. Brittany Henderson

Allen S. Ho MD is Associate Professor of Surgery, Director of the Head and Neck Cancer Program, and Co-Director of the Thyroid Cancer Program at Cedars-Sinai Medical Center. As a fellowship-trained head and neck surgeon. His practice focuses on the treatment of head and neck tumors, including HPV(+) throat cancers and thyroid malignancies. He leads the multidisciplinary Cedars-Sinai Head and Neck Tumor Board, which provides consensus management options for complex, advanced cases. Dr. Ho’s research interests are highly integrated into his clinical practice. His current efforts lie in cancer proteomics, HPV(+) oropharyngeal cancer pathogenesis, and thyroid cancer molecular assays. Dr. Ho has published as lead author in journals that include Nature Genetics, JCO, JAMA Oncology, and Thyroid, and is Editor of the textbook Multidisciplinary Care of the Head and Neck Cancer Patient (Springer 2018). Dr. Ho serves on national committees within the AHNS and ATA, and leads a national trial on thyroid cancer active surveillance (ClinicalTrials.gov ID: NCT02609685). He maintains expertise in transoral robotic surgery (TORS), minimally invasive thyroidectomy approaches, and nerve preservation techniques. Dr. Ho’s overarching aim is to partner with patients to optimize treatment and provide compassionate, exceptional care. In this interview — a discussion about Dr. Ho’s research; Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review. Topics include: prostate and thyroid cancer parallels prostate cancer and practical acceptance of active surveillance randomized and followed patients through true active surveillance overall survival, comparing thyroid and prostrate cancer tolerance of risk Older versus younger patient priorities Younger patient  thought process Weighing quality of life and risk Hypothyroidism, parathyroidism, laryngeal nerve risk in thyroidectomy… asymptomatic patients being made symptomatic due to treatment Physicians have embraced active surveillance for prostate cancer more than thyroid The patient leans on physician for guidance The Finland study: 17M in U.S. have thyroid cancer Extrapolation — Patients who die of other conditions, in autopsies very small thyroid cancers found in 36% of patients A lot of small cancers that need not be diagnosed The physicians perspective and influencing the active surveillance decision Shared decision making process Terminology… some people choose active surveillance even when nodule is greater than 2cm Jury is still out on what is considered safe size Size and lymph node spread is still being defined Moving away from Gleason system Some cancers are aggressive Some cancers are slow and not lethal Incidental cancers The word cancer or the c word… and shifting away from fear Radiology guidelines The Cedars Sinai active surveillance program 50% of patients who are offered surveillance accept it… which mirrors Japan Alienation of active surveillance patients Anxious, calm, and risk and prioritize risks of surgery  Thyroid cancer tends to strike younger patients.  Prostrate cancer tends to be older. Prostrate cancer may not improve survival Surgery in thyroid versus prostate is safer Radiation ad toxicity NOTES Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review 50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering 89: Your Patient ‘Type’ May Determine Your Thyroid Cancer Treatment → Dr. Michael Tuttle from Sloan Kettering 77: Broadway Performer Says No to Thyroid Cancer Surgery → Surveillance Instead 87: Is There a Stigma to Choosing Active Surveillance? → Dr. Louise Davies from The Dartmouth Institute Vigilancia activa en el tratamiento del microcarcinoma de tiroides. Dr. Allen Ho 

96: Thyroid and Prostate Cancer — Surgery Outcomes Sometimes Worse Than No Surgery — Weighing Risks and Outcomes with Dr. Allen Ho

