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

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

En esta entrevista hablamos sobre:

• El nombre del cáncer ha cambiado
• La tasa de supervivencia con cáncer ha cambiado para mejor
• La mitad tiene nódulos, muchos de ellos tendrán cáncer
• 10% de esos tienen cáncer
• No es necesario operar con todo el cáncer de tiroides
• 2.5 millones de personas en Colombia tienen cáncer de tiroides
• No biopsia todos los nódulos
• ¿Qué es la fobia al cáncer?
• Lo que no sabemos no nos perjudicará
• No biopsiar pequeños nódulos tiroideos
• BETHESDA IV en inconcluso
• La vida sin tu tiroides cambia tu vida, para peor en la mayoría de los casos
• A veces ocurre piel seca y peso
• Problemas de calcio
• Cambio de voz después de la cirugía de tiroides
• No todo el cáncer es fatal

Dr José A. Hakim -- Manejo quirúrgico actual del cáncer de cabeza y cuello

Dr. Antonio Hakim

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?

H. Gilbert Welch, MD, MPH

An internationally recognized expert on the effects of medical screening and over-diagnosis

Dr. Gilbert Welch’s work is leading many patients and physicians think carefully about what leads to good health. For Welch, the answer is often “less testing” and “less medicine” with more emphasis on non-medical factors, such as diet, exercise, and finding purpose in life.

Welch’s research examines the problems created by medicine’s efforts to detect disease early: physicians test too often, treat too aggressively, and tell too many people that they are sick. Most of his work has focused on overdiagnosis in cancer screening: in particular, screening for melanoma, thyroid, breast, and prostate cancer. He is the author of three books: Less Medicine, More Health: 7 Assumptions That Drive Too Much Health Care (2015), Overdiagnosed: Making People Sick in the Pursuit of Health(2012), and Should I Be Tested for Cancer? (2006). His op-eds on health care have appeared in numerous national media outlets, including the Los Angeles Times, The New York Times, the Washington Post, and the Wall Street Journal.

Welch is a professor of medicine at the Geisel School of Medicine, an adjunct professor of business administration at the Tuck School of Business, and an adjunct professor of public policy at Dartmouth College. He has initiated and taught courses on health policy, biostatistics, and the science of inference.

In this episode, the following topics are discussed:

• overdiagnosis is about how its found, and is a side effect of screening
• when screening for early forms of cancer
• some cancer is never going to cause the patient problems
• some cancer never becomes clinically evident
• we are looking so hard for cancer, that there is more than is possible
• birds, rabbits, turtles
• can’t fence in birds or aggressive cancers
• rabbits you can catch if you build enough fences
• turtles aren’t going anywhere anyway
• certain organs have a lot of turtles, prostate, lung, thyroid, breast
• ovedrdiagniosis only occurs when we are trying to look for early forms
• screening can benefit, but also cause harm
• breasts, prostate, and thyroid carry a lot of cancers. 
• overcoming cancer phobia, and reducing patient anxiety. 
• the best test is not the one that finds the most cancers, the best test is to find the ones that matter
• paradigm shift is happening in regard to cancer. 
• liquid biopsies, looking at biomarkers
• CA125

NOTES

H. Gilbert Welch, MD, MPH

Less Medicine, More Health: 7 Assumptions That Drive Too Much Health Care (2015)

Overdiagnosed: Making People Sick in the Pursuit of Health(2012)

Should I Be Tested for Cancer? (2006)

Patient Resources

American Thyroid Association 

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