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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and today, we're giving an update on hyperthyroidism. Joining me in this panel round table is Dr. Jessica Fazendin. She's an Assistant Professor, an Endocrine Surgeon, and the Medical Student Clerkship Director in the Department of Surgery at UAB Medicine. Dr. John Porterfield. He's a Professor and an Endocrine Surgeon and Dr. Brenessa Lindeman, she's the Section Chief and Fellowship Director for Endocrine Surgery at UAB Medicine. Doctors, I'm so pleased to have you join us. A couple of you have been on with us before, as we're giving this update. So Dr. Porterfield, I'd like to start with you in this round table. Why don't you kind of give us a little bit about hyperthyroidism, it's prevalence. Set the stage for us if you would.

John Porterfield, MD (Guest): Fantastic. Well, thank you for this opportunity. Hyperthyroidism is really just an overactive thyroid, whenever the thyroid gland produces too much of the thyroid hormone thyroxine. It can be challenging to diagnose as the symptoms can mimic lots of other medical conditions. And so patients may come into clinic with varying things. They may have unintentional weight loss. They may have a change in how their appetite is. They may have arrhythmias or atypical rapid heartbeats, those types of things. But there's a whole, long list of symptoms that patients may present with. And then that can be typically evaluated with a few basic thyroid laboratory function tests to be able to see what their thyroid stimulating hormone is as well as to see what their thyroxine levels are in their body. Really, not a tremendous amount has changed. It's been a very stable disease as far as how it's diagnosed and what causes it. We'll talk more about, kind of what's new in treatment, but it typically comes down to one of the auto-immune diseases like Graves Disease or Hashimoto's Thyroiditis that will cause patients to be hyperthyroid.

They can also have a thyroid nodules themselves that can produce too much of the thyroid hormone or a disease called Plummer's disease, that influences the entire gland. So, it's multiple nodules making too much of the thyroid hormone. And so it's really up to medical providers to be able to sort out in hyperthyroidism, which is, what are the causes because they have a little difference in how we treat them and they can have different rates of recurrence and that type of thing.

Host: Dr. Fazendin, since you have not been on with us before, and I hear that you are the lead researcher. Give us an update on anything that's changed. Any research studies that you're involved in that other providers may not know about.

Jessica Fazendin, MD (Guest): Well, again, just to echo with what Dr. Porterfield said. I'm so happy to be on this call and discussing this important topic with my partners. We've been able to collaborate with one another and take a huge subset of the population, referrals from all over the state and the region and study these patients with hyperthyroidism. And obviously this is a group of surgeons discussing surgical treatment of this disease process. And so our most recent study was really looking at the effect of surgery and its outcomes. We've been able to show that this is a safe surgery for patients and that they have excellent outcomes in terms of symptom resolution, as well as a cure for this disease.

And most recently we were able to look at over 200 patients, a group that are what we call controlled hyperthyroid patients. So, those that have been on medication who have lab levels that are still somewhat within the normal range as compared to patients who for very many reasons, can't take the medication, have side effects for medication, all during the treatment of their disease process. And we're able to show that through surgical intervention, we can safely get these patients through treatment, and on the other side of surgery to achieve a cure without going into any undue side effects during that surgical intervention.

Brenessa Lindeman, MD (Guest): And I would just like to add to that, that historically the treatment algorithms for hyperthyroidism have required physicians to render patients euthyroid. So ensuring that their thyroid hormone levels are normal prior to pursuing surgical intervention as a curative treatment for hyperthyroidism. And as Dr. Fazendin pointed out, there are quite a number of patients it's estimated up to 20% of patients have some side effect from antithyroid medications. So, there are quite a number of patients that cannot get their thyroid hormone levels back into the normal range prior to surgery. And so what her and our group's research has shown, is that these patients, though they were historically thought to be at risk of going into a very severe and life-threatening condition known as thyroid storm, while they are under general anesthesia, that in fact, this doesn't happen in practice. And in our cohort of over 200 patients, this was not seen and that all of the patients made it through thyroidectomy very safely and with very low rates of complications.

Host: Isn't that so interesting. So, Dr. Lindeman, as you're telling us a little bit about how treatment has evolved over the years, is there any other literature from other research that you think is important to share that you want other providers to know about?

