Thursday, April 13, 2006

Who Should Take Care of Your Thyroid Nodule or Cancer?

There has been a big shift in the way thyroid cancer should be treated, and nodules evaluated. Before your primary care physician, referred you for studies, and only when it was obvious it was a nodule or cancer, did they refer you to others. In the past it was felt the obvious referral was to an endocrinologist, even though many PMD's sent you directly to a surgeon. The endocrinologist sent you for an ultrasound at the hospital radiologist's office. He sent you for a scan at the nuclear medicine department, and did a biopsy without ultrasound guidance in the office. The Endocrinologist sent the slides to the hospital for review. Then if the diagnosis was suspicious, atypical, or indeterminate, or frank cancer, he sent you to his local general surgeon. After the surgery, the endocrinologist deferred to the nuclear medicine physician, or the radiologist about the need and extent of radiation therapy. The NM physician almost always recommended Therapy.
The physicians treating you would return you to your primary care, who would monitor your thyroid hormone therapy.

What is wrong with this?

There is defects in the care of the thyroid nodule or cancer patient at each and every phase of this protocol.

1. The PMD should seek expert help ASAP, and not waste time with testing that is not needed or a waste. Feel a lump = refer! The best expert is a clinical thyroidologist, or endocrinologist with certified training in the personal use of ultrasound and nuclear medicine.
2. The PMD, or the patient needs to learn who is available with training in
interventional thyroidology, and refer direct to that physician. The main clue, is the endocrinologist trained in US, and USG biopsy by American College of Endocrinology? Radiologist, and nuclear medicine physicians, with their technicians are not the ones to be doing studies on your patients. The personal hands on clinical thyroidologist, or endocrinologist that is certified by ACE is the right person for your patient.
3. Before sending the patient to surgery, request a second opinion on the pathologist. There is a very wide variation in their ability to read thyroid biopsies. The overuse of a suspicious report, has resulted in too many needless surgeries.Even pathologists will tell you that thyroid is one of the hardest slides to read for them. Beware, and get another opinion.
4. Before surgery, you need to have several things done. First, a pre-op Cancer marker. That is a thyroglobulin TG. Make sure it was drawn BEFORE or 30 after the FNA, as it can be elevated by the trauma of the FNA biopsy.
5. Then, if the biopsy is positive, or very stronly suggestive of cancer, be sure to have a pre-op Lymph node evaluation by ultra-sensitive ultrasound, done by your trusty clinical thyroidologist, or US certified endocrinologist. The finding of abnormal cancer nodes, proven by cytology, and or washings for thyroglobulin will change the extent of the surgery needed 40% of the time.
4. If you are satified that your patient has a high likelyhood of cancer, then research to find the closest thyroid surgeon. A thyroid surgeon is one who dose 50-150 thyroidectomies a year, and certifies that a central compartment node removal will be standard in all his cancer cases. It will be worth a drive or flight to the nearest real expert. Failure to remove the central compartment nodes will result in an increased recurrence rate for years afterward. Finding lateral neck nodes on the pre-op node US will result in a lateral neck node removal at the time of the initial surgery.
5. Post surgery care is not the place to rely on the oncologist, surgeon,radiologist, or nuclear medicine physician. Oncologist treat other cancers, not thyroid cancer, which is a hormonal cancer, best treated by thyroid experts. NM types are still passing out high doses of radiation, and making people sick with thyroid hormone withdrawal for useless total body scans in low risk cases. Radiation is no cure, and can cause solid tumors and blood tumors years later, when it is unnecessary in low risk cases. Yearly bouts of severe symptoms of thyroid withdrawal, to get a total body scan, when they are clearly not needed, in most cancer cases is cruel and unnecessary today. Cancer markers,and Ultrasensitive US done by real thyroid cancer experts is the best way to follow thyroid cancer today.
Careful staging by the thyroidologist will be the first step to decide the extent of the further therapy.
6. The therapy with radiation, and the use of thyroid hormone as "chemotherapy, not just replacement, is and should always be under supervision of the clinical thyroidologist, until there is clear indication that the disease is under control.
That is when the TG is non-detectable on TSH suppression, and in in some expert's hands, stays that way after Thyrogen stimulation ( rh TSH ). TSH must be suppressed until it is clear the patient is safe. It is not O.K. to have a TSH in the normal range, if there is clear evidence of disease, by elevated TG.
7. No one cares more about the status of the cancer, and nodule patients under their care, than a hands on clinical thyroidologist, or a ACE certified US endocrinologist.
8. Failure to seek the new age clinical endocrinologist or thyroidologist may result in future problems for your patients.

Good Luck,

Richard B. Guttler, MD,FACE
Academy of Clinical Thyroidologists
Clinical Professor of Medicine
Keck School of Medicine
University of Southern California
Sanatr Monica Thyroid Center

No comments: