Search for tag: "thyroid"

Dr. Jones: "It brought a lump to my throat." This is a phrase that usually implies an emotional response to something. But what if there's really a lump in your throat? Or really a lump in your neck? This is Dr. Kirtley Jones from Obstetrics and Gynecology at the University of Utah Health, and we're talking about thyroid cancer and women today on The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Most of the time one of our most important hormone glands in our body just does its thing without us feeling it. For women, men are another story, the thyroid is the only gland that we can touch with our fingers. It's sort of a flat butterfly-shaped gland about two inches across in the front of our neck in front of our throat. It regulates the metabolism at every cell in the body.

Millions of women have thyroid problems, the most common being under or overactive thyroid. The majority of people in the United States with thyroid problems are women. We're not sure why that's the case except that most thyroid problems are due to autoimmune disease, antibodies that we make against part of the thyroid gland. All autoimmune diseases are more common in women.

Over and underactive thyroid symptoms are vague. The symptoms are feeling cold or slightly depressed. For underactive thyroid, feeling hot, your heart pounding and anxious, maybe weight loss are common for overactive thyroid. Sometimes the thyroid is slightly enlarged with over or underactive thyroid problems, but thyroid cancer presents as a lump. Sometimes the lump is noticed by the patient, but sometimes it presents with hoarseness of voice or difficulty swallowing, and sometimes the lump is detected by a clinician during a physical exam.

It's important to know that lumps in the thyroid are very common, and only 5% to 10 % of lumps in the thyroid in women are cancer. Now, thyroid cancer is the most cancer in women 15 to 30 years of age and is the second most common cancer after breast cancer in women under 50. Seventy-five percent of all thyroid cancers occur in women. And thyroid cancers generally happen younger in women than men.

There are a number of risk factors for thyroid cancer, the majority of which you can't change. I already mentioned that being a woman is one of them and you mostly can't change that. There are families that have genetic mutations that make cancers more common, and thyroid cancers are part of that family risk.

Another risk for thyroid cancer is exposure to radiation, especially as a child. The most common reason for a young person to have radiation exposure these days is because of radiation treatment for another cancer when the person was a child. Also, for those of us who grew up in the Intermountain West, the increased exposure to radiation from nuclear testing in the 50s is associated with a slightly increased risk of thyroid cancer. And of course exposure to an accident at a nuclear power plant that releases radiation can increase the risk, but this is uncommon.

Finally, children with a low diet in iodine are at an increased risk, but that's uncommon in the U.S. because table salt and sea salt have iodine and iodine is found in fish and is added when salt is added to some foods. Now, if you have a lump in your thyroid or an enlargement in the front of your neck where your thyroid is, you should see your doctor. The doctor will feel your thyroid, do a blood test to check out the thyroid hormones, and sometimes check a blood test to see if you have antibodies to your thyroid.

If there's any question of a lump in the thyroid, an ultrasound of your thyroid is the next step. If the ultrasound shows a lump, the next step could be to collect cells from the lump with a small needle. Now there's some controversy about when to do this test. So many thyroid lumps or nodules are totally benign. If the lump is less than a half inch or about one centimeter, most experts would just recommend watching it over time, unless of course you have a family history of thyroid cancer. In that case, you really need to watch things more carefully and the biopsy would be right.

If it's over an inch, most experts will recommend a biopsy. Now, if the biopsy shows cancerous cells, the next step is surgery usually to remove the thyroid and make sure the cancer hasn't spread to the lymph nodes. If it's spread, the next step can be radiation. It's most important to know that thyroid hormone can be easily and inexpensively replaced with a pill if you've had your thyroid removed. The other important fact, and listen up, is that thyroid cancer in young women is very curable with over 90%, survival for 20 years. So thyroid cancer is one of the most curable kinds of cancers.

So if you have a lump in your throat, first check out and make sure it isn't really your adorable child or the movie you're watching, but if it really is a lump in your neck, and bring it to your attention to your doctor. The chances are highly likely that it isn't cancer, but it should be evaluated. And if it's found to be thyroid cancer, it's often easily cured in women, and that's the best news. And thanks for joining us on The Scope.

