Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole and we have a panel for you today with two UAB Medicine Otolaryngologists, Head and Neck Endocrine Surgeons, highlighting thyroid disease and thyroid cancer. Joining me is Dr. Andrew Fuson. He's an Assistant Professor, and Dr. Daniel Rocke. He's an associate professor.

Doctors, thank you so much for joining us today. And Dr. Rocke, as I understand it, you're new to UAB Medicine. Tell us a little bit about yourself and how you came to be at UAB Medicine.

Daniel J. Rocke, MD: Yeah, thanks, Melanie. I'm really excited to be here at UAB. I trained at Duke University for residency and did a fellowship in Toronto where I learned a lot about head and neck endocrine surgery. And I spent nine years at Duke, as an attending surgeon there, and made the move here to UAB because it was a great opportunity to, I think, take care of patients with thyroid and parathyroid problems, which is my passion.

Host: Thank you for sharing that with us. So, Dr. Rocke, give us a brief overview of thyroid diseases in general and their prevalence, including cancer. Tell us what you've seen in the trends.

Daniel J. Rocke, MD: I think as surgeons, we tend to be at the end of the line in some ways for this in that we're seeing patients who are surgical candidates and we typically see three types of patients in our clinics. One is our patients who have hyperfunctioning thyroid glands, so hyperthyroidism.

This is overall like, not that uncommon. We see it about one to three percent of the population and more commonly, in females and surgery is an option for some patients. And, so we see a lot of patients for that. We see patients who have thyroid enlargement that's causing compressive symptoms, difficulty swallowing, difficulty breathing.

Really hard to know the prevalence of this. Thyroids can be enlarged, but they don't often cause symptoms and you know, important to help patients sort that out. And then the last thing is thyroid nodules. And we see a lot of this and it's really, really common, especially in women, especially women over the age of 50. Most of these are benign, but really important to get these worked up. And we are seeing more of these and it's not entirely clear why that is. I think most people think it's due to increased use of medical imaging for looking for other things, but there also seems to be a rise in thyroid cancers. 

And probably it's just that we're detecting these more because of using imaging modalities. But they're very, very common. So that's pretty much what we see mostly in our surgical clinics.

Host: Thank you. Dr. Fuson, I'd like you to speak about risk factors. Dr. Rocke mentioned women more prevalent than men, but speak about some of the risk factors and common conditions that can lead to thyroid disorders.

Andrew Fuson, MD: Thyroid disorders can absolutely run in families. Functional thyroid disorders, I like to group thyroid disorders into functional and structural thyroid disease. Functional thyroid disorders like Graves disease or hypothyroidism can run in families.

But the most common way we find these is folks who, just sporadic incidence of thyroid nodules or of functional thyroid disorders. Thyroid nodules are more common in overweight or obese people, more common in smokers and in those who drink excessively. And of course the highest risk folks with thyroid disorders are those who've been exposed to ionizing radiation, but that is exceedingly rare.

Daniel J. Rocke, MD: We mostly see the radiation exposure being a risk factor in people who've been exposed in childhood or adolescence. And as Dr. Fuson said, it's really, pretty rare for us to see this. And especially as radiation has fallen out of favor for things that it had been used for in the past.

Melanie Cole, MS (Host): Well, Dr. Fuson, as we think about thyroid disorders in general, and patients with abnormalities sometimes come to medical attention for several reasons. So when you're speaking to other providers and thinking of the clinical presentation, what should they be looking for that would send up those red flags and send them in for referral?

Andrew Fuson, MD: Any palpable neck mass, particularly a thyroid nodule, deserves to be worked up, as Dr. Rocke mentioned earlier today. The best way to work that up is, of course, with an ultrasound, and then that ultrasound will give us a risk stratification of that thyroid nodule, in terms of its risk for cancer and its need, really, in the end, to be removed.

The other functional thyroid disorders, people who aren't well controlled on their medications, or who aren't tolerating their medications well, probably do deserve a surgical consultation to see if surgery can cure their disease.