Dr. Lindeman: Absolutely. There have been a few important studies that have been published over the last few years. One notable one was from the Journal Thyroid in 2018. And this study was performed by authors from Finland and they studied a comparative cohort of a large number of patients from across that nation with hyperthyroidism. And they compared those patients who had treatment of their hyperthyroidism definitively with either radioactive iodine or with thyroid surgery compared to patients that were not treated. And they found that rates of cardiovascular disease were much more common in patients that remained hyperthyroid either because they weren't treated, or importantly, patients who were treated with radioactive iodine, but we're not fully treated such that they became hypothyroid following the treatment. Those patients were at risk for both cardiac arrhythmias in an ongoing manner, but also they were at risk for cardiovascular disease in general, including what is felt to be ischemic cardiovascular disease.

And so I think that leads at least me, to the conclusion that there are more systemic effects of hyperthyroidism that we don't quite understand, but whenever it is identified that we need to be increasingly aggressive with the way in which we treat it so that we offer patients the best possible quality of care, particularly over the long term.

Dr. Porterfield: And I would add to that, that I completely agree that surgery has changed so much even just in the last 20 years as far as how we have been able to use different anesthetic protocols. We've been able to use different preoperative and postoperative protocols for all types of surgery to not only be able to do this in an outpatient way in many situations now, but often even in a very short stay outpatient setting where patients are able to leave the hospital literally within an hour or two of an operation, which years ago would have required, a longer hospital stay. And so it has allowed surgery to be a safer, less invasive and lower life impact to the patients.

Whereas in the past with radioactive iodine or medical management, it was thought this was great because it avoids surgery. But that was back in an era when surgery was very different than it is now. And so, all three of us and our partners here all too often, we'll see patients who should have been referred to surgery sooner. And they have suffered some quite grave consequences from getting to us late after having tried antithyroidal medications or after having tried radioactive iodine, which can take many months to see patients reach a hypothyroid state, which as Dr. Lindeman just mentioned, that hypothyroid state, if not managed appropriately can also bring on complications as well. So surgery has changed a lot, even in the last decade.

Dr. Lindeman: That's a really important point, Dr. Porterfield. Because I think the other thing I hear from patients and from my colleagues in endocrinology and primary care is that for so long the risks of surgery for hyperthyroidism were felt to be prohibitive. That we were putting patients at high risk due to fibrosis or vascularity of the thyroid gland. And that by contrast, radioactive iodine as a mechanism for definitive therapy was felt to be entirely safe. And while the risk profile for radioactive iodine, particularly in the short term is very favorable, there's a very important study that was published in JAMA Internal Medicine in 2017. The lead author is Carrie Kitahora, and that showed an association of radioactive iodine treatment with cancer mortality in patients that had hyperthyroidism and they studied over 18,000 patients.

In what was a 24 year extension of a study that had been ongoing for over 50 years. But the approach they took that was able to identify these different results was they measured the organ absorbed doses of the radioactive iodine that was administered, and they found a statistically significant positive dose-response relationship for the risk of death for all solid cancers and particularly for breast cancer; finding that for every 100 milligray of radiation patients received, they had a 12% increased risk of contracting and dying from breast cancer. And so that has caused me to counsel, particularly my young female patients with Graves disease in a much different way than I did prior to the publication of this study.

Host: Dr. Fazendin, we've been talking about this multimodal approach to hyperthyroidism, medication, radioiodine therapy, and surgery. And as this condition has many aspects of treatment modalities, can you tell us about the importance of a multidisciplinary approach and why that's so important for these patients?

Dr. Fazendin: That's a great question. I think my partners and I would all agree that this should be a multimodal approach. Early referral as Dr. Porterfield mentioned, I think is key. Counseling patients that there are more than one strategy to treat and effectively manage this disease is important. And while we're surgeons, who definitely believe in the therapies that we offer, it doesn't mean that we're going to take every person to surgery if it isn't right for that individual. And so I really do think that individualized care, a multidisciplinary approach, both with referring primary care doctors and endocrinologists, and just really picking the best therapy for that particular patient and giving them some autonomy over their care with choices, is key to helping treat hyperthyroid diseases.