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Interviewer: Your primary care doctor told you that you have thyroid nodules. What should you do now? Dr. Dev Abraham is a Medical Director at the Utah Diabetes and Endocrinology Center.

A lot of times, Dr. Abraham, from what I understand, people find out about these thyroid nodules while the doctor was looking for something else and then they're told, "You have thyroid nodules." Should that person worry at that point?

Dr. Abraham: They shouldn't worry, but at the same time, they should have a very careful and judicious evaluation. What do I mean by that? Almost a third to half of US population can have thyroid nodules. And fortunately, the vast majority of thyroid nodules are benign thyroid nodules. So if one looks at how common thyroid cancers are in nodules, it is about 4-8% on an average. So 4 to 8 out of 100 nodules turn out to be thyroid cancer.

Interviewer: So if somebody had one of these incidental findings of a thyroid nodule, they should make an appointment with somebody such as yourself, an endocrinologist?

Dr. Abraham: Yes. Most endocrinologists are capable of evaluating patients for thyroid nodules.

Interviewer: And then, when they come into your office, what types of things will you do to evaluate to see if it's cancerous or not?

Dr. Abraham: We look at their clinical risk profile. Patients who have been exposed to external beam radiation, typical external beam radiation exposure occurs in some cancers, such as Hodgkin's Disease and leukemias for children. Or disasters such as Chernobyl and recently the Fukushima Daiichi Plant disaster in Japan. All of these radiation exposures can increase patient's risk for developing thyroid nodules. Also, if there is a strong family history of thyroid cancer, that is also a risk factor for careful evaluation.

So we look at the risk factors in patients and also the size and features of the nodule. And we perform what is called fine needle aspiration biopsy during the same visit.

Interviewer: And is there a time when you might just watch to see if they continue to grow?

Dr. Abraham: Yes. Very small nodules, we generally don't do biopsies or nodules with the certain benign characteristics on ultrasound.

Interviewer: And then what about those nodules that turn out to be not cancerous? Is there any other harm to leaving them there?

Dr. Abraham: There is really no harm, but we do recommend some surveillance over duration of time simply because in patients who have developed one nodule in a thyroid gland, they are at risk of developing other nodules. And some of the nodules that come about in the future may not start in an innocent manner. So we do recommend some surveillance. The frequency you'll have to discuss with your physician on a case-by-case basis. They would tailor it to your risk factor profile.

Interviewer: Are there any questions, common questions or concerns people have that I haven't addressed?

Dr. Abraham: Recently, it came to recognition of the frequency of thyroid cancer in general population. This is following a study that came out of South Korea, where they were actively screening for other cancers such as breast and colon and stomach, etc., and lungs. They also added thyroid cancer as a part of added screening or a value added screening. What they found out was, they diagnosed a whole bunch of sub-clinical, minute thyroid cancer in general population and they subjected a vast amount of Korean population to surgery. When in fact they came to harm by actually going through the surgery than from the cancer itself.

So now we know that what we call this microscopic, or sub-clinical, thyroid cancer is literally common in general population that we cannot even use sometimes an ultrasound to diagnose. And these cancers coexist with us and we die of something else. And simply diagnosing these causes more harm is what came out of that study.

So increasingly in the US, there is a view that is coming that even if there is a small thyroid cancer that was diagnosed by biopsy or a small nodule, we choose not to even do the biopsy and we watch these patients because surgery is not a completely safe procedure, even in the best surgical hands. There is a certain percentage of a chance things can go bad. So that's an important thing that should be discussed with patients.

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updated: February 27, 2019
originally published: April 13, 2016

Interviewer: Could it be a thyroid problem that's sabotaging your diet and weight loss plan? We'll find out next on The Scope.

