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Scott Webb: In the realm of cancer diagnosis and cancer care, thyroid cancer stands out as being unique from diagnosis to treatment. Today, we'll hear from Dr. Michael Hancock, an endocrinologist with Franciscan Physician Network, diabetes and endocrinology specialists, and learn how thyroid cancer differs from other types of cancers, as well as early signs of thyroid cancer. this is the Franciscan Health Doc Pod. I'm Scott Webb, Dr. Hancock, as we begin today, can you start by telling us what thyroid cancer is and maybe give us an overview of how it's different from other types of cancer?

Dr. Michael Hancock: Thyroid cancer is a cancer that starts in the thyroid Gland, It's the most common cancer of the endocrine system. We have four major categories of thyroid cancer. The most common is called papillary. And that's what we'll spend the most time talking about today. There's another variant called follicular much less common version called medullary thyroid cancer, and then the least common type of cancer, which is called anaplastic thyroid cancer. About nine out of 10 thyroid cancers are considered what we call differentiated, which means it looks very similar to thyroid tissue under the microscope, and those would be the papillary and the vicular thyroid cancer.

One of the things that separates thyroid cancer from a lot of other cancers is it's often diagnosed at a younger age than most other adult cancers. About two thirds of people diagnosed with thyroid cancer are between the ages of 20 and 55, seven and 10 cases of thyroid cancer are in women. And why that is the case is not exactly clear to us. There aren't a lot of risk factors for thyroid cancer. The most common risk factor is the history of radiation therapy, especially at a young age. So folks who have had radiation therapy, maybe for a childhood cancer, like a Hodgkin's lymphoma or something like that will have a higher risk of thyroid cancer.

Or folks who were exposed to a dose of radiation maybe as part of an environmental disaster or something as a child will have a higher lifetime risk of thyroid cancer, but most patients with thyroid cancer have no identifiable risk factors. the other thing.That differentiates thyroid cancer from most other cancers is that as far as I'm aware, it's the only cancer that takes your age into account when it comes to the staging of the cancer. So staging is a common way for folks who take care of cancers to determine how far along the cancer is.

If it's spread to other parts of the body and things like that. And if you're young, if you're under 55 the long term prognosis is quite good for papillary thyroid cancer. there are only stages one and two for folks under the age of 55, which speaks to the relatively good prognosis. Another factor that differentiates thyroid cancer from other types of cancer is that thyroid cancer doesn't usually require chemotherapy or external radiation treatment. External radiation would be where people show up to radiation oncology for repeated treatments over and over again, over the course of a couple to several weeks.

That's usually not required for thyroid cancer. The patient will be on thyroid hormone after their surgery for thyroid cancer to replace the thyroid hormone that the gland was making prior to the surgery. Overall the big differentiating factor from thyroid cancer compared to other cancers is that the long term survival rate is quite good, over 90% for most patient.

Scott Webb: Yeah, so some good takeaways there, obviously survival is quite high. It doesn't usually require chemo and radiation. And for me, I just turned 54. So good to know that 54 is still considered young. You said under 55 is young. So I feel good about that. So I'm encouraged as we get rolling here and get moving through. So what signs or symptoms are there for thyroid cancer and how do you diagnose it?

Dr. Michael Hancock: Thyroid cancer is generally diagnosed by first discovering a thyroid nodule. Thyroid nodules are very common. They're present in up to 50% of people normally. Most of those nodules are not cancerous. In adults, about 10% of thyroid nodules are cancerous. The risk of a nodule being cancerous is a little bit higher in children. It's about 20 to 30%. Although thyroid nodules overall are less common in children than in adults. Oftentimes there are no symptoms. Although people may notice a lump in their neck, they may see something in the mirror when they're getting ready in the bathroom in the morning or something like that.

But most of them are discovered incidentally. So by that, I mean, people are having a test for some other reason. Maybe they have an ultrasound of the arteries in their neck to look for a blockage or they have a cat scan of their head, neck or chest for, headaches or a cough or something. And they'll report, whatever it is they're looking for, originally for the scan. But then incidentally, there is a thyroid nodule and then they'll take the work up from there. When people have symptoms from thyroid cancer. Most commonly it'll be experienced as an unexplained cough or some persistent hoarseness.