M. Regina Castro, MD is a consultant in the Division of Endocrinology at the Mayo Clinic in  Rochester, MN.  She is an Associate Professor of Medicine. She is the Associate Program Director for the Endocrinology Fellowship program,  and Director of Endocrinology rotation for the  Internal Medicine Residency.  She is also a member of the Thyroid Core Group at Mayo Clinic. She served from 2009 to 2015 as Thyroid Section Editor for AACE Self-Assessment Program and has authored several chapters on Hyperthyroidism, Thyroid Nodules and thyroid cancer. She has served on various committees of the ATA, including Patient Education and Advocacy committee, the  editorial board of Clinical Thyroidology  for Patients (CTFP),  Trainees and Career Advancement committee  and  is at present  the  Chair of the Patient Affairs and Education Committee. She currently serves on the ATA Board of Directors. Her professional/academic Interests:  Clinical research related to thyroid nodules and thyroid cancer,  clinical care of patients with various thyroid diseases, and medical education. During this interview, the following topics are addressed: What is a thyroid nodule?  A lump that could be benign or cancerous The prevalence depends on how you search for them 60% of people in the U.S. will have nodules 90% are benign Sometimes done during routine physical exam Sometimes the patient discovers it Usually is discovered when imaging is done for other reasons — during CT scan Medical history of radiation to head or neck as a child, family history of thyroid cancer, size of nodule, abnormal lymph nodes in the neck Usually patients with a nodule are asymptomatic Best test to look at the nodule is an ultrasound of the nodule Features in the ultra sound determines how suspicious a nodule is A biopsy is ordered based on appearance, if nodules are clearly defined are more likely to suggest they are benign If nodule looks dark or borders are irregular, or increased blood flow within the nodule may cause concern Quality and resolution of thyroid ultra sound is high resolution and provides a clear look Coaching patients through the anxiety through a possible biopsy The majority of nodules can be observed ATA guidelines suggest observation based on the result of the biopsy Suspicious nodules that are less than 1cm are sometimes determined to best observe and not remove Cancer will be in only 5% of biopsies A smaller, low risk cancer should warrant a lesser surgery — and reduce the chance of surgical complications When to remove a nodule even if no cancer?  If other structures are being obstructed, such as breathing or swallowing, sometimes surgery relieves symptoms regardless if cancer or not Observation — and follow up recommendations 15% are labeled indeterminate If surgery, surgeon needs to be experienced — many surgeons conducting thyroid surgery are low in experience The Mayo Clinic thyroid cancer team Biopsy results in two hours versus two weeks NOTES The American Thyroid Association Dr. Regina Castro 64: Managing Indeterminate Thyroid Nodules, with Dr. Kimberly Vanderveen from Denver Center for Endocrine Surgery  

94: Everything You Need to Know About Thyroid Nodules with Dr. Regina Castro from Mayo Clinic

Dr. Milner is well published with texts, medical journal articles and studies in cardiology, endocrinology, pulmonology, oncology, and environmental medicine. Dr. Milner calls his practice “integrated endocrinology” balancing all the endocrine hormones using bio-identical hormone replacement and amino acid neurotransmitter precursors.  Dr. Milner’s articles include treatment protocols for hypothyroidism, ”Hypothyroidism: Optimizing Medication with Slow-Release Compounded Thyroid Replacement” was published in the peer review journal of compounding pharmacists, International Journal of Pharmaceutical Compounding.  In this interview, the following topics are discussed: Starving in the midst of plenty Slow release T3 and T4 Hypothyroidism Hyperthyroidism or Graves Disease Often RAI leads to hypothyroidism Visiting a naturopath while being treated by traditional endocrinologist TSH suppression for thyroid cancer patients Ordering blood tests of TSH, Free T4, Free T4, and reverse T3 Converting T4 into T3 Slow released T3 Manufactured T3 is not slow release 2005 article was published 150,000 pharmacist in U.S., and about 5,000 are compounding Slow release blends are the same T4 from Synthroid and T3 from Cytomel Slow release agent is hydroxypropyl melanose Side effects of too much T3 or T4 The risk is compounder error or inconsistency Binder sensitivity is another reason for compounding Desiccated thyroid hormone compared to slow release Auto-immune disease and desiccated treatment Overwhelming response to slow release is when patients symptoms of hypothyroidism alleviate A small percentage of people do not do better on slow release Basel body temperatures 96.5 temperature in the morning, and hypothyroid symptoms is a concern in regard to treatment Testing temperature in the morning, ideally done using mercury thermometer How to use temperature testing as an indicator of hypothyroidism Body temp should be over 97.8 first thing in the morning Hypothyroidism will be overweight and difficult to lose weight, and brain fog, sluggish, dry skin, hair loss, Eating well, active, and weight gain Hypoglycemic or adrenal overload and low body temperature High cortisol levels Standard of care of Cytomel in contrast with conventional endocrinologist T3 has a short half life Half life — How long does it take a drug to bring blood levels to normal levels?  Half life of T3 is up to 70 days Starving in the midst of plenty with T4 Insurance coverage of slow release T3 — T4 Cost of slow release T3 — T4 is approximately $40 monthly Most important testing for TT patient is checking parathyroid gland status — and their role in calcium function Important to measure calcium for TT patients Caution about soy, broccoli, brussel sprouts, cauliflower, and calcium and thyroid hormone When to thyroid replacement hormone — first thing in the morning, 1 hour before eating, T4 replacement before bed — advantages to more stable levels Slow release, combination therapy, should be taken in the morning Estrogen deficiency Brief summaries of the following symptoms: painful feet, dizziness, fatigue, hair loss, iron deficiency, chronic pain, tyrosine turning into dopamine and then adrenaline, sleep problems and anxiety and hypothyroidism, insomnia and cortisone and adrenaline at nigh and DHEA, cortisol measured throughout the day, muscle spasms, Avoid refined sugar and high amounts of alcohol Drink more water Caution: food and its importance: smoothies and soluble fiber — fiber interacts with nutrients.    Avoid this, as it effects absorption of medications Emotional attachment to disease — fixation and complaining without making changes.  NOTES International Academy of Compounding Pharmacists 75: Fat, Foggy, and Depressed After Thyroidectomy? You May Benefit From T3, with Dr. Antonio Bianco from Rush University 19: Hypothyroidism – Moving From Fat, Foggy & Fatigued to Feeling Fit & Focused with Elle Russ Hypothyroidism: Optimizing Therapy with Slow-Release Compounded Thyroid Replacement  

