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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:
- How big is the tumor?
- How was the tumor discovered?
- Are there any symptoms?
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.
NOTES:
Dr. Michael Tuttle, from Sloan Kettering
Yasuhiro Itoa and Akira Miyauchi
Nonoperative management of low-risk differentiated thyroid carcinoma
After receiving his Fellowship from the Royal College of Surgeons of Canada in 1978, he spent two further years of advanced training, one as a Gordon Richards Fellow at the Princess Margaret Hospital in Toronto in Radiation and Medical Oncology and a second year as a McLaughlin Fellow, training in Head and Neck Oncology at the Royal Marsden Hospital in London, UK. He was the first fellow of the Advanced Training Council sponsored by the two head and neck societies.
A Full Professor, he occupies the Temmy Latner/Dynacare Chair in Head and Neck Oncology at the University of Toronto, Faculty of Medicine. He is former Otolaryngologist-in-Chief at the Mount Sinai Hospital stepping down after fulfilling his 10 year appointment. He has an active practice focusing on head and neck oncology with a primary interest in endocrine surgery of the head and neck.
He has given over 500 scholarly presentations, has been invited as a visiting professor and surgeon internationally, and has published over 280 articles in the scientific literature. He has been involved in a number of administrative roles in the American Head and Neck Society and is also on the editorial board of a number of high impact journals focusing on head and neck oncology. He has recently been appointed to the National Institute of Health (in Washington DC) task force on the management of thyroid cancer.
He is the Director of the University of Toronto Head and Neck Oncology Fellowship, considered to be one of the top three such fellowships in North America.
He was the program chair and congress chair of the First and Second World Congresses on Thyroid Cancer held in 2009 and 2013 in Toronto. He was the Keynote speaker at the Congress held in Boston in 2017. He has been invited worldwide to deliver keynotes in the management of thyroid malignancies.
In this episode the following topics are discussed:
- Cost of thyroid surgery in varies depending on jurisdiction
- Surgery and active surveillance is a fixed cost
- Costs after surgery
- TG tests, ultrasound, thyroid hormone costs
- Contrary to some proponents, surgery is not more cost effective than active surveillance
- Hypo parathyroidism leads to daily doses of calcium and vitamin D
- If there is RLN damage, then there could be more surgery and voice therapy
- There are more costs than solely the surgical fee
- Levothyroxine costs
- Ramifications of degree of thyroid cancer
- Thyroid cancer is a low risk of death
- Many people die with thyroid cancer but don’t die from it
- Possibility versus probability
- Emotional expense of malignancy and being labeled survivor
- Lead a normal life or the survivor label
- Lifetime cost of thryoidectomy
- Medical costs and cost of travel, time of work, baby-sitters, and all expenses that go into managing thryoidectomy for ancillary items
- How long can someone live without thyroid replacement hormone post thyroidectomy?
- Quality of life post thyroidectomy
- Psychological wellbeing
- Do not do a FNA for nodule under 1 cm
NOTES
Jeremy Freeman's scientific contributions
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:
- Do not let a doctor operate on you unless the surgeon can prove to you that he/she has done a minimum of 150 annual thyroid surgeries, and for a minimum of ten years. This means, do not see a surgeon unless he/she has completed a minimum of 1500 thyroid surgeries.
- Damage to voice box nerves is preventable, when surgery is done right.
- 90% of thyroid surgeries done in the U.S. are by doctors doing fewer than fifteen thyroid surgeries per year
- There is a growing trend of patients being more informed compared to years past
- Do not rush into a surgery. Vet your doctor and hospital. Talk to people and make sure you have selected a skilled surgeon
- Surgery is not franchisable, use caution when
- If a case is too complex, important that a less experienced surgeon seek help from a more experienced surgeon
- Incomplete surgery is completely unacceptable (persistence of disease)
- Advice to surgeons, especially less-experienced ones
Other Doctor Thyroid episodes referenced during this interview:
The Parathyroid, and a Safer — Less-Scarring Thyroid Surgery with Dr. Babak Larian from Cedars-Sinai
SHOW NOTES:
Book: Atlas of Head and Neck Surgery
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.
