Doctor Califano es Endocrinóloga del Instituto de Oncología AH Roffo, Universidad de Buenos Aires.
Es miembro del Departamento de Tiroides de la Sociedad Argentina de Endocrinología y Metabolismo y de la Sociedad Latinoamericana de Tiroides.
Es coautora del Consenso Multisocietario Argenino para el Manejo del Cáncer de Tiroides Diferenciado.
En esta entrevista, discutimos lo siguiente:
I sometimes get asked, why am I doing this podcast?
What started out as a pet project is now being listened to in over 30 countries and with as many as 20000 downloads per episode. So far, thyroid patients are embracing the opportunity to hear from the world’s leading thyroid doctors, and gaining the information needed to make better decisions related to health.
So why did I start Doctor Thyroid?
My motivation for doing this podcast is to help patients avoid bad experiences related to thyroid cancer and thyroid disease, including bad surgery. And, provide resources to help make better health decisions and improve quality of life.
My thyroid surgery resulted in errors, which have downgraded my quality of life significantly. Knowing what I know now, I would have picked a different surgeon, or chosen no surgery at all. Because, as this interview will discuss, although perceived as safe, thyroid surgery is not without risks.
To be published next month, new research reveals thyroid surgery errors are five times more likely than previously reported.
The study was conducted by Dr. Maria Papaleontiou. She is an Assistant Professor of Internal Medicine with an appointment in the Division of Metabolism, Endocrinology and Diabetes. She graduated medical school from the prestigious Charles University in the Czech Republic and subsequently spent several years conducting research at the Geriatrics Division at Weill Cornell Medical College. She then completed her internal medicine residency at Saint Peter’s University Hospital in New Jersey and her endocrinology fellowship at the University of Michigan. She joined the faculty at the University of Michigan in 2013. She is a recipient of Fulbright and Howard Hughes Medical Institute scholarships. Dr. Papaleontiou’s practice focuses on thyroid disorders and thyroid cancer. She is especially interested in the treatment of endocrine disorders in older adults. She also conducts health services research in the field of thyroidology and aging.
RELATED DOCTOR THYROID INTERVIEWS
Dr. Rashika Bansal is a PGY-2 resident in Internal Medicine at St. Joseph's Regional Medical Center in Paterson, NJ. Her major research has been with diabetes prevalence and awareness in rural India, with special interest in thyroid disease.
In this episode Dr. Bansal shares the research she presented at AACE 2017 and ENDO 2017, regarding the poor readability scores for thyroid cancer web sites.
The challenge for these web sites and health institutions is to translate thyroid education from complex to simple and easy to understand. Currently, many patients are not following with treatment, citing confusion after being exposed to the various thyroid cancer education resources.
In this interview, items discussed include:
Dr. Ralph P. Tufano is the Director of the Division of Head and Neck Endocrine Surgery at The Johns Hopkins School of Medicine, and conducts thyroid and parathyroid surgery with a focus on optimizing outcomes. He is a recognized world authority on the management of thyroid cancer, thyroid nodules, benign thyroid diseases and parathyroid disease. He has expertise in the management of thyroid cancer nodal metastases, advanced and invasive thyroid cancers as well as recurrent thyroid cancers. His work in molecular markers, improving surgical outcomes, nerve monitoring and exploring novel treatment techniques for thyroid and parathyroid diseases has helped the medical field tailor and personalize treatment for patients with these conditions. He is a Charles W. Cummings Professor, sits on the American Thyroid Association Board of Directors, is Director of the Division of Head and Neck Endocrine Surgery, and is a part of the Department of Otolaryngology-Head and Neck Surgery. He conducts approximately 450 thyroid surgeries annually.
The USPSTF upholds its 1996 recommendation against screening for thyroid cancer among asymptomatic adults.
The USPSTF commissioned the systematic review due to the rising incidence of thyroid cancers against a background of stable mortality, which is suggestive of over-treatment. And in view of the results, the task force concluded with “moderate certainty” that the harms outweigh the benefits of screening.