95: Hypothyroidism and Combination Therapy of T3 and T4 with Dr. Martin Milner from Portland, Oregon

Dr. Leonard Wartofsky is Professor of Medicine, Georgetown University School of Medicine and Chairman Emeritus, Department of Medicine, MedStar Washington Hospital Center.  He trained in internal medicine at Barnes Hospital, Washington University and in endocrinology with Dr. Sidney Ingbar, Harvard University Service, Thorndike Memorial Laboratory, Boston.   Dr. Wartofsky is past President of both the American Thyroid Association and The Endocrine Society.  He is the editor of books on thyroid cancer for both physicians and for patients, and thyroid cancer is his primary clinical focus.   He is the author or coauthor of over 350 articles and book chapters in the medical literature, is recent past Editor-in-Chief of the Journal of Clinical Endocrinology & Metabolism, and is the current Editor-in-Chief of Endocrine Reviews. In this episode, Dr. Wartofsky discusses the following: Bioavailability versus content of a thyroid replacement tablet, and how it is absorbed. Hypothyroidism causes When is replacement thyroid replacement hormone necessary? The history of replacement thyroid hormone going back to 1891 The early treatment included a chopped up sheep thyroid and served as a ‘tartar’, often resulting in vomiting Myxedema coma The danger of taking generic T4; are cheaper, larger profit margin, but the content varies. Synthroid versus generic Manufacturing plants in Italy, India, Puerto Rico are known to produce generics Content versus absorption when taking generic T4 An explanation of TSH 1.39 is a healthy TSH level for women in the U.S. Symptoms of hypothyroidism, such as a slow mind, poor memory, dry skin, brittle hair, slow heart rate, problems with pregnancy, miscarriage, and hypertension. Screening TSH levels if contemplating pregnancy T4 is the most prescribed drug in the U.S. Hypothyroidism is common when there is a family history Auto-immune disease is often associated with hypothyroidism An explanation of T3 An explanation of desiccated thyroid The T3 ‘buzz’ Muhammed Ali’s overdose of T3 Dangers of too much T3 When to take T4 medication, and caution toward taking mediations that interfere with absorption Coffee and thyroid hormone absorption Losing muscle and bone by taking too much thyroid hormone Taking ownership of your disease NOTES Listen to Doctor Thyroid Related Episode : 37: Adding T3 to T4 Will Make You Feel Better? For Some the Answer is ‘Yes’ with Dr. Antonio Bianco from Rush University American Thyroid Association Leonard Wartofsky

93: Has anything changed in the past 50 years of treating thyroid disease? (including thyroid cancer) The answer is yes. → Dr. Leonard Wartofsky from MedStar

Dr. Jorge Calvo Lugar de estudio: U. de Panamà, Hospital de la Caja de Seguro Social, Fundaciòn Santa Fe (Colombia) U. Del Norte (Argentina), Sistema Integrado de Salud (Veraguas) Otros estudios: Laparoscopía, Curso de postgrado de Cirugía Gastrointestinal, Curso de postgrado de Cirugía de Cabeza y Cuello   En este episodio, se tratan los siguientes temas: ¿Cómo será la vida después de la cirugía? Embarazo después del cáncer de tiroides Parálisis de las cuerdas vocales Las complicaciones incluyen voz e hipo-calcio Sangrado durante la cirugía Tratamiento para hypo-calcium Vitamina D Embarazo y radiación TSH elevada después de la cirugía Problemas de TSH suprimido Número uno de miedo del paciente cuando se le diagnostica cáncer de tiroides y antes de la cirugía 32 años como cirujano tiroideo - cáncer papilar de tiroides Vigilancia activa Tasas de mortalidad del cáncer papilar de tiroides Recurrencia La mejor hora del día para tomar un reemplazo de tiroides Más información: www.doctiroides.com

92: Treinta años después y más de 5000 pacientes con cáncer papilar de tiroides → y solo dos murieron, con el Dr. Jorge Calvo desde Panama