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:
- Incidence versus mortality
- Worldwide trends related to thyroid cancer
- Papillary Microcarcinoma of the Thyroid (PMCT)
- Unfavorable events following immediate surgery
- Results of research which began in 1993
- The current trend in the incidence of thyroid cancer is expected to create an added cost of $3.5 billion by 2030, to the individual and as a society.
NOTES
In this interview, items discussed include:
- the emotional burden of being diagnosed with cancer and the haste that sometimes follows
- the unnecessary damage of thyroid surgery, including the cutting of the laryngeal nerve resulting in vocal cord paralysis, low calcium levels and a need to supplement calcium and Vitamin D for life, and leaving residual disease behind
- knowing your risk factor and finding the right medical team to address it
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.
NOTES:
This episode details the medical approach to thyroid nodules. Topics include:
• 60% of the U.S. population has thyroid nodules
• Discovered when evaluating other neck issues such as an unrelated pain
• What happens when you are told you have a thyroid nodule?
• How to know if your thyroid nodule is cancerous?
• When is surgery done despite the nodule being benign?
• Decreasing patient anxiety with quick biopsy results
• The American Thyroid Association as a resource for patients and physicians
• A word of caution about sourcing medical information from online resources
Dr. M Regina Castro is an endocrinologist in Rochester, Minnesota and is affiliated with Mayo Clinic. She received her medical degree from Central University of Venezuela and has been in practice for more than 20 years. Dr. Castro accepts several types of health insurance, listed below. She is one of 78 doctors at Mayo Clinic who specialize in Endocrinology, Diabetes & Metabolism. She also speaks multiple languages, including Spanish and French.
NOTES:
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.
NOTES:
Dr. Bridget Brady is Austin’s first fellowship trained endocrine surgeon. She has a passion for and expertise in disease of the thyroid, parathyroid, and adrenal glands. Since completing her endocrine surgery fellowship in 2006 under Matthias Rothmund, MD, an internationally acclaimed endocrine surgeon, she has performed thousands of thyroidectomies and parathyroidectomies here in Austin. Dr. Brady focuses on a variety of minimally invasive techniques to optimize patients’ medical and cosmetic outcomes. Her fellowship training in Germany and experience in Austin have enabled her to specialize in patients with recurrent or persistent disease of the thyroid and parathyroid, including thyroid cancer. She offers complete diagnostic workups including in-office ultrasounds and FNA biopsies of thyroid nodules and lymph nodes.
Dr. Brady was named director of endocrine surgery for the new medical school in Austin. She was also recently chosen to teach general surgeons seeking additional training in endocrine surgery. Dr. Brady instructs these endocrine surgeons from the Baylor Scott and White fellowship program.
In this episode the following topics are discussed:
- Austin Thyroid Surgeons sees 30 patients per week with thyroid nodules
- Up to 80% of US population could have a thyroid nodule(s)
- less than 5% of Dr Brady's thyroid nodule patients test positive for cancer
- How relevant is what I don’t know won’t hurt me in thyroid cancer and biopsies of nodules?
- BETHESDA system or the middle category, also known as indeterminate
- For thyroid nodules that are indeterminate, historically a surgery would be performed
- With molecular testing, surgery can be decreased by up to 50%
- Afirma molecular testing uses messenger RNA
- If Afirma comes back suspicious it does NOT necessarily mean it is cancer
- Insurance covers molecular testing
- Nest steps for a doctor who would like to incorporate molecular testing
- Suspicious results with molecular testing can still be benign on final pathology
- How do you calmly tell a patient they have cancer?
NOTES
Dr. Bridget Brady
Dr. Amanda Laird, MD is an endocrine surgeon and Chief of Endocrine Surgery at the Rutgers Cancer Institute of New Jersey in New Brunswick, New Jersey. She is currently licensed to practice medicine in New Jersey and New York. She is affiliated with Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Hospital.