Daniel J. Rocke, MD: The only thing I would add to that is just the importance of examining the thyroid in every patient. It's not always an easy physical examination to do. Dr. Fuson mentioned obesity as a risk factor. And that's, true. And it also makes it more difficult. When in doubt, ultrasound is a great imaging modality, no ionizing radiation exposure. So it's basically zero risk imaging modality that when in doubt I think it's worth exploring.

Host: Well, then Dr. Rocke, once diagnostic criteria is met and you've determined what's going on, speak about some of the exciting treatment modalities for thyroid disorders, nodules, but also talk about cancer, which definitely is not as common, but certainly I'm sure you're seeing it. So how are treatment plans individualized?

Daniel J. Rocke, MD: As Dr. Fuson said that the first step in looking at a thyroid nodule is ultrasound. And, it's a relatively simple imaging modality. But it's really the best. It's better than CT. It's better than MRI. It's better than a PET scan. And it gives us so much really useful information.

And Dr. Fuson and I both do ultrasounds in clinic. And I think that's something that is really important, because the ultrasound is as good as the person who's doing it. And we do ultrasounds all the time. I think we're really, really good at it. And there are lots of times when the ultrasound that I do in clinic, or that Dr. Fuson will do in clinic, will change the management for a patient. And so I think that's always, the workhorse of what gets us the information that we need. But, needle biopsy is the second step in patients who have a nodule that meets criteria for a biopsy. And we get really good information on what's going on in that nodule from the biopsy.

But there's a lot of really cool technology out there that's developed in the last couple of decades. We're looking at the molecular profile of these nodules. There are somewhere about 25 percent of thyroid biopsies end up being indeterminate, which is means that there are enough cells there that pathologists can look at, but they just can't tell from looking at it.

So these molecular tests have been really godsends to us because they take patients that we would otherwise have operated on and they allow us to risk stratify them. A lot of these patients can just be observed because we're confident this is a benign nodule. And then in some patients we get really useful information that can help guide the decision whether to have surgery, but also the extent of the surgery. How much surgery is appropriate.

So, it's really cool technology. It's getting better all the time and it's really helping patients.

Andrew Fuson, MD: When somebody comes to our office, and as Dr. Rocke indicated earlier, we're kind of the end of the line. Somebody's very likely already seen their primary care doctor. Maybe you've already seen a radiologist gotten an ultrasound or a biopsy. But what patients are looking for is more information so they can make a better informed decision.

And I think the last 10 or 20 years in treatment of thyroid cancer have really enabled us to do that. And that's number one with a surgeon performed ultrasound that both Dr. Rocke and I do, as he mentioned, and with molecular studies.

Daniel J. Rocke, MD: Yeah. I think the benefit of that is that you can individualize the treatment for your patient in ways that just were not possible in the past. And sometimes the molecular profile from these tests will lead you to be more aggressive with your surgery because you know that those genetic abnormalities that you're seeing are associated with higher risk cancers, but the opposite is also true.

There are molecular profiles that while sometimes associated with cancers are typically associated with less aggressive cancers. And one of the trends that we've seen over the past several decades, really, is just de-escalation of the amount of treatment that we do for thyroid nodules and thyroid cancers, and we know that this is a disease that does have a good prognosis, and I think we have over-treated these in the past.

And we want to get the best outcome for patients, but we can do that by doing less, and it really helps patients a lot.

Host: That's interesting. So, Dr. Fuson, when you're speaking about treatments, watching and waiting, good prognosis for most of these patients, many of these patients, tell us a little bit about what that looks like for the patient themselves. How do you work with these patients as far as their daily life? How thyroid disorders affect their quality of life, the anxiety of watching and waiting, because I think that it certainly is where we're going in many aspects of medicine, however, then there is taking into account that quality of life and the patient's own anxiety surrounding whatever's wrong.