They may feel a lump in their throat. They may feel some abnormal lymph nodes in their neck and the doctor, we call that lymph adenopathy. , they may notice some swallowing difficulty where foods especially solids more so than liquids will feel like they get stuck at the level of the thyroid gland or just above the collarbone. And they will rarely show up with trouble breathing. If there's a nodule or a tumor in the neck, that's pushing on the windpipe. When there's concern for a thyroid cancer with any of these symptoms, hoarseness cough, lump in the neck.

Then the first thing that will happen when the person presents that to their doctor or a primary care provider is they're gonna get a physical exam that person's gonna feel their neck. See what they can tell from feeling the thyroid gland, feeling around the lymph nodes in the area. And the physical exam is always our first step, but it's not always our only step. And that physical exam is obviously the right thing to do, but there's a lot of the thyroid gland that you can't feel from the outside. And so you can miss nodules solely by relying on the physical exam.

So most of the time patients are gonna end up then going for an ultrasound to their ultrasound is a technology that uses sound waves to create pictures. Doesn't use radiation we're lucky in the thyroid world. And that ultrasound is a great way to look at the thyroid gland. We don't have to often go to cat scans or MRIs. So it has a nice combination of being one in the imaging world, a pretty inexpensive test and two, it gets great pictures without any radiation exposure. There will often be a blood test called TSH when a thyroid nodule is discovered.

And the reason for that is to make sure that the thyroid nodule isn't causing the thyroid to produce overly high amounts of thyroid hormone. Most of the time that blood test is gonna be normal. And if you discover a nodule that is suspicious enough for thyroid cancer, that you wanna evaluate it further, then the next step is what's called a fine needle aspiration biopsy. And the fine needle aspiration biopsy is essentially a small needle. That's poked through the skin, into the nodule itself. When the needle penetrates the nodule, a very small amount of the tissue comes out into the needle.

They can then take that tissue, put it on a microscope slide and have the laboratory doctors examine it to tell if there's signs of any thyroid cancer there or not. And the interpretation of that type of test is pretty nuanced and it requires a lot of expertise from the laboratory doctor or pathologist, but essentially you'll get one of three answers from a fine needle aspiration biopsy. The most common answer we get is benign, which means this is not cancerous. And that's always what we hope for. Sometimes you get an answer that says, this is thyroid cancer. And then you know what you're dealing with.

And then sometimes they can't tell exactly what it is under the microscope for various reasons. So there is this kind of category C would be, I don't know. But then within, I don't know, sometimes they don't know because maybe just not a lot of cells came out with the biopsy. And so sometimes we'll have to re biopsy patients for that. One of the less common ones, the follicular thyroid cancer that we had talked about a little bit earlier that type of biopsy doesn't diagnose that type of cancer terribly well. So in that case, there are some genetic tests that can be run on the tissue to help us get an idea of the likelihood of cancer in a nodule.

And sometimes those patients just go for surgery where that part of the gland is removed surgically, like in an operating room with anesthesia the fine needle aspiration doesn't require any of that. That's why we like it so much. done outpatient. It's done the radiology department with the guidance of the ultrasound. So they know exactly where the needle's going. And you get that without any anesthesia You leave the hospital basically with a bandaid on your neck. That's about it. People tend to do really well with that.

So we like the FNA or finding needle aspiration for biopsy and diagnosis. But sometimes we do need to still send patients to surgery to get the answer. Very seldom are we using cat scans or MRIs or pet scans to evaluate these, but on certain situations, those are appropriate tests.

Scott Webb: Yeah. And you said that often the nodules are found or identified quite incidentally or accidently. But if folks wanted to, if they were concerned for any reason, if they wanted to perform a self check at home, is there a proper way to do that?

Dr. Michael Hancock: There's a group called the United states Preventative Service Task Force. And they are tasked with coming up with recommendations on all kinds of screening tests. So they make recommendations on other screening tests like colonoscopies, mammograms, et cetera whether or not we should take aspirin to prevent a heart attack or stroke. they evaluate all that type of evidence. And in 2017, they looked at all the evidence that was available for thyroid self. And they were not able to find enough evidence to show that for the general population, that a routine thyroid self-exam at home is effective in improving outcomes with thyroid cancer.