In this interview, Dr. Laird reflects on a decade of treating papillary thyroid cancer patients and reports none have died. In this interview we also explore these questions:
- Prognosis and what will happen in the long run and quality of life.
- Surgery complications.
- Levothyroxine side-effects, including weight gain.
- Life after surgery and RAI.
- What causes thyroid cancer.
- What time of day to take thyroid replacement medication.
- What blood tests should be ordered and is fasting necessary prior to thyroid lab work.
NOTES
Dr. Danielle Ofri is a doctor at Bellevue Hospital in New York City. She is one of the foremost voices in the medical world today, shining an unflinching light on the realities of healthcare and speaking passionately about the doctor-patient relationship. Her newest book is "When We Do Harm: A Doctor Confronts Medical Error."
Ofri is a regular contributor to the New York Times and is also the editor-in-chief of the Bellevue Literary Review. She lives in New York City and is determined to get through the Bach cello suites before she kicks the bucket.
In this episode:
- Medical error is the third leading cause of death?
After heart disease and cancer. - Intended audience for the book? A general audience; lay-public and medical professionals.
- It is difficult to define a medial error. Starting medication at wrong dose? What errors cause death? This can be vague.
- Hospitalized patients are different than the general public
- All sorts of patient harm should be brought to light — shift the medical field to “more safe” should be our goal.
- Once you are in the patient chair, one loses their strength and power.
- System flaws: more common error is a qualified professional who is burdened by design flaws — including false alarms.
- Collaboration and intellectual humility — recognizing we don’t know.
- Patients are sicker and more chronic conditions, mean collaboration helps reduce error.
- Denmark as an example to error response: acknowledge and apologize.
- The U.S. malpractice system as part of the problem.
- Qualifiers of malpractice: harm occurred, doctor was the cause, and consequence was big enough to make the case worthwhile.
- Who is making the laws about malpractice? Could be an underlining agenda.
- Recourse for patients: 1. Talk with doctor or nurse. 2. The hospital’s patient advocate. 3. Insurance patient advocates. 4. Local Board of Health. 5. Keep notes, and have a paper trail.
- The system is not designed to get information easy — take advantage of CARES Act.
- When transparency backfires; if a doctor is treating high risk patients, then their error will be higher.
- Doctors penalized for spending more time with a patient.
- The need for silence or time to think.
- The problem with the “reimbursement” model.
- Medical error, adverse events, and unintended consequences.
- Over-treating and over-diagnosis in regard to prostate or thyroid.
- Statute of limitations.
- Errors that don’t cause harm.
- Wash your hands and stop and think.
Dr. Ofri’s Links:
“When We Do Harm: A Doctor Confronts Medical Error”
Recent events - Dr. Ofri:
tinyurl.com/BLRViral Covid Writing Goes Viral: How Literary and Social Media Writing Became a Lifeline during the Pandemic
tinyurl.com/ReadingTheBody Reading the Body: Poetry, Dance & Disability
Notes
Doctor Thyroid with Philip James
philipjames@docthyroid.com
Dr. Shaha specializes in head and neck surgery, with a particular interest in thyroid and parathyroid surgery. He uses an algorithm of selective thyroid tumor criteria (the size, location, stage and type of cancer, along with the patient’s age), to tailor therapy to each individual’s circumstances. This can help thyroid cancer patients avoid unnecessary and potentially damaging over-treatment, while still providing the best option for control of their cancer and better quality of life after treatment. Dr. Shaha works very closely with Memorial Sloan Ketterings’ endocrinologists to monitor the careful post-treatment hormone balancing necessary for thyroid cancer patients. Many academic hospitals and medical societies worldwide have invited Dr. Shaha to speak on the principles of targeted thyroid surgery and to share his expertise in the treatment of head and neck cancers.
In this interview, topics include:
- The first question a surgeon should ask and why.
- When talking active surveillance or observation, changing the language to deferred intervention, ‘we are going to defer’.
- Understanding the biology of the cancer
- The biology of thyroid cancer is a friendly cancer.
- Anxiety when diagnosed with cancer.