Dr. Porterfield: And I would add, that one of the, that has been positive that has come out of this COVID epidemic has been our adoption of Telemedicine, in a real way here at UAB, such that now patients can come from all over the region and they can come to Birmingham, really just for even just as short as 48 hours. They can see their anesthesiologists the day before. They can proceed on to surgery the next day, typically we'll ask them to stay overnight in the Birmingham area, but then they're able to go home. And so that's allowed us to be able to kind of be in the endocrinologist's office or to be in a primary care provider's office.

And for us to be able to have a visit that patients don't have to wait until we have an opening in our clinic schedule, we can actually talk to them the week that they learn of their diagnosis, and then we're able to coordinate an itinerary for them when they come to Birmingham because travel can be expensive and we don't want patients having to travel back and forth to be able to reach advanced surgical care. So we've learned a lot from how we can be more efficient in managing patients so that again, they have less of an impact to their life and schedule.

Host: It is so interesting to me, how you providers have really adapted Telemedicine and I don't think it's going anywhere, but it's really incited us all to be more innovative and creative in our health care. And I'd like to give you each a chance for a final thought. Dr. Porterfield, starting with, speak about anything that's changed the landscape for you in hyperthyroidism care, because you did just talk about Telemedicine and briefly earlier, you mentioned radiologic imaging, some things in surgery. Tell us anything you would like to mention that has changed the landscape or that you find very exciting.

Dr. Porterfield: I really am excited about all the changes that have happened for the benefit of patients with Telemedicine. I see more patients per week than I ever have in my career. I get to talk to patients every day, from all over the region. And as a referring doc may contact us. I've even talked to doctors and patients in the exam room together, and that availability should have always been there. And it just feels so right that we now have the ability to do that with these devices that are in our hands and with our entire team of nurses and our entire team of scheduling support here at UAB that can collect outside records. We have a system that works throughout the entire state where images can be uploaded and we can see them.

And to be able to do that on a Smart device, in a mobile setting, to be able to go over images with other physicians, and to be able to go over laboratory studies and things in a real time way, it has really, really changed the way I practice medicine. And I don't think it will revert back to the past. I think we will stay with a lot of the things that we have learned and it'll be for the betterment of patients.

Host: I agree. And I appreciate you speaking about the things that have significantly augmented your diagnostic and therapeutic capabilities and Dr. Lindeman, as we've been talking about surgery and medical management. What about adherence and follow-up? What challenges or things that you have overcome recently would you like to mention as far as patient care?

Dr. Lindeman: I think you hit the nail on the head that no matter what diagnosis that we identify, no matter what therapy we prescribe or perform in terms of an operative intervention, that the most important thing is being able to meet the needs of the individual patient in front of us. And those needs are going to be different from person to person based on their circumstances. In addition to what Dr. Porterfield has been discussing, with the advent of remote technologies and the explosion in the use of Telemedicine, we are also happy to offer a multidisciplinary clinic to patients that if the physician that they have been seeing isn't set up yet for Tele-health capabilities and they want their patient to be seen by an endocrinologist and an endocrine surgeon on the same day; then we have opportunities to facilitate that through our multi-disciplinary Endocrine Tumor Clinic. And so it's always great to see these patients with hyperthyroidism and really walk them through what are the options for their ongoing treatment, because it does require continued medication or continued surveillance. And that's true, no matter what therapeutic strategy is ultimately chosen. And so we're very happy here at UAB Medicine to be able to work with patients and customize those treatment plans to ensure the greatest rates of success for each and every individual that we see.

Host: What an exciting time to be in your field and Dr. Fazendin, last word to you. Looking forward to this next 10 years in the field, what do you feel will be some of the most important areas of research? Give us a little blueprint for future research and what you'd like to see accomplished.

Dr. Fazendin: Well, to amplify what my partners have said and to build on your question, I'm so excited where our research is going and how UAB and our multidisciplinary approach really is at the of treatment, and changing the paradigm. We practice so much medicine as a nation based on anecdotal evidence. And it's really great to be part of system and a group of individuals that want to study this to get to the root of the issue and to expand indications for intervention so that we can reach the most patients, in an appropriate, cost-effective and timely fashion. And so I really think that UAB, along with my colleagues here are going to push that research, so that we can change guideline recommendations, so that just, as I said, we reach as many patients, in the best way possible.

Host: Well, I am sure you will. And thank you all for joining us today. What an interesting round table this was. Come back and update us anytime you'd like.

And a physician can refer a patient to UAB Medicine by calling the mist line at 800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. Until next time, I'm Melanie Cole.