The 5-year survival rate for invasive thyroid cancer is 97.9%, and the 10-year survival rate is more than 95%, according to the National Cancer Institute. This leads some people to refer to it as a "good cancer." “The idea behind that ‘good cancer’ statement is a positive one,” said study co-author Raymon Grogan, MD, Assistant Professor of Surgery at the University of Chicago Medicine, in Chicago, IL. “It is physicians trying to make people feel better. But, I think it’s had the opposite effect over time.” The number of thyroid cancer survivors is rising rapidly due to the combination of an increasing incidence, high survival rates, and a young age at diagnosis, according to Dr. Grogan and co-author Briseis Aschebrook-Kilfoy, PhD, Assistant Research Professor in Epidemiology at the University of Chicago Medicine, who lead the North American Thyroid Cancer Survivorship Study (NATCSS). The incidence of thyroid cancer will double by 2019 and thyroid cancer survivors could soon represent up to 10% of all cancer survivors in the United States, the researchers predicted. But there’s a difference between surviving and living happily ever after. Once treatment is over, thyroid cancer survivors then face a high rate of recurrence and an anxiety-filled lifetime of cancer surveillance. When the researchers heard clinic patients express these survival concerns firsthand, they sought to study this poorly investigated area. The investigators recruited 1,174 thyroid cancer survivors whose mean time from diagnosis was 5 years (89.9% were female, average age was 48), and evaluated their quality of life using a questionnaire that assessed physical, psychological, social, and spiritual wellbeing on a 0-10 scale, with 0 being the worst. Survivors of thyroid cancer reported worse quality of life—with an average overall score of 5.56 out of 10—than the mean quality of life score of 6.75 reported by survivors of other cancer types (including colorectal and breast) that have poorer prognoses and more invasive treatments. “I think we all have this fear of cancer that has been ingrained in our society,” Dr. Grogan said. “So, no matter what the prognosis is, we’re just terrified that we have a cancer. And, I think this [finding] shows that.” Thyroid cancer survivors who were younger, female, less educated, and those who participated in survivorship groups all reported even worse quality of life than other study participants. However, after 5 years of survival, quality of life gradually began to increase over time in both women and men, the researchers found. In order to further understand the psychological wellbeing of the growing number of thyroid cancer survivors, the researchers plan to continue to follow this cohort for the long term. NOTES Briseis Aschebrook-Kilfoy Raymon Grogan, M.D., MS, FACS Thyroid cancer patients report poor quality of life despite 'good' diagnosis Why do thyroid cancer patients report poor quality of life despite a high survival rate?

91: Thyroid Cancer Patients Report Poor Quality of Life After Diagnosis and Treatment → Dr. Aschebrook and Dr. Grogan from UChicago Medicine

Dr. Akira Miyauchi Professor Akira Miyauchi (Figure 1) is President and COO of Kuma Hospital, Center of Excellence in Thyroid Care, Kobe, Japan. He is a Japanese endocrine surgeon, and a pioneer in active surveillance, and visionary in regard to treatment of thyroid cancer.  World renowned researcher, and lecturer. As the associate professor of the Department of Surgery, Kagawa Medical University, he proposed and initiated a clinical trial of active surveillance for low-risk papillary micro cancer in collaboration with Kuma Hospital in 1993. In 2001, he was appointed the President of Kuma Hospital. Since then, he has been keen on the study of evaluating treatments for papillary micro cancer, observation versus surgery. During this episode, the following topics are discussed: Financial burden of surgery versus total cost of active surveillance over ten years. Stretching Exercises for Neck Setting patient expectations prior to FNA to manage anxiety When the laryngeal nerve is severed during thyroid surgery, it can and should be repaired, with proper surgeon skill and training. Rather than being stationery and immobile, patients should practice neck stretching exercise within 24 hours proceeding surgery.  There should be no fear about separating the incision. Total cost of surgery is 4.1x the cost compared to the cost of active surveillance.  In the U.S., the cost is higher. Incidence versus mortality Worldwide trends related to thyroid cancer Papillary Microcarcinoma of the Thyroid (PMCT) Unfavorable events following immediate surgery Results of research which began in 1993 The current trend in the incidence of thyroid cancer is expected to create an added cost of $3.5 billion by 2030, to the individual and as a society. By providing patient an active surveillance brochure prior to FNA, they are more open to not proceeding with surgery for small thyroid cancer management. Patient voice restores to near normal when repair of laryngeal nerve is done correctly.  All surgeons should be executing this to perfection. When doing next stretches one-day post surgery, patients report feeling much better and less pain, even one year after surgery. Protocol for delaying surgery depends on the patient’s age.  Older patients are less likely to require surgery.  75% of patients will not require surgery for their lifetime.   Listen to Doctor Thyroid here!  Akira Miyauchi, MD 35: Rethinking Thyroid Cancer ? When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles 21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies 50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering PAPERS and RESEARCH  Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid. Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery TSH-suppressive doses of levothyroxine are required to achieve preoperative native serum triiodothyronine levels in patients who have undergone total thyroidectomy. Stretching exercises to reduce symptoms of postoperative neck discomfort after thyroid surgery: prospective randomized study. Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve. Listen to Doctor Thyroid here!  