- Medical legalities — spend a lot of time with patient — and empower patient.
- Let the treatment not be worse than the disease.
- Large tumors, more than 4 cm, bulky nodes, voice hoarseness, vocal cord is paralyzed. All circumstances where surgery maybe advocated.
- If a tumor is benign but there is presence of compressive goiters, or deviation of trachea or swallowing difficulty.
- Considering the condition of the patient, age, cardiac issues.
- When voice is critical to the patients livelihood, such as teachers, politicians, and singers.
- Main three complications of surgery include bleeding, change of voice, calcium problems.
- Non-academic surgeons.
- Cancer treatment requires a team: surgeons, anesthesiologist, pre-op, radiologist, pathologist, endocrinologists, oncologists.
- When wind pipe is involved with tumor.
- When in surgical business a long time, you become humble no matter how good you are.
- Family present during consultation.
- God gave you an organ — you took it away — now you are on a pill — since the surgery its ’just’ not the same.
- When treatment is out of the box — many will not agree with you.
- How to develop a scale to measure quality of life.
- To avoid scarring, surgery maybe conducted through the armpit in Korea and Japan.
- Fibrosis
- Progress in understanding biology of thyroid cancer only cancer, that there is 98% survival.
NOTES:
RELATED EPISODES:
42: Flame Retardants Connected to Thyroid Cancer, with Dr. Julie Ann Sosa from Duke University
21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies
36: 1 in 3 People Die With Thyroid Cancer — Not From with Dr. Seth Landefeld from UAB
During this interview, Dr. Tuttle discusses the following points:
- Challenges of managing thyroid cancer as outlined by the guidelines
- Scaling back care for insurance-challenged patients, and adopting a plan that gets the same result without needing the expensive tests
- Desired outcome is survival and no recurrence, a third is for no harm that would be caused by an unnecessary surgery
- Unwanted side affects of thyroid cancer include nerve damage, parathyroid damage, and infections
- RAI sometimes has unwanted side affects
- With technology, ultrasounds and biopsies, we know some cancers do not need to be treated, as they are now being found very early
- Change in ATA guidelines, low risk cancers can be considered for observation
- Two different kinds of patient profiles: Minimalist and Maximalist
- 1cm or 1.5cm?
- Patient characteristic, ultra sound characteristics, and the medical team characteristics weighs who is the most appropriate for observation
- 400 active surveillance patients currently at MSKCC
- Certain parts of the world are harder to offer observation as a treatment due to practicality, examples include Latina America where multi-nodular goiters are common, and Germany still is iodine deficient
About Dr. Tuttle, in his words:
I am a board-certified endocrinologist who specializes in caring for patients with advanced thyroid cancer. I work as part of a multidisciplinary team including surgeons, pathologists, radiologists, nuclear medicine specialists, and radiation oncologists that provides individualized care to patients treated at Memorial Sloan Kettering for thyroid cancer.
In addition to treating patients I am also actively researching new treatments for advanced thyroid cancer. I am a professor of medicine at the Joan and Sanford I. Weill Medical College of Cornell University and travel extensively both in the US and abroad, lecturing on the difficult issues that sometimes arise in the management of patients with thyroid cancer. My research projects in radiation-induced thyroid cancer have taken me from Kwajalein Atoll in the Marshall Islands to the Hanford Nuclear power-plant in Washington State to regions in Russia that were exposed to fallout from the Chernobyl accident.
I am an active member of the American Thyroid Association (ATA) and the Endocrine Society. In addition to serving on the ATA committee that produced the current guidelines for the management of benign and malignant nodules, I am also a Chairman of the National Comprehensive Cancer Network Thyroid Cancer Panel, a consultant to the Endocrinologic and Metabolic Drugs Advisory Committee of the FDA, and a consultant to the Chernobyl Tissue Bank.
NOTES
Listen to Doctor Thyroid
American Thyroid Association
Dr. Michael Tuttle
RELATED EPISODES
21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies
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.
