Surgery for Low-Risk Thyroid Cancer

Most thyroid cancer is small and slow-growing. Dr. Kenneth Burman shares why it's best to remove the cancer surgically before it has a chance to spread. TRANSCRIPT Intro: MedStar Washington Hospital Center presents medical intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. Host: Today I am joined by Dr. Kenneth Burman. Thanks for joining us today. Dr. Burman: Thank you very much for the invitation. I've been here about 20 years. It's really been a great experience. I've enjoyed it. We've had great support and we see a large number of thyroid patients and we have a big group so that gives us a lot of insight and experience regarding various thyroid issues. Host: And you've probably seen a lot of change in 20 years, I would think. Dr. Burman: Yes. Our ability in all of medicine to diagnose and treat diseases, especially cancer, has changed dramatically, and that applies to thyroid cancer as well. Host: For, especially, low-risk thyroid cancer, what shall we do? Should we have surgery, or should we do active surveillance? What, what do we mean by active surveillance, to begin with? Dr. Burman: You, you happen to hit a very controversial area. So, until about 5 or 10 years ago, we would treat most thyroid cancers the same and specifically I am talking about papillary thyroid cancer and not talking about other types of thyroid cancer such as medullary cancer and anaplastic cancer, which are totally different diseases. So, focusing on papillary thyroid cancer which accounts for about 90 percent of all thyroid cancers, in general, it's an indolent disease that's picked up by identifying a nodule in a patient's thyroid, biopsying it, showing that it's likely cancer or is cancer, and then recommending surgery. The surgery could be either removing the whole thyroid gland or a portion of the thyroid gland and then, in some cases, administering radioactive iodine therapy. And those have been the time-honored treatments and assessments for papillary thyroid cancer. But what's happened in the last five to 10 years is that it's recognized that the vast majority of patients with papillary thyroid cancer do well, the mortality rate is low, probably less than 3 to 5 percent over 10 to 20 years, and it's especially low in most younger individuals. So, we don't want to expose people to unnecessary diagnosis and treatment modalities that they may not need. So, the issue is, or isn't, that there are a group of patients with slow-growing indolent thyroid cancers that we could just watch? The answer to that question is unknown at the present time. There are various clinical trials around the country, especially in New York, where they're taking the patients with small papillary thyroid cancers, doing a biopsy and not operating and just monitoring those patients. But the outcome of those results will take many years, maybe decades, to determine whether that's the appropriate course. In summary, the answer to your question is if we can identify a young, healthy patient with no other risk factors for thyroid cancer that would make it grow, and the thyroid cancer is small, meaning less than one centimeter, and the patient is willing to be monitored, there are some physicians, especially in a clinical trial, that would just monitor that patient with sonograms every 3 to 6 months for an indefinite period of time and follow it and if the nodule increased in size by about 20 percent or 30 percent or more they would then re-biopsy and then consider surgery. The standard of care, however, in the United States at the present time is to identify a thyroid cancer and to perform surgery. If it's a small papillary cancer that appears to be indolent, it's perfectly appropriate to do a lobectomy alone and leave the other lobe intact. If it's more aggressive cancer you might want to (or larger cancer) you might want to do a total thyroidectomy. Host: So, what would be the advantages to not do surgery? Dr. Burman: Well, first of all, with regard to surgery, surgery must be performed by an experienced thyroid surgeon. And it's an interesting observation that approximately 90 to 95 percent of thyroid surgeries in the United States are performed by surgeons who do 5 or less a year. So, you certainly want to go to an established institution with experienced thyroid surgeons. The risk of complications of thyroid surgery, even of taking out one lobe, include permanent or temporary low calcium and permanent or temporary hoarseness as the two most common complications that are still relatively uncommon. In experienced hands, they occur in less than 5 percent of patients, but in less experienced hands, the risk is much higher. So, for the population of the United States as a whole, if you find a small papillary thyroid cancer, and you don't have access to an experienced surgeon, the question is, is it safer to just monitor those patients and if the nodule grows and may cause more impingement of surrounding tissue, to then operate. That isn't the standard of care in the United States at the present time, but some physicians are doing that and there are active monitoring clinical trials. Host: And what's your stand? Do you typically recommend surgery since it's the standard of care, or do you ever recommend monitoring? Dr. Burman: In the vast majority of cases, our approach is to note that the mortality rate from thyroid cancer under present treatment and diagnosis regimens is really good. The prognosis is really good. The mortality is very low. The morbidity is relatively low as well of recurrent disease, so it makes most sense to us to, once you diagnose thyroid cancer, to recommend a lobectomy, but especially in patients who are otherwise relatively healthy and have a nodule that is more than 5-10 millimeters. Of course, there are exceptions. If a patient is 80 years old and has metastatic cancer from another cause, or heart problems, you're going to temper your advice appropriately. Host: So, just to clarify, you do recommend, typically, the more surgical approach, correct? Dr. Burman: Correct. Host: Yup. And how do you talk about this with patients? Do you give them the options? Dr. Burman: Well, first off, you have to have a great relationship with your surgeons. We have 3 excellent endocrine surgeons who do approximately 700 to 800 thyroid cases a year in total. So, they're very, very experienced and very interactive, and we present most of our complicated patients in a conference where there's a multidisciplinary approach. So that is optimal in this circumstance helping to make a decision about the appropriate course of therapy. It's the surgeon themselves and the patient that make the final decision whether it should be lobectomy or total thyroidectomy, but it's the whole team, including endocrinologists, that decide whether the patient should be sent for surgery in the first place. Host: What other things should people consider? Dr. Burman: I think the most important thing is the experience of the surgeon and interaction with the endocrinologists and surgeon with a full discussion of the advantages and disadvantages of each approach of monitoring versus lobectomy. Host: Thank you so much for coming on the show today and sharing your knowledge on low-risk thyroid cancer options. Dr. Burman: Thank you for the invitation. 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