90: The Results of 30 Years of Patients Receiving Active Surveillance Instead of Surgery → Dr. Akira Miyauchi from Kuma Hospital in Kobe, Japan

During this interview, Dr. Tuttle discusses the following points: Challenges of managing thyroid cancer as outlined by the guidelines Scaling back care for insurance-challenged patients, and adopting a plan that gets the same result without needing the expensive tests Desired outcome is survival and no recurrence, a third is for no harm that would be caused by an unnecessary surgery Unwanted side affects of thyroid cancer include nerve damage, parathyroid damage, and infections RAI sometimes has unwanted side affects With technology, ultrasounds and biopsies, we know some cancers do not need to be treated, as they are now being found very early Change in ATA guidelines, low risk cancers can be considered for observation Two different kinds of patient profiles: Minimalist and Maximalist 1cm or 1.5cm? Patient characteristic, ultra sound characteristics, and the medical team characteristics weighs who is the most appropriate for observation 400 active surveillance patients currently at MSKCC Certain parts of the world are harder to offer observation as a treatment due to practicality, examples include Latina America where multi-nodular goiters are common, and Germany still is iodine deficient About Dr. Tuttle, in his words: I am a board-certified endocrinologist who specializes in caring for patients with advanced thyroid cancer. I work as part of a multidisciplinary team including surgeons, pathologists, radiologists, nuclear medicine specialists, and radiation oncologists that provides individualized care to patients treated at Memorial Sloan Kettering for thyroid cancer. In addition to treating patients I am also actively researching new treatments for advanced thyroid cancer. I am a professor of medicine at the Joan and Sanford I. Weill Medical College of Cornell University and travel extensively both in the US and abroad, lecturing on the difficult issues that sometimes arise in the management of patients with thyroid cancer. My research projects in radiation-induced thyroid cancer have taken me from Kwajalein Atoll in the Marshall Islands to the Hanford Nuclear power-plant in Washington State to regions in Russia that were exposed to fallout from the Chernobyl accident. I am an active member of the American Thyroid Association (ATA) and the Endocrine Society. In addition to serving on the ATA committee that produced the current guidelines for the management of benign and malignant nodules, I am also a Chairman of the National Comprehensive Cancer Network Thyroid Cancer Panel, a consultant to the Endocrinologic and Metabolic Drugs Advisory Committee of the FDA, and a consultant to the Chernobyl Tissue Bank. NOTES Listen to Doctor Thyroid American Thyroid Association Dr. Michael Tuttle RELATED EPISODES 35: Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles 22: Avoiding Thyroid Cancer Surgery, Depending on the Size with Dr. Miyauchi from Kuma Hospital in Kobe, Japan 21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

89: Your Patient ‘Type’ May Determine Your Thyroid Cancer Treatment → Dr. Michael Tuttle from Sloan Kettering

Dr. Allen Ho is a fellowship-trained head and neck surgeon who focuses on head and neck tumors, including HPV(+) throat cancers and thyroid malignancies. As director of the Head and Neck Cancer Program and co-director of the Thyroid Cancer Program, he leads the multidisciplinary Cedars-Sinai Head and Neck Tumor Board, which provides consensus management options for complex, advanced cases. Ho’s research interests are highly integrated into his clinical practice. His current efforts lie in cancer proteomics, HPV(+) oropharyngeal cancer pathogenesis, and thyroid cancer molecular assays. He has presented his research at AACR, ASCO, AHNS, and ATA, and has published extensively as lead author in journals that include Nature Genetics, Journal of Clinical Oncology, Cancer, and Thyroid. Ho serves on national committees within the ATA and AHNS, and is principal investigator of a national trial on micropapillary thyroid cancer active surveillance (ClinicalTrials.gov ID: NCT02609685). He maintains expertise in transoral robotic surgery (TORS), minimally invasive thyroidectomy approaches, and nerve preservation techniques. Ho’s overarching mission is to partner with patients to optimize treatment and provide compassionate, exceptional care. Weighing treatment options for thyroid cancer, with deep consideration for the patient’s lifestyle, could become the new norm in assessing whether surgery is the best path.  Dr. Allen Ho states, “if a patient is a ballerina or an opera singer, or any other profession that could be jeopardized due to undesired consequences of thyroid cancer surgery, then the best treatment path maybe active surveillance.”  Undesired consequences of thyroid cancer surgery could be vocal cord paralysis, damage to the parathyroid glands resulting in calcium deficiencies, excessive bleeding or formation of a major blood clot in the neck, shoulder nerve damage, numbness, wound infection, and mental impairment due to hypothyroid-like symptoms.  Or in the case of a ballerina, undesired scarring could jeopardize a career.    The above risks occur in approximately 10% of thyroid cancer surgeries.  Although, some thyroid cancer treatment centers have a much more reduced incidence of undesired consequences, while others much higher.  In order to address the above and remove the risk of thyroid cancer surgery, Cedars-Sinai has become the first west coast hospital to launch an active surveillance study as optional treatment for thyroid cancer.  The study includes 200 patients from across the country who have chosen the wait and see approach rather than hurry into a surgery that could result in undesired, major life changes.   By waiting, this means these patients will dodge the need to take daily hormone replacement medication for the rest of their lives as the result of a thyroidectomy.  Other active surveillance research Although this is the first study for active surveillance on the west coast, other studies are ongoing, including Sloan Kettering as directed by Dr. Tuttle, Kuma Hospital in Kobe as directed by Dr. Miyauchi, and the Dartmouth Institute as directed by Dr. Louise Davies. The team Dr. Ho says the “de-escalating” of treatment for thyroid cancer will become the new trend.  The active surveillance thyroid cancer team at Cedars-Sinai is orchestrated to the patient’s needs, and includes the pathologist, endocrinologist, and surgeon. NOTES Allen Ho, MD Active Surveillance of Thyroid Cancer Under Study 22: Avoiding Thyroid Cancer Surgery, Depending on the Size with Dr. Miyauchi from Kuma Hospital in Kobe, Japan 21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