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Interviewer: You've been trying to lose weight but you're just not seeing the results that you would like to see and you've been at it for a little while. Now, you're starting to wonder if there's something else in play like maybe it's a thyroid problem that's sabotaging your weight loss. Dr. Dev Abraham is the Medical Director of the Utah Diabetes and Endocrinology Center. So could a thyroid problem sabotage my diet and weight loss plan?

Dr. Abraham: There's a little misconception with regards to thyroid and weight connection. If you look at the older textbooks, it is very categorically stated that it is the cause of weight gain. So in another words, if someone gains weight, they must have thyroid problem. It's not necessarily true in modern times for several reasons.

The number one reason is in olden days they didn't have an accurate way of testing thyroid dysfunction with blood tests, let alone reliable, reproducible blood tests. In the last 15, 20 years duration, we have super accurate thyroid blood tests so it's very easy to determine whether weight change a person may experience is due to thyroid or not.

If you look at how much weight patients gain when you don't take thyroid hormones for months, it's really a small amount on an average of few pounds. If someone gains 50 pounds, 100 pounds over a span of a year or two years, it's uncharacteristic for a thyroid hormone imbalance to do that.

Interviewer: It's something else at that point.

Dr. Abraham: It is usually something else. But thyroid is often the first test that's often done because it's a very simple and easily available test. And it's also very, very treatable. So even if that much weight gain cannot be attributed to thyroid, if these patients have mild abnormality of the thyroid we still try to treat it first because it's a simple remedy.

Interviewer: So in the instance of somebody trying to lose weight and we're taking them at their word that their diet is on, their exercise is on, but they're not losing weight, could it be a thyroid problem that's causing that?

Dr. Abraham: It should definitely be tested, but if the test comes negative for thyroid dysfunction, that virtually rules out thyroid as a cause for the weight fluctuations.

Interviewer: And as a physician, how often have you seen thyroid being responsible for somebody not being able to lose weight or putting on weight unexpectedly?

Dr. Abraham: A very, very small percent.

Interviewer: Oh, really?

Dr. Abraham: Yes.

Interviewer: So it's a whole different kind of thinking than it was?

Dr. Abraham: It is, absolutely. If you look at the amount of weight gain that the society is experiencing, which is stated to get worse, it's quite astronomical. If only thyroid is the problem for this weight gain, we literally would be able to cure obesity.

Interviewer: With a pill.

Dr. Abraham: With a pill.

Interviewer: And that's what we want.

Dr. Abraham: And that hasn't occurred because the thyroid is usually not the single main cause.

Interviewer: So it sounds like, unfortunately, if I've been trying to lose weight and I'm not losing weight and I think everything else is right, it's probably not going to be my thyroid.

Dr. Abraham: That is a fair statement to make with a few exceptions. If there is a strong family history of thyroid dysfunction, in particularly female members of the family, or if there has been unexpected thyroid abnormality after childbirth, in those subjects, at least a test should be done before making that determination whether it is the thyroid or not. But it is accurate, in most patients if there is weight fluctuations, that's independent of thyroid. At least in the current day situation.

Interviewer: So look someplace else? Maybe I just need to exercise a little harder.

Dr. Abraham: Well, exercise is extremely important to lose weight but if you, for example, walk on a flat surface, you expend the equivalent of a slice of breads worth of calories. So one extra pound weight gain during Christmas, for example, can have the equivalent calories of about 3,500 calories. Which is about walking on a steady pace for about 35 miles.

So to expect weight loss purely by exercise is a very difficult process. But a combination of caloric restriction and adding some exercise has a multiplying effect with regards to weight loss. So most of the programs that are offered through the Utah Diabetes and Endocrinology Center focus on a whole health improvement with regards to dietary modification, exercise and caloric restriction without becoming deficient in micronutrients.

Interviewer: And sometimes it just takes time?

Dr. Abraham: It does take a longer time than most patients anticipate with weight loss and they give up sometimes. And that's what we try to encourage, any small loss is still a step in the right direction.

Interviewer: What about those individuals that they have been really religious but they're not losing anything? They're not gaining but they're not losing.

