In this episode of PodMD, experienced Endocrine Surgeon and Surgical Oncologist A/Prof Anthony Glover will be discussing the new way to treat thyroid nodules, including initial diagnoses, when to refer, the likelihood of recurrence from treatment and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Anthony Glover, Dr Glover is a practicing Endocrine Surgeon and Surgical Oncologist. Anthony specialises in the care of thyroid, parathyroid and adrenal disease, endocrine cancer biology and the development of surgical competencies and professional skills.
Today, we’ll be discussing the topic of new ways to treat thyroid nodules
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Anthony, thanks for talking with us on Pod MD today.
Anthony: Thank you for having me
The topic of today’s discussion is new ways to treat thyroid cancer. Anthony, just quickly give an overview of thyroid cancer here?
Anthony: Yeah. So thyroid cancer was once regarded as a rare cancer, but it’s now the seventh, most common cancer in Australian women. And most thyroid cancers are well-differentiated and called thyroid cancers, which rarely cause death, but they cause significant problems due to recurrence and locally invasion. And they co more commonly in women in about four to one ratio. There are other rare forms of thyroid cancer, um, which a follicular poorly differentiated and anaplastic thyroid cancer.
What is initial diagnosis like? Do you have any red flags you see in clinic?
Anthony: So, most thyroid cancers are picked up incidentally. So, when a patient has a scan performed for another reason, so quite commonly, a patient may have a scan for a sore throat or a problem in their neck. And then they’re found to have a thyroid nodule, um, which is suspicious on imaging. Um, when third cancers get more advanced, they can present with a hard mass in the thyroid or signs of invasion, such as a hoarse voice, uh, which can be due to invasion of the recurrent laryngeal nerve, which is next to the thyroid and provides the motor nerve supply to the larynx, uh, which, uh, is important for voice. So, the red flags would be any signs of local invasion, um, such as a hoarse voice or difficulty breathing.
What were the treatments widely available? And what are available now?
Anthony: Yeah, so traditionally thyroid cancer was treated with a one size fits, all kind of approach. Um, and classically that was to remove the entire thyroid. So, um, a total thyroidectomy and many patients as well after that received radioactive iodine treatment. But we now know that for many patients were over-treating them. Uh, and for some patients, they have a worse quality of life, um, following this approach. So today there’s a wide range of different treatment options available, which can be from active surveillance, which is just watching small cancers to Hemi thyroidectomy, or removing half the thyroid for low-risk cancers. And then the more traditional total thyroidectomy for higher risk cancers in the last 10 years, we’ve also seen, uh, the introduction of a number of new medications, which can treat and downstage thyroid cancers, such as Ric inhibitors and tyrosine kinase inhibitors. So, patients previously that were not suitable for surgery and now are responding to these medications and able to have surgery, which greatly improves their quality of life
What are the advancements in treatments?
Anthony: Yeah, so I think the big advancements definitely one is active surveillance. So that’s a treatment program where instead of removing a small cancer, which is usually less than one centimetre, you can observe the cancer. Um, so that was first characterized in Japan, where they’ve been doing this approach for about 30 years now. And what they’ve found is that patients with these small cancers, very few of them progressed. So about one in 10 will progress. And if they do progress, it’s, the cancer may get a bit bigger or they may get some involved lymph nodes, which can still be treated by surgery. So, for some patients who don’t want to have surgery and who are willing to be followed up, that’s a great advancement for them. There’s also a big advancement in person personalizing care bait based on what the patient’s risk is. Um, and also what their preferences are for follow-up between having their whole thyroid removed or half their thyroid removed for surgery. And then as I mentioned, there’s these new medications, which are really exciting, which can downstage more advanced local cancers
Who is applicable for each treatment
Anthony: Yeah. So, for all these treatments, it’s decided in each treatment, it requires a very careful assessment of both the cancer and a shared decision-making approach with the cancer, with the patient. Um, so the example of active surveillance, so for these small cancers, there are any suitable would be observed in particular situations. So, we have to, when we look at the cancer and look at it under the ultrasound, we need to think about where it is in the thyroid and what might happen, where if it would grow.
So, if the cancer is right next to the trachea and next to the area where the recurrent laryngeal nerve is, that’s not going to be a suitable cancer for active surveillance, whereas a cancer that’s away from the trachea and it’s inside the thyroid. So intra thyroidal, um, would be a good, um, could be a good cancer active surveillance. And it also depends on the patient as well with active surveillance, patients need regular ultrasound, so they need to be motivated and they also need to have that desire to avoid surgery and be willing to have regular follow-up
What is the likelihood of recurrence from each treatment?
Anthony: Yeah, so they, they don’t change the biology, but the thing is because we understand the biology better, we can better type, uh, the treatments we offer our patients. So, for these small cancers that are one centimetre or less the chance of them, um, so growing, um, or for the patient to develop some, uh, lymph node metastasis next to the thyroid is around 10%. Um, so as I was saying before in Japan, they’ve been doing this treatment for about 30 years and they haven’t had any patients that have progressed, um, and died from this approach.
So, it is quite a safe approach. And for some patients, they are willing to accept that risk. Obviously other patients are not as willing to accept that risk. Interestingly, um, for young younger patients, there is a higher chance that will progress. Um, so they may not be as willing to, to take that active surveillance approach for the higher risk cancers. Their account’s rates, um, can be around 20 to 30%, which can be reduced by the more aggressive traditional treatment with total thyroidectomy and radioactive iodine ablation. So, I think all these different treatments really offer an approach for the patients to decide what’s best for them, um, depending what, what they want from their treatment, uh, and avoiding medication, uh, and also deciding what risks they’re willing to take as part of their follow-up
When should a GP refer?
Anthony: So, I think with thyroid cancers, the decision making can be quite complex. And I think all patients with a suspected thyroid cancer should be referred to a clinician that has experience in dealing with thyroid cancer. And it’s important that those clinicians are involved in a part of an MDT to ensure patients can explore the different treatment options and work out which treatment is best for them. And that depends also on the characteristics of their thyroid cancer as well. Um, so there’s quite a few different options. So usually, it’s probably best that clinicians that treat at least 25 thyroid cancers a year, um, uh, involved in those discussions with their patients so they can fully advise them what is likely to happen with each treatment
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on a new treatments and advancement for thyroid cancer
Anthony: So, I think the first thing is now thyroid cancer is one of the most common cancers in Australian women. Uh, and the incidence is continuing to rise, uh, mainly because we’re finding more of these cancers, um, through scans. The second point is that there’s multiple treatment options depending, um, available depending on what the patient’s wishes are and the character characteristics of the cancer, um, especially its size and its location. So, I think it’s essential that patients, when they’re deciding on treatment, they have the opportunity to discuss these options with clinicians and with their family that have experience with all these treatments and, and decide which is best for them. Finally, I think the new medications such as the req inhibitors mean that patients with advanced disease, which in the past were not operable and are able to be down staged making surgery possible and adding another treatment option for these patients
Thanks for your time and the insights you’ve provided.
Anthony: Thanks for that