88: For Some Thyroid Cancer Patients, No Surgery is the Best Treatment → Dr. Allen Ho from Cedars Sinai

The past year has been fascinating and highly fruitful year for Dartmouth Institute Associate Professor Louise Davies, MD, MS. A 2017-2018 Fulbright Global Scholar, Davis spent several months in Japan at the Kuma Hospital in Kobe, Japan, studying the hospital's pioneering surveillance program for thyroid cancer. Davies, the chief of otolaryngology-head & neck surgery-at the Veterans Affairs Medical Center in White River Junction, Vermont, has researched U.S. patients' experiences of monitoring thyroid cancers they self-identify as overdiagnosed, and has found that such patients often feel unsupported, even ostracized. Following her stay in Japan, Davies, who also develops and teaches courses in qualitative research methods in Dartmouth Institute's MPH programs, spent several months in the U.K. at the Health Experiences Research Group (HERG) at Oxford University. There, she learned skills that will help her develop web-based materials to raise public awareness about surveillance, surveillance programs, and overdiagnosis in general. As if the year wasn't packed enough, Davies also visited the site of the Fukushima Daiichi nuclear power plant, site of the 2011 nuclear accident in Japan. Unrelated to her Fulbright work, Davies is a member of an international task force organized through the International Agency for Research on Cancer, a branch of the World Health Organization. The task force will make recommendations on the monitoring of the thyroid gland after nuclear accidents. Learn more about her incredible year and what's next for her research in overdiagnosis! Q: As a practicing physician, how did your interest in overdiagnosis develop? A: My interest in over diagnosis grew from my work with Dr. Gil Welch, dating back to 2004. He was and is a mentor to me, and we developed the work on thyroid cancer together. I have always had an interest in making sure that patients receive care that aligned with their values. The problem of overdiagnosis is particularly intriguing because if people do not understand the concept, they may undergo treatment that, had they understood more about their risks, they might not have elected. Finding ways to solve that problem has been a fascinating focus for me. Q: Is overdiagnosis and/or overtreatment in thyroid cancer on the rise, if so what accounts for this increase? A: Thyroid cancer incidence has more than tripled in the U.S. over the past 30 years. The majority of the increase has been due to the detection of small cancers, which we know exist as a subclinical reservoir in otherwise asymptomatic people. As more attention has been drawn to the problem of overdiagnosis, the rate of increase has slowed, which has been gratifying to see; although it has not stopped completely or reversed. In the most recent national guidelines on the treatment of thyroid cancer (from the American Thyroid Association), there has been a clear suggestion that treatment should be more conservative for the small cancers that are so commonly detected now. It is not yet clear how much of an impact these new guidelines have had on practice patterns. Q: You've studied the experiences of patients who are diagnosed with thyroid cancer but choose not to intervene. What are some of the commonalities you've found? A: The patients who were the first to understand that their small, asymptomatic thyroid cancers picked up incidentally might not need immediate intervention, but instead could be monitored through regular checkups and active surveillance did not receive a lot of support from the medical community. Many managed their cancer by keeping it a secret, which can be stressful in itself, and several stopped getting follow ups-the recommended care if surveillance rather than interventions chosen for a small thyroid cancer. This was a unique group of patients who represented the first people to undertake what is a new and incompletely understood treatment option in the U.S. As such, they are probably more representative of people going against medical convention than thyroid cancer patients who elect to undertake surveillance, per se. Q: What will/have you been looking for when evaluating the surveillance program at Kuma Hospital? How will you combine this with your own U.S. pilot data? My goal in going to Kuma Hospital last fall was to understand more about the active surveillance program they have there. They were the first in the world to run such program and collect data on it, and have been doing so since 1993. I wanted to understand their data on active surveillance in more detail. I wanted to understand the patient experience of being on surveillance, and how the program worked operationally. I was able to do all those things and gathered patient experience data through a survey as well as interviews. I also was lucky to get to spend a fair amount of time in the operating room, where I learned a number of new surgical techniques that will advance my own practice in thyroid surgery. My goal is to report what I learned at Kuma Hospital as broadly as possible, so that people in the U.S. begin to feel comfortable adopting active surveillance as a method of managing the early thyroid cancers that are appropriate candidates for surveillance. What's next for you in overdiagnosis research? My work on the task force about thyroid monitoring after nuclear power plant accidents has given me a new appreciation for the complexity of public health communication about risk, emergency preparedness, and the problem of over diagnosis when it comes to policy setting. I hope to be able to continue to contribute in other ways to the broader public health discussion about over diagnosis. In my next steps looking at the epidemiology of thyroid cancer, I plan to focus on understanding more about why we see such variation in thyroid cancer incidence across geography, age groups, and gender. NOTES Louise Davies, MD, MS Thyroid cancer and overdiagnosis American Thyroid Association 35: Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles 21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies 50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering

87: Is There a Stigma when Choosing Active Surveillance? → Dr. Louise Davies from The Dartmouth Institute

 El Dr. Duque es un Cirujano de Cabeza y Cuello, formado en la Universidad de Miami, actualmente  trabaja en el Hospital Pablo Tobon Uribe de Medellin. Al años opera unos 220 pacientes con problemas  de tiroides, de estos la mayoría con  cancer de tiroides. El Dr. Duque ha escrito un libro titulado !Uuuyy. TENGO CANCER DE TIROIDES¡   (Antes de inciar esta entrevista , me gustaria  dejar claro que  el fin de esta entrevista es informativo. Muy respetuosamente le solicitaria todos los que se unen a esta entrevista, No hacer preguntas  sobre casos personales, o mencionar nombres de personas o medicos tratantes , el fin de estas y otras entrevistas que hago es informar.) Temas de este entrevista uncluye:  Que tan común es el cancer de tiroides, de estos cual es el mas común? Cuéntenos un poco sobre el tratamiento con Yodo radioactivo. Como y porque decido escribir un libro sobre cancer de tiroides Cuando se publicara este libro, donde se puede conseguir Quien es  un buen cirujano de  tiroides, donde puedo buscar un cirujano con experiencia  Nodulos de tiroides Libro Uuuyyy tengo cáncer de tiroides Doctor Thyroid Doctor Tiroides  Doctor Tiroides con Philip James Dr. Carlos Duque     

86: Que hago si tengo cancer de tiroides? → Dr. Carlos Simon Duque

 Fabián Pitoia, MD, Ph D.   Jefe de la sección tiroides, División Endocrinología Hospital de Clinicas decla universidad de Buenos Aires Sub director de la carrera de medicos especialistas en Endocrinología- hospital de clinicas   Docente adscripto de medicina interna.   Temas de este entrevista incluye:   El tema de hoy es la gestión de la vigilancia activa microcarcinoma ¿qué es el microcarcinoma y qué es la vigilancia activa? Para aquellos que siguen el podcast de Doc Thyroid, es posible que conozcan mi historia, tuve una tiroidectomía y cáncer de tiroides. Cuando escuché la palabra cáncer de mi médico, creó miedo y ansiedad. Pero, ¿la palabra cáncer relacionada con el cáncer de tiroides es diferente? (papilar) ¿Puede decirnos cómo y por qué esto es cierto? Por ejemplo, en comparación con el cáncer de cerebro o el cáncer de páncreas ... ¿Cuántos pacientes con cáncer papilar de tiroides ves un año? ¿Cuántos pacientes con cáncer papilar de tiroides han muerto bajo su cuidado? (La intención de esta pregunta es reducir el miedo en la audiencia sobre la palabra cáncer) Cuéntanos más sobre la vigilancia activa ... es una nueva practica? ¿Y por qué estamos escuchando más sobre esto últimamente? ¿Cómo sabe un paciente si es adecuado para ellos? ¿Cuál es el tratamiento para los pacientes que eligen este tratamiento? ¿Todos los hospitales en América Latina ofrecen vigilancia activa? ¿Cómo puede un paciente encontrar doctores que lo ofrezcan? La Dra. Davies dice que algunos pacientes en su programa dicen sentirse "estúpidos" por dejar el cáncer en su cuerpo. ¿Hay apoyo emocional para aquellos que eligen Vigilancia Activa Microcarcinoma? Dr. Fabian Pitoia

85: Vigilancia Activa Microcarcinoma en Cancer de Tiroides → Fabián Pitoia, MD, Ph D.