If you're really interested in doing thyroid self exams at home, what I would encourage is maybe when you're at a yearly physical with your doctor or your primary care doctor, just ask them to go through it with you. And so if you feel something, then they can help, okay. Is that a normal structure that I'm feeling or is that something abnormal? I do get questions like that in the office sometimes where somebody will feel something. An d they'll get concerned, obviously, cuz. they're worried. That's why they're checking, they're checking because they're worried about something to begin with. And a lot of times I'll be able to say, no, that's a normal salivary gland or that's . Part of your thyroid cartilage or something. And you can kind of allay those fears immediately.

Scott Webb: that kinda leads me to my next question. I think we're all fairly familiar with oncologists. And we think of cancer, we think oncologists, but when it comes to thyroid cancer oncologists are not the ones to treat it. So maybe you can, take us through that a little bit. Why is that? And why would an endocrinologist be the right person, the right fit for thyroid cancer?

Dr. Michael Hancock: I think of thyroid cancer treatment, really as a team approach because no single area of medicine is entirely responsible for the patient's care. Everybody has a different role. An endocrinologist role for thyroid cancer is often in diagnosis. So we help people navigate through if they find a nodule or if they see one on a scan, incidentally, does it need a biopsy or not? We help with any follow up testing, if there's anything needed after a biopsy. But the primary treatment for thyroid cancer is surgery. If you have a chance to take it out, that's always the best option.

So in that case surgeons have a key role obviously for the surgery and it's gonna be an ear, nose and throat surgeon, or a general surgeon trained in endocrine surgery who are gonna do those surgeries for the most part. Oncologists, not that they aren't aware of thyroid cancer or wouldn't know what to do with it. They don't typically play the primary role and in part it's because that long term prognosis is so good and patients very seldom need traditional chemotherapy. But I do have patients where an oncologist is involved.

And those aren't common situations, but they do pop up from time to time. Other areas of medicine that are involved in the care the patients are gonna be the nuclear medicine department. Especially if the patient needs radioactive iodine treatment after their surgery, we will occasionally use an oncologist. Sometimes we'll also use a radiation oncologist if someone needs a higher dose of radiation treatment. Those are not very common at all, but those people do constitute part of the team and they may not get a lot of playing time, but when we need them, it's great that they're on board.

Thyroid cancer requires lifelong follow up for a couple of reasons. Those people are on thyroid hormone and that is definitely our area in a thyroid hormone replace, and endocrinology that is one of our areas we get lots and lots of training in, so we're very comfortable doing that. And then there's some long term thyroid cancer surveillance testing that we will essentially quarterback to or coordinate . Neck ultrasound is part of the routine follow up looking for any abnormal lymph nodes after surgery. And there is some blood testing for a protein called thyroglobulin and thyroglobulin is a protein that's made exclusively by thyroid tissue.

So if you've had your thyroid gland removed then your thyroglobulin level should be really pretty low. So we can use thyroglobulin as a tumor marker for long term surveillance to detect any recurrences, should they occur.

Scott Webb: So let's talk about the treatment options is it like, a mechanic where we start, with the most obvious thing and we work our way up? Is surgery a last resort or is it, the gold standard and so on?

Dr. Michael Hancock: Surgery is our primary option. Whenever it's accessible to surgery, we always want to look at that option and that's gonna be with an experienced ear, nose and throat surgeon, or an endocrine surgeon, depending on your hospital. And both types of folks are gonna be highly qualified for that type of surgery. And most of us who deal with thyroid cancer routinely in our practice, we have people that we work with a lot for surgery, we rely on them extensively for that the role of radioactive iodine treatment depends on the stage of the cancer.

So thyroid cancer is essentially divided into low, moderate, or high risk and that risk is not necessarily risk of dying from the cancer, but can also include risk of recurrence. People who have a low risk for recurrence or severe health threat or death from thyroid cancer, we've not seen that they actually get benefit from being treated with radioactive iodine. So what radioactive iodine does is it will get rid of any tiny amounts of remaining normal thyroid tissue that might be in the neck. Or if there's a, maybe a small lymph node, that's got some thyroid cancer invading it.