The USPSTF emphasizes, however, that this recommendation pertains only to the general asymptomatic adult population, and not to individuals who present with throat symptoms, lumps or swelling, or those at high risk for thyroid cancer.
A global problem
The over-diagnosis of thyroid cancer is worldwide.
South Korean doctors treated these newly diagnosed thyroid cancers by completely removing the thyroid—a thyroidectomy. People who undergo these surgeries require thyroid replacement hormones for the rest of their lives. And adjusting the dose can be difficult. Patients suffer from too much thyroid replacement hormone (sweating, heart palpitations, and weight loss) or too little (sleepiness, depression, constipation, and weight gain). Worse, because of nerves that travel close to the thyroid, some patients suffer vocal-cord paralysis, which affects speech.
Over-diagnosis and over-treatment of thyroid cancer hasn’t been limited to South Korea. In France, Italy, Croatia, Israel, China, Australia, Canada, and the Czech Republic, the rates of thyroid cancer have more than doubled. In the United States, they’ve tripled. In all of these countries, as had been the case in South Korea, the incidence of death from thyroid cancer has remained the same.
1 in 3 people die with thyroid cancer, not of.
RELATED DOCTOR THYROID INTERVIEWS
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.
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.
About Dr. Allen Ho
Allen Ho, MD, 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.
This is a candid interview with Dr. Gary Clayman about thyroid cancer surgery and making sure a patient receives the best available care.
Dr. Clayman has performed more than four hundred thyroid cancer operations per year for over twenty years among patients ranging from 6 months to 100+ years of age. Nearly half of Dr. Clayman’s patients have undergone failed initial surgery for their thyroid cancer by another surgeon or have recurrent, persistent, or aggressive thyroid cancer. If it pertains to thyroid surgery or thyroid cancer, there is likely nothing that he hasn’t seen.
Dr. Clayman left the M. D. Anderson Cancer Center in the fall of 2016 to form the Clayman Thyroid Cancer Center in Tampa, Florida
If someone is considering surgery, Dr. Clayman discusses important topics, including:
Other Doctor Thyroid episodes referenced during this interview:
Andrew J. Bauer, MD is an Associate Professor of Pediatrics at the Perelman School of Medicine, University of Pennsylvania and serves as the Director of the Thyroid Center in the Division of Endocrinology and Diabetes at The Children’s Hospital of Philadelphia. Dr. Bauer maintains active membership as a fellow in the American Academy of Pediatrics (FAAP), the Endocrine Society, the Pediatric Endocrine Society, and the American Thyroid Association. He also volunteers as a consultant for the Thyroid Cancer Survivors Association and the Graves’ Disease and Thyroid Foundation. In the American Thyroid Association Dr. Bauer has recently served as a member of the pre-operative staging committee, the thyroid hormone replacement committee, and as a co-chair for the task force charged to author guidelines on the evaluation and treatment of pediatric thyroid nodules and differentiated thyroid cancer. His clinical and research areas of interest are focused on the study of pediatric thyroid disease, to include hyperthyroidism, thyroid nodular disease, thyroid cancer, and inherited syndromes associated with an increased risk of developing thyroid nodules and thyroid cancer.
In this episode Dr. Bauer shares the complexities of managing children with thyroid nodules, and differentiated thyroid cancer. This is a must listen interview for parents whose child has a thyroid nodule or thyroid cancer diagnosis.
There are a several important differences in how pediatric thyroid nodules and differentiated thyroid cancer (DTC) present and respond to therapy. Kids are less frequently diagnosed with a thyroid nodule; however, the risk for malignancy is four- to fivefold higher compared with an adult thyroid nodule. For DTC (specifically papillary thyroid cancer), more than 50% of pediatric-aged patients will have metastases to cervical lymph nodes at the time of diagnosis, but because the tumors typically retain the ability to absorb iodine (retain differentiation), disease-specific mortality is very low, with > 95% of pediatric patients surviving from the disease. This is true even for children with pulmonary metastases, which occur in approximately 15% of patients who present with lateral neck disease.