Andrew Fuson, MD: There are two sides to that story, right? One is the anxiety associated with doing less surgery or not doing surgery at all. That's the anxiety of watching a thyroid nodule with yearly ultrasounds or repeating biopsies instead of proceeding directly to surgery.

And then there's the other side of that, which is how does a thyroid surgery, a total thyroidectomy impact somebody's life? So I think first the anxiety of observing a thyroid nodule or repeating biopsies. You know, I think the most important factor with that on the physician side is educating the patient, like so many things in medicine.

These diseases, and particularly thyroid nodules, are so, so common. If we did an ultrasound of everybody, probably half the people that we ultrasounded would have some sort of thyroid nodule. And such a vanishingly small percentage of those will need to be treated eventually.

I think educating people about that, and the fact that we do watch these things closely, and the technology we have to watch them, is so good and very sensitive for detecting any changes or concerning signs. Now, the other side of that is how do we counsel somebody who's going through a thyroidectomy for a thyroid cancer, that needs the entire thyroid removed or needs lymph nodes removed?

Thyroid surgery is an exceedingly safe surgery. And the main changes to quality of life for patients are the fact that they'll be on a daily medicine, when their whole thyroid is removed and the immediate recovery from surgery, which is generally in the neighborhood of two weeks.

Dan, how are you counseling people regarding thyroidectomy and the changes to their life afterwards?

Daniel J. Rocke, MD: You gave a great answer Andrew, on that, and the only thing I would add is that, as we talk about quality of life, well, it's very true that thyroid surgery is safe, and the risk profile is very low, and that's especially true when you go to high volume surgeons like Dr. Fuson and me. It is important also to understand that some of the potential quality of life issues are related to some of the outcomes related to treatment.

And by that, I mean, if you were one of the very few people who had low calcium issues after, that is a quality of life issue. And so, it's a very small percentage, when you go to somebody who does this a lot. But it's worth considering when you think about how much surgery to do and just in counseling patients about what to expect afterwards. I think it's a really important part of our discussion with the patients.

Host: Doctors, this is a really great conversation and very enlightening, really letting us know what's going on in your field today. I'd love to give you each a chance for a final thought here. So Dr. Fuson, why don't you start. Any ongoing research, recent developments in the understanding and treatment of thyroid disease, any breakthroughs, clinical trials you'd like to let other providers know about that you're doing at UAB Medicine?

Andrew Fuson, MD: The most exciting thing for us in endocrine surgery right now is honestly the addition to Dr. Rocke and our multidisciplinary team at UAB in treating endocrine disease. We work really closely with Endocrine Oncology, and Dr. Vodopivec which is a unique resource that we have here at UAB, which is an endocrinologist dedicated exclusively to thyroid cancer.

And then not to mention the rest of the team in the multidisciplinary team who helps us treat thyroid cancer. I think that's the most exciting thing that I've experienced since I've been here at UAB a little over two years now. And I think we're quite simply just getting better at treating folks with endocrine disease.

Daniel J. Rocke, MD: The only thing I would add to that is just, or emphasize is just, there's a lot of things that we're learning about immunotherapy comes to mind and how for some patients who have more aggressive forms of thyroid cancer, we may be able to use this upfront to decrease the amount of surgery that we need to do.

And the molecular testing that we talked about before, those tests just continue to get better. It's really important technology because it's limiting the unnecessary surgeries that were done in the pastjust to get a diagnosis. 

But I think,as Dr. Fuson said, the thing, one of the things that we do really well here at UAB is just involve multiple different specialties in this. And our tumor board, for example, where we have surgeons and endocrinologists and radiologists and pathologists all talking about patients and putting our heads together and coming up with the best treatment plan for the patient. That's invaluable.

You know I often tell patients that the most important thing in treating, especially for cancer, is that we do the right thing the first time, because that's the best chance at cure and it's worth putting in that time to get all the information and worth having the appropriate discussions, and I think we do that really well here.

Melanie Cole, MS (Host): Thank you both so much for joining us and sharing your expertise for other providers today. And for more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.