NOTES
RELATED DOCTOR THYROID INTERVIEWS
21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies
Dr. Gerard Doherty, an acclaimed endocrine surgeon, is a graduate of Holy Cross and the Yale School of Medicine. He completed residency training at UCSF, including Medical Staff Fellowship at the National Cancer Institute. Dr. Doherty joined Washington University School of Medicine in 1993, and became Professor of Surgery in 2001. In 2002 he became Head of General Surgery and the Norman W. Thompson Professor of Surgery at the University of Michigan, where he also served as the General Surgery Program Director and Vice Chair of the Department of Surgery. From 2012 to 2016, Dr. Doherty was the Utley Professor and Chair of Surgery at Boston University and Surgeon-in-Chief at Boston Medical Center before becoming Moseley Professor of Surgery at Harvard Medical School, and Surgeon-in-Chief at Brigham and Women’s Hospital and Dana-Farber Cancer Institute.
Dr. Doherty was trained in Surgical Oncology, and has practiced the breadth of that specialty, including as founder and co-director of the Breast Health Center at Barnes-Jewish Hospital. His clinical and administrative work was integral in the establishment of the Siteman Cancer Center at Washington University. Since joining the University of Michigan in 2002, he has focused mainly on surgical diseases of the thyroid, parathyroid, endocrine pancreas and adrenal glands as well as the surgical management of Multiple Endocrine Neoplasia syndromes. He has devoted substantial effort to medical student and resident education policy. His bibliography includes over 300 peer-reviewed articles, reviews and book chapters, and several edited books.
He currently serves as President of the International Association of Endocrine Surgeons, Past-President of the American Association of Endocrine Surgeons, Editor-in-Chief of VideoEndocrinology and Reviews Editor of JAMA Surgery. He is a director of the Surgical Oncology Board of the American Board of Surgery.
In this episode, the following topics are discussed:
- Imaging has increased thyroid nodule discovery.
- Following patients with small thyroid cancer — analogous to prostate cancer. Better followed than treated.
- Tiny thyroid cancers can be defined by those nodules less than 1/4 inch in size.
- Less RAI is being used as a part of thyroid cancer treatment. This means, less need to do total thyroidectomy or thyroid lobectomy.
- Dry mouth and dry eyes are risks to doing RAI. Also, there is risk to developing a second malignancy. Most of the secondary cancers are leukemia.
- Risks to operation include changes to voice and calcium levels. Thyroid surgery is a safe operation but not risk free.
- Best question for a patient to ask is, who is my treatment team?
- The quarterback of treatment team is often the endocrinologist .
- Cluster of issues can happen after RAI, such as the need to carry water and eye drops for life.
- For some patients taking thyroid hormone replacement, their blood levels are correct, but still does not feel well on standard treatment protocol.
- By the end of two weeks, most people go back to what they were doing before surgery with a relatively normal state.
- Scarring reduction; massage, aloe, Vitamin E.
NOTES:
Bryan McIver, MD, PhD
Dr. McIver contributes to Moffitt Cancer Center almost 20 years of clinical experience in the care of patients with endocrine diseases, specializing in the evaluation of patients with thyroid nodules and thyroid cancer. He has a particular interest in the management of patients with advanced and aggressive forms of cancer and the role of genetic and molecular techniques to improve the accuracy of diagnosis; to tailor appropriate treatment to a patientdisease. Dr. McIver has a long-standing basic research interest in the genetic regulation of growth, invasion and spread of thyroid tumors of all types. His primary research focus is the use of molecular and genetic information to more accurately diagnose thyroid cancer and to predict outcomes in the disease. Dr. McIver received his MB ChB degree from the University of Edinburgh Medical School in Scotland. He completed an Internal Medicine residency at the Royal Infirmary of Edinburgh, followed by a clinical fellowship and clinical investigator fellowship in Endocrinology at the School of Graduate Medical Education at Mayo Clinic in Rochester, MN. Prior to joining Moffitt, he was employed as Professor and Consultant at the Mayo Clinic and Foundation in the Division of Endocrinology & Metabolism. Amongst his most proud accomplishments, Dr. McIver counts his two commitment to education of medical students, residents and fellows; his involvement as a founding member of the World Congress on Thyroid Cancer, an international conference held every four years; and his appointment as a member of the Endowed and Master Clinician Program at the Mayo Clinic, recognizing excellence in patient care.