With the high risk for malignancy and the invasive potential of the cancer, there has been a stronger tendency to take kids with thyroid nodules to the operating room (OR) and to administer RAI to those found to have DTC. With a greater realization of the increased risk for surgical complications as well as the short- and long-term complications of RAI treatment, the guidelines emphasize the need for appropriate preoperative assessment of nodules, and the approach to surgical resection, and they provide a stratification system and guidance for surveillance to identify which patients may benefit from RAI. The stratification system, called the "ATA pediatric risk classification," is not designed to identify patients at risk of dying of disease; it is designed to identify patients at increased likelihood of having persistent disease.
We have known about these differences for years, but the approach to evaluation and care has never been summarized into a pediatric-specific guideline. The adult guidelines aren't organized to address the differences in presentation, and the adult staging systems are targeted to identify patients at increased risk for disease-specific mortality. So, the adult guidelines are not transferable to the pediatric population.
You have been diagnosed with thyroid cancer, and choose no surgery. Although thyroid cancer diagnosis has spiked around the world, a trend is to pass on surgery if the cancer is identified as low risk. In doing so, mortality rate does not increase and it avoids unfavorable events sometimes related to surgery, such as vocal chord paralysis, hypothyroidsm, financial costs, and lifelong thyroid hormone treatment.
In this episode, we visit with Dr. hypothyroidism, a pioneer in prescribing active surveillance in place of immediate surgery.
Dr. Miyauchi is President and COO of Kuma Hospital, Center for Excellence in Thyroid Care, Kobe, Japan. He is an endocrine surgeon, especially interested in thyroid and parathyroid diseases. He earned his MD and PhD at Osaka University Medical School in 1970 and 1978, respectively. He was Associate Professor of Department of Surgery, Kagawa Medical University until he was appointed to Vice President of Kuma Hospital in 1998. Since 2001, he is at his present position. About 2,000 operations, including about 1,300 thyroid cancer cases, are done every year at Kuma Hospital. He is currently serving as Chairman of the Asian Association of Endocrine Surgeons. He also served as Council of the International Association of Endocrine Surgeons until August 2015.
Topics covered, include:
You have been diagnosed with thyroid cancer, and contrary to your doctor's advice, you choose to not proceed with surgery. Is this a patient trend, and how often are patients making this decision?
In a qualitative analysis, Dr. Louise Davies reports on the experience of US patients who self-identify as having an over-diagnosed thyroid cancer.
How likely is death as result of thyroid cancer? In a study by H. Harach, he sites that when reviewing random autopsies, thyroid cancer was prevalent in 34% of the cadavers.
Dr. Davies states, if diagnosed with thyroid cancer, important questions to ask, include:
Dr. Davies says those who choose to opt for no surgery are sometimes called stupid by those who know them, and end up feeling isolated and anxious, with little or no support.
Louise Davies, MD, MS, FACS is an Associate Professor at Geisel School of Medicine
and Dartmouth Institute for Health Policy & Clinical Practice (TDI).
She is Chief, Otolaryngology at Veterans Administration, White River Jct., VT
Dr. Davies is an otolaryngologist - head & neck surgeon whose thyroid related research is aimed at defining and documenting the problem of rising thyroid cancer incidence and developing management approaches to the problem in ways that are safe and effective. Clinically, Dr. Davies cares for patients with both head and neck and thyroid cancer and general otolaryngology problems primarily at the VA hospital, with a limited practice at Dartmouth Hitchcock Medical Center. Her career is defined by her goal of helping patients and physicians make good decisions for their cancer care by providing clear, helpful data in useful formats at the needed time and place.
Yasuhiro Itoa and Akira Miyauchi
Dr. Schneider specializes in endocrine surgery, treating diseases of the thyroid, parathyroid, and adrenal glands. He utilizes several minimally invasive techniques to treat endocrine disorders (endoscopic thyroidectomy, minimally invasive parathyroidectomy, laparoscopic adrenalectomy, focused exploration for recurrent thyroid cancer).