Bryan McIver, MD, PhD Dr. McIver contributes to Moffitt Cancer Center almost 20 years of clinical experience in the care of patients with endocrine diseases, specializing in the evaluation of patients with thyroid nodules and thyroid cancer. He has a particular interest in the management of patients with advanced and aggressive forms of cancer and the role of genetic and molecular techniques to improve the accuracy of diagnosis; to tailor appropriate treatment to a patientdisease. Dr. McIver has a long-standing basic research interest in the genetic regulation of growth, invasion and spread of thyroid tumors of all types. His primary research focus is the use of molecular and genetic information to more accurately diagnose thyroid cancer and to predict outcomes in the disease. Dr. McIver received his MB ChB degree from the University of Edinburgh Medical School in Scotland. He completed an Internal Medicine residency at the Royal Infirmary of Edinburgh, followed by a clinical fellowship and clinical investigator fellowship in Endocrinology at the School of Graduate Medical Education at Mayo Clinic in Rochester, MN. Prior to joining Moffitt, he was employed as Professor and Consultant at the Mayo Clinic and Foundation in the Division of Endocrinology & Metabolism. Amongst his most proud accomplishments, Dr. McIver counts his two commitment to education of medical students, residents and fellows; his involvement as a founding member of the World Congress on Thyroid Cancer, an international conference held every four years; and his appointment as a member of the Endowed and Master Clinician Program at the Mayo Clinic, recognizing excellence in patient care.   In this episode, the follwoiung  By sixty years old, more common to have nodule than not Most nodules are benign When to do a biopsy How to interpret the results of biopsy Advances in thyroid cancer Ultrasound technology advancements Molecular markers Cytopathology categorizations Molecular marker technologies Gene expression classifier Afirma Identifying aggressive cancer Types and sub-types of thyroid cancers Invasive and aggressive thyroid cancers Papillary versus anapestic thyroid cancer Biopsy results in 2 - 3 hours Clinical studies that have transformed thyroid treatment Less aggressive surgery and less radioactive iodine Targeted chemotherapies Immunotherapy The importance of clinical trial environments, or thoughtful philosophy The minimum necessary surgery Do not rush into thyroid cancer surgery NOTES: American Thyroid Association Bryan McIver, MD, PhD Ian D. Hay, M.D., Ph.D. Hossein Gharib, M.D. PAST EPISODES 32: Thyroid Cancer Surgery? The Single Most Important Question to Ask Your Surgeon with Dr. Gary Clayman 

84: Diagnosed With Thyroid Cancer?  —  Stop —  Do Not Rush Into Surgery → Dr. Bryan McIver - Moffitt Cancer Center

 Jonas de Souza participates in both clinical and outcomes research studies on malignancies of the upper aerodigestive tract, especially head and neck cancers. His research focuses on the use of novel therapeutic agents along with measurements of financial burden, patients’ preferences, and the trade-offs between the risks and benefits of cancer therapies. His research has sought to integrate outcomes research, patient preferences, health policy, and economics into clinical practice. His ultimate goal is to increase access to essential cancer therapies by providing policy makers and scientific communities with the required information on patient preferences and on barriers that lie between cancer patients and access to care.   De Souza has authored and presented papers and given lectures on head and neck malignancies, reimbursement methods in oncology, and evidence-based care. He is the principal investigator for a trial examining the role of SPECT-CT in the follow-up of patients with locally advanced head and neck cancers.   De Souza earned his MD from the University of Rio de Janeiro State. He completed his residency specializing in internal medicine at the University of Texas Health Science Center in 2008 and a fellowship focusing on hematology/oncology at the University of Chicago in 2011.   During this episode the following topics are discussed: “Financial toxicity,” or the financial burdens that some patients suffer as a result of the cost of their treatments can cause damage to their physical and emotional well-being.  Financial impact of thyroid cancer Lost income or high out-of-pocket costs for treatment, medication or related care. Like any other side effect, financial toxicity should be disclosed and discussed with the patients. Patients with thyroid cancer had a 41% increased risk for unemployment at 2 years      Jonas de Souza MD, MBA   The High Cost of Cancer Care May Take Physical and Emotional Toll on Patients   Thyroid Cancer Diagnosis Affects Employment, Income

83: The Financial Risk of Thyroid Surgery → Dr. Jonas de Souza - Oncologist, Medical Director at Humana

This show is for thyroid patients determined to improve their quality of life, with the best information available. You will gain insight from those who have discovered improved well-being regardless of setbacks, and hear from leading healthcare professionals, including endocrinologists, surgeons, functional medicine practitioners, and radiologists.

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Doctor Thyroid

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