In this episode, the follwoiung
- By sixty years old, more common to have nodule than not
- Most nodules are benign
- When to do a biopsy
- How to interpret the results of biopsy
- Advances in thyroid cancer
- Ultrasound technology advancements
- Molecular markers
- Cytopathology categorizations
- Molecular marker technologies
- Gene expression classifier
- Afirma
- Identifying aggressive cancer
- Types and sub-types of thyroid cancers
- Invasive and aggressive thyroid cancers
- Papillary versus anapestic thyroid cancer
- Biopsy results in 2 - 3 hours
- Clinical studies that have transformed thyroid treatment
- Less aggressive surgery and less radioactive iodine
- Targeted chemotherapies
- Immunotherapy
- The importance of clinical trial environments, or thoughtful philosophy
- The minimum necessary surgery
- Do not rush into thyroid cancer surgery
NOTES:
PAST EPISODES
James L. Netterville, M.D.
Mark C. Smith Professor of Head and Neck Surgery, Professor of Otolaryngology
Director, Head & Neck Oncologic Surgery
Associate Director, Bill Wilkerson Center for Otolaryngology and Communication Sciences
Dr. Netterville is the Director of Head and Neck Surgery at Vanderbilt and is an international leading authority of treating head and neck cancer. He is one of the world's experts in the treatment of skull base tumors and has a vast clinical experience.
Todays topic's include:
- Reoccurrence thyroid disease patients in paratracheal, thyroid bed, and cervical lymph nodes
- Papillary thyroid cancer and subtypes: tall cell, columnar, oncocytic, clear cell, hobnail
- The extreme importance of the pathologist
- Facebook is one of the number one sources of referrals
- The changing landscape of researching physicians
- PubMed and Index Medicus have replaced the library and medical literature
- In past 5 years patients are seeking advice from peers and experiences from others
- Patients have become the bets marketers for physicians versus the institution
- performing thyroid surgery on professional singers
- Patients are attached to a doctor and care team, which is often driven by social media
- Paratracheal region, and difficulty in ultrasound
- Selective neck dissection
- The evil remnant: when a surgeon inadvertently leaves thyroid cancer behind
- Three areas where thyroid cancer reoccurs: where remnant is left behind, hidden paratracheal lymph nodes,
- Lymph nodes in levels II, III, IV
- Some surgeons’ misperceptions about the effectiveness of RAI as a means to cleaning up poor surgery
- Doing a thyroid surgery is easy. Doing it right is hard. The importance of finding a surgeon who knows how to do it right
- Damage to RLN and leaving cancer behind or remnant, is due to inexperience
- Working around larynx and voice box during thyroid surgery
- Challenges with the trachea during thyroid surgery
- Grafting the RLN
- Grafting the RLN, in line graft, ends of motor nerves and sewing them back to the RLN
- Thyroid marketing and the term minimally invasive
- Superior RLN protection
- Preserving the cricothyroid muscle, especially singers
- The importance of being a good listener
- Vetting a surgeon by searching social media or reputation, publications, and volume
- Is thyroid cancer a cancer or just a nuisance. Chances are it is not going to kill you.
- Doctors managing their reputation online
- RAI and killing gross disease fallacy
- A surgeon's personal brand versus institution branding
- Online eduction
NOTES
Vanderbilt-Ingram Cancer Center
Funding surgical educational camps in Africa
Aggressive Variants of Papillary Thyroid Carcinoma: Hobnail, Tall Cell, Columnar, and Solid
Dr. Akira Miyauchi
Professor Akira Miyauchi (Figure 1) is President and COO of Kuma Hospital, Center of Excellence in Thyroid Care, Kobe, Japan. He is a Japanese endocrine surgeon, and a pioneer in active surveillance, and visionary in regard to treatment of thyroid cancer. World renowned researcher, and lecturer. As the associate professor of the Department of Surgery, Kagawa Medical University, he proposed and initiated a clinical trial of active surveillance for low-risk papillary micro cancer in collaboration with Kuma Hospital in 1993. In 2001, he was appointed the President of Kuma Hospital. Since then, he has been keen on the study of evaluating treatments for papillary micro cancer, observation versus surgery.