This episode explores the following topics:
Dr. David Schneider
El Dr Fabián Pitoia es Médico Endocrinólogo, es Jefe de la Sección Tiroides y Coordinador del Área Investigación de la División Endocrinología del Hospital de Clínicas - Universidad de Buenos Aires, es Docente adscripto de la Facultad de Medicina - Jefe de Trabajos prácticos de Medicina B (Facultad de Medicina - UBA) y Docente de la Carrera de Especialistas en Endocrinología y Metabolismo de la UBA.
Especialidad recertificada en Diciembre de 2013.
El Dr Pitoia tiene más de 200 publicaciones de sus investigaciones, más de 50 listadas en Pubmed, ha sido primer autor de las Guías Latinoamericanas para el diagnóstico y tratamiento del cáncer de tiroides, también el primer autor de las Guías Intersocietarias Argentinas para manejo de pacientes con cáncer de tiroides 2014.
En esta entrevista, discutiremos:
Dr. Babak Larian is a highly experienced, board certified Ear, Nose, & Throat Specialist and Head & Neck surgeon. Dr. Larian is the current Clinical Chief of the Division of Otolaryngology at Cedars-Sinai Hospital in Los Angeles. Dr. Larian's Center For Head and Neck Surgery is located in Beverly Hills, California.
In this episode, Dr. Larian discusses his experience treating thyroid disorders, including his medical missions to Central America. During this interview, you will hear greater detail about the following topics:
Dr. Babak Larian
American Thyroid Association Guidelines
El Dr. Carlos Simon Duque es un especialista en cabeza y cuello de Colombia. En esta entrevista, discutiremos una visión general del cáncer de tiroides, incluyendo las siguientes preguntas:
¿Qué debe saber un paciente antes de la cirugía, qué esperar?
Después de la cirugía, un paciente puede sentir síntomas como hipotiroidismo. ¿Cómo lo manejas mejor?
¿Cuáles son algunas de las luchas mas complicados que usted ve con sus pacientes después de la tiroidectomía?
¿Qué pacientes recuperan mejor? ¿Qué puede hacer un paciente para sentirse mejor después de la cirugía?
¿Cuándo es el mejor momento del día para tomar la medicina de la tiroides?
Usted ha trabajado tanto en los Estados Unidos como en Colombia, ¿cuáles son algunas de las diferencias en la atención y el tratamiento?
¿Qué has descubierto a lo largo del camino, que le dirías a usted de 30 años de edad si puede?
¿Actualmente está trabajando en algún estudio o investigación?
Dr. Douglas Van Nostrand, MD is the Director of Nuclear Medicine and the Program Director of the Nuclear Medicine Residency Program at Washington Hospital Center and Professor of Medicine, Georgetown University Hospital Center.
His specialty is nuclear medicine, and his primary area of interest and expertise is the nuclear medicine diagnosis and treatment of thyroid cancer. He has held numerous academic and medical society positions including Clinical Professor of Radiology and Nuclear Medicine, Uniformed Services University of Health Sciences; past President, Mid-Eastern Society of Nuclear Medicine, Director of Continuing Medical Education Department, and other elected positions of the Medical Staff of Good Samaritan Hospital. He has over 150 articles published and has been the co-editor of seven medical books including the medical textbook entitled Thyroid Cancer, A Comprehensive Guide to Clinical Management.
In this episode, get the critical questions to ask prior to committing to a surgeon. And, other useful strategies to make sure a patient gets the best outcome possible.
Hear about the advances in thyroid ultra sound technology, along with the patient process from diagnosis to surgery. Key topics in this episode include how to research a surgeon, requesting a second opinion, selecting the best hospital, and the challenges faced when operating on the neck.
This episode features Dr. Joseph Sniezek, who is the Medical Director of Head & Neck Endocrine Surgery for Swedish Health Services.
Too often, the time between being told by your doctor to get an ultrasound to biopsy, often results in anxiety and a disconnect between surgeon - radiologist - pathologist. Now, with better technology, especially in the area of ultra sound, the multiple trips to specialists can be eliminated.