Then the radioactive iodine will hit that area. Thyroid tissue is the only tissue in our body that really uses Iodine normally. So the nuclear medicine doctors they just order up radioactive iodine and those cells will take the radioactive iodine in. Once they take it in, they can't spit it out. They can't expel it. And so then it just delivers radiation in a very targeted way to thyroid tissue. Radioactive iodine is helpful to avoid recurrences in people who have moderate or high risk thyroid cancer staging. And the staging is generally done after the surgery.

So staging depends on the size of the tumor and the gland. And if there were any abnormal lymph nodes that were discovered during surgery, so the bigger the tumor primarily, and the more lymph nodes are involved at the time of the initial surgery, than the higher the stage or the more aggressive the cancer. And then the more likely those patients are going to get benefit from radioactive iodine. Traditional chemotherapy is not generally needed or effective for this type of cancer. External radiation can sometimes be useful for very aggressive types of thyroid cancer.

And those don't happen very often, but there's rarely a role for that. And then the most common reason that we've used oncologists on our team, is if someone has thyroid cancer that has spread or they have some sort of recurrence that for whatever reason is not in a spot that's amenable to surgery that can't be operated on. And our oncologists, they have done a great job using medications called tyrosine kinase inhibitors. And there are a few different ones that they have to choose from. And that would be the role for the oncologist for our thyroid cancer patient.

Scott Webb: The neck is pretty complex. There's a lot of stuff in there. Maybe you can explain the importance of picking a really experienced surgeon for this type of work?

Dr. Michael Hancock: Surgeons who are trained in ear, nose and throat surgery, they get really great training in this type of surgery. And generally you'll see that the people who do the most of them are the people who are actively seeking out these types of surgeries. They enjoy doing these surgeries. They're really good at it. And people like me will tend to use the same folks over and over again. There are a lot of sensitive structures in our neck including the nerves that go to the voice box. So part of the reason people may sometimes show up with hoarseness with a thyroid cancer is because the tumors pressing on that nerve. So that's how close it lives to the thyroid normally.

There are glands behind the Thyroid called parathyroid glands that help control the calcium level in our blood. And those can sometimes be injured during the surgery. so that's another role that we serve in is helping detect calcium problems after a thyroid surgery. Essentially the surgeons are gonna be surgeons who are very interested and competent in this type of surgery that we would refer patients to think a lot of times patients leave it to their referring doctor. They trust the judgment of their primary care doctor or their endocrinologist. But always, if there's somebody that you've seen before, somebody that, you know, and trust, that's always a good person to get an opinion from too.

Scott Webb: Doctor, this has been really educational. So as we wrap up here, what are your takeaways for people who listen to this, suspect they may have thyroid cancer or a family member, or a friend, or just want to know more about it, what are your takeaways?

Dr. Michael Hancock: Keep in mind that if you have concerns, talk to your doctor, they can help you sort through how concerned should I be? If it comes down to an issue of ruling out or being suspicious for a thyroid tumor, of any sort expect probably an ultrasound's gonna be the best way to evaluate that. Thyroid cancer isn't necessarily preventable. We haven't identified a lot preventable actions you can take. We recommend engaging in just general healthy lifestyle, like we all should do. And then if you are doing home thyroid exams, anything you would find that you would be concerned about or felt abnormal to you or felt different definitely let your doctor know about that.

So you can get that checked out. Most commonly, just keep in mind the symptoms, hoarseness, food getting stuck, right at the level of the thyroid or any other lumps or bumps in your neck, cause would be the most common symptoms that patients would show up with.

Scott Webb: As I said, it's so great to have your expertise today and really understand thyroid cancer, your role, the team approach, and so on. So thank you so much. You stay well.

Dr. Michael Hancock: Thank you. Thank you. Appreciate it. Nice to talk to you.

Scott Webb: For more information on thyroid cancer, visit Franciscanhealth.org and search thyroid cancer. You can also visit Franciscandocs.org to find an endocrinologist near you. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.