During this episode, the following topics are discussed:
- Financial burden of surgery versus total cost of active surveillance over ten years.
- Stretching Exercises for Neck
Setting patient expectations prior to FNA to manage anxiety - When the laryngeal nerve is severed during thyroid surgery, it can and should be repaired, with proper surgeon skill and training.
- Rather than being stationery and immobile, patients should practice neck stretching exercise within 24 hours proceeding surgery. There should be no fear about separating the incision.
- Total cost of surgery is 4.1x the cost compared to the cost of active surveillance. In the U.S., the cost is higher.
- Incidence versus mortality
- Worldwide trends related to thyroid cancer
- Papillary Microcarcinoma of the Thyroid (PMCT)
- Unfavorable events following immediate surgery
- Results of research which began in 1993
- The current trend in the incidence of thyroid cancer is expected to create an added cost of $3.5 billion by 2030, to the individual and as a society.
By providing patient an active surveillance brochure prior to FNA, they are more open to not proceeding with surgery for small thyroid cancer management.
Patient voice restores to near normal when repair of laryngeal nerve is done correctly. All surgeons should be executing this to perfection.
When doing next stretches one-day post surgery, patients report feeling much better and less pain, even one year after surgery.
Protocol for delaying surgery depends on the patient’s age. Older patients are less likely to require surgery. 75% of patients will not require surgery for their lifetime.
Listen to Doctor Thyroid here!
Akira Miyauchi, MD
35: Rethinking Thyroid Cancer ? When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles
21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies
50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering
PAPERS and RESEARCH
Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance
Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid.
Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery
TSH-suppressive doses of levothyroxine are required to achieve preoperative native serum triiodothyronine levels in patients who have undergone total thyroidectomy.
Stretching exercises to reduce symptoms of postoperative neck discomfort after thyroid surgery: prospective randomized study.
Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve. Listen to Doctor Thyroid here!
Dr. Jorge Calvo
Lugar de estudio:
U. de Panamà, Hospital de la Caja de Seguro Social, Fundaciòn Santa Fe (Colombia) U. Del Norte (Argentina), Sistema Integrado de Salud (Veraguas)
Otros estudios:
Laparoscopía, Curso de postgrado de Cirugía Gastrointestinal, Curso de postgrado de Cirugía de Cabeza y Cuello
En este episodio, se tratan los siguientes temas:
- ¿Cómo será la vida después de la cirugía?
- Embarazo después del cáncer de tiroides
- Parálisis de las cuerdas vocales
- Las complicaciones incluyen voz e hipo-calcio
- Sangrado durante la cirugía
- Tratamiento para hypo-calcium
- Vitamina D
- Embarazo y radiación
- TSH elevada después de la cirugía
- Problemas de TSH suprimido
- Número uno de miedo del paciente cuando se le diagnostica cáncer de tiroides y antes de la cirugía
- 32 años como cirujano tiroideo - cáncer papilar de tiroides
- Vigilancia activa
- Tasas de mortalidad del cáncer papilar de tiroides
- Recurrencia
- La mejor hora del día para tomar un reemplazo de tiroides
Más información:
www.doctiroides.com
Allen S. Ho MD is Associate Professor of Surgery, Director of the Head and Neck Cancer Program, and Co-Director of the Thyroid Cancer Program at Cedars-Sinai Medical Center. As a fellowship-trained head and neck surgeon. His practice focuses on the treatment of head and neck tumors, including HPV(+) throat cancers and thyroid malignancies. He leads the multidisciplinary Cedars-Sinai Head and Neck Tumor Board, which provides consensus management options for complex, advanced cases. Dr. 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. Dr. Ho has published as lead author in journals that include Nature Genetics, JCO, JAMA Oncology, and Thyroid, and is Editor of the textbook Multidisciplinary Care of the Head and Neck Cancer Patient (Springer 2018). Dr. Ho serves on national committees within the AHNS and ATA, and leads a national trial on thyroid cancer active surveillance (ClinicalTrials.gov ID: NCT02609685). He maintains expertise in transoral robotic surgery (TORS), minimally invasive thyroidectomy approaches, and nerve preservation techniques. Dr. Ho’s overarching aim is to partner with patients to optimize treatment and provide compassionate, exceptional care.
In this interview — a discussion about Dr. Ho’s research; Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review. Topics include:
- prostate and thyroid cancer parallels
- prostate cancer and practical acceptance of active surveillance
- randomized and followed patients through true active surveillance
- overall survival, comparing thyroid and prostrate cancer
- tolerance of risk
- Older versus younger patient priorities
- Younger patient thought process
- Weighing quality of life and risk
- Hypothyroidism, parathyroidism, laryngeal nerve risk in thyroidectomy… asymptomatic patients being made symptomatic due to treatment
- Physicians have embraced active surveillance for prostate cancer more than thyroid
- The patient leans on physician for guidance
- The Finland study: 17M in U.S. have thyroid cancer
- Extrapolation — Patients who die of other conditions, in autopsies very small thyroid cancers found in 36% of patients
- A lot of small cancers that need not be diagnosed
- The physicians perspective and influencing the active surveillance decision
- Shared decision making process
- Terminology… some people choose active surveillance even when nodule is greater than 2cm
- Jury is still out on what is considered safe size
- Size and lymph node spread is still being defined
- Moving away from Gleason system
- Some cancers are aggressive
- Some cancers are slow and not lethal
- Incidental cancers
- The word cancer or the c word… and shifting away from fear
- Radiology guidelines
- The Cedars Sinai active surveillance program
- 50% of patients who are offered surveillance accept it… which mirrors Japan
- Alienation of active surveillance patients
- Anxious, calm, and risk and prioritize risks of surgery
- Thyroid cancer tends to strike younger patients. Prostrate cancer tends to be older.
- Prostrate cancer may not improve survival
- Surgery in thyroid versus prostate is safer
- Radiation ad toxicity
NOTES
Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review
77: Broadway Performer Says No to Thyroid Cancer Surgery → Surveillance Instead
Vigilancia activa en el tratamiento del microcarcinoma de tiroides.
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
- ¿qué es el microcarcinoma y qué es la vigilancia activa?
- Para aquellos que siguen el podcast de Doc Thyroid, es posible que conozcan mi historia, tuve una tiroidectomía y cáncer de tiroides.
- Cuando escuché la palabra cáncer de mi médico, creó miedo y ansiedad. Pero, ¿la palabra cáncer relacionada con el cáncer de tiroides es diferente? (papilar)
- ¿Puede decirnos cómo y por qué esto es cierto? Por ejemplo, en comparación con el cáncer de cerebro o el cáncer de páncreas ...
- ¿Cuántos pacientes con cáncer papilar de tiroides ves un año?
- ¿Cuántos pacientes con cáncer papilar de tiroides han muerto bajo su cuidado? (La intención de esta pregunta es reducir el miedo en la audiencia sobre la palabra cáncer)
- Cuéntanos más sobre la vigilancia activa ... es una nueva practica? ¿Y por qué estamos escuchando más sobre esto últimamente?
- ¿Cómo sabe un paciente si es adecuado para ellos?
- ¿Cuál es el tratamiento para los pacientes que eligen este tratamiento?
- ¿Todos los hospitales en América Latina ofrecen vigilancia activa?
- ¿Cómo puede un paciente encontrar doctores que lo ofrezcan?
- La Dra. Davies dice que algunos pacientes en su programa dicen sentirse "estúpidos" por dejar el cáncer en su cuerpo. ¿Hay apoyo emocional para aquellos que eligen Vigilancia Activa Microcarcinoma?
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
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
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
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