Dr. Abraham: It's a very complicated mechanism of why an individual gains weight. What we're beginning to understand is that there is a reset mechanism of how much calories does one need to feel full. In other words, these are probably mechanisms and centers in the brain that reset and we always feel hungry when there are enough calories that are retained in our system that we haven't burned yet. So researchers are still working on it. So it appears to be multiple factors that are involved.

Interviewer: And your piece of advice to that person still trying to lose that weight?

Dr. Abraham: A multi-pronged or multi-disciplinary approach works the best. You cannot change your genetics, it's too late to choose your parents, but at the same time, you can work with what you have if you have a plan about it. Sometimes, it does involve including professionals who are skilled in those fields to guide patients to decide the right thing. Not one cap fits all in this situation. So we try to modify what works best for each patient.

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Interviewer: Thyroid Cancer, what is it, what causes it, what are the signs, and what can you do about it? That's next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Marcus Monroe is a head and neck cancer expert at University of Utah Health Care. Today, it's thyroid cancer. First of all, let's just start out with, what is your thyroid and then we'll get to what is thyroid cancer.

Dr. Monroe: So your thyroid is an endocrine gland. It's a gland that's located in the neck, just above the collar bones. It's a butterfly shaped gland and it crosses over your windpipe. Its main functions are actually quite broad. It is involved in regulating a variety of bodily functions, including blood pressure, heart rate, body temperature, energy use, metabolism. In a very basic way, your thyroid gland can be thought of as your body's thermostat.

Interviewer: And then what causes... what is thyroid cancer? Other than cancer of the thyroid.

Dr. Monroe: Yes, so thyroid cancer is actually a group of cancers. The most common types are termed well-differentiated thyroid cancer, include papillary thyroid cancer, follicular cancer, and these account for over 95% of all thyroid cancers. There are rare, inherited types of thyroid cancer called medullary thyroid cancer and then some rare aggressive variants called anaplastic thyroid cancer.

But in general, when most people speak of thyroid cancer, they're most commonly referring to those most common types of follicular and papillary thyroid cancer. Something we've demonstrated in research that is that is done here at University of Utah, demonstrating in small but increased risk of even these well differentiated thyroid cancers in family members of patients with thyroid cancer. And that's been known before, that there is probably a family link. For the medullary thyroid cancer, there is a very clear genetic component associated with mutations in the RET gene, so that's a little bit different entity but also has a very strong genetic link.

Interviewer: And, as a result of that stronger genetic link, if you know that that's in your family then you should be a little bit more aware of that, I suppose?

Dr. Monroe: Yeah, it's something to be aware of.

Interviewer: So what else causes it? There can be a genetic component, what else?

Dr. Monroe: The majority of patients we know of no specific genetic component. The number of environmental exposures that have been associated with thyroid cancer are actually pretty few. The one that has really been conclusively demonstrated is the previous exposure to radiation, and we know that from some of the follow-up studies that have been done in areas that have had nuclear fallout, like the Chernobyl region, have seen vastly increased rates of thyroid cancer.

Interestingly here in Utah, there have been studies done that have demonstrated higher rates of thyroid cancer, particularly in areas that have nuclear fallout from the nuclear testing that was done in Nevada in the 1950s and '60s.

Other risk factors for thyroid cancer that aren't quite as well established include female gender, so we know that thyroid cancer is more common in females and is thought to potentially be related to some hormones, but that hasn't really been worked out. And we also have a link with obesity. We see an increase in thyroid cancer with an increase in obesity, although these links are not as strongly linked as the one with radiation.

Interviewer: What are some of the signs? What am I looking for? How do I know that I might need to Google something or go to my doctor?

Dr. Monroe: Yeah, so thyroid cancer is a little unique in that the vast majority of patients are asymptomatic and have thyroid nodules discovered either on a routine exam for some other condition or an imaging studies performed for a completely unrelated diagnosis. Specific signs of thyroid cancer can include a lump in the neck, changes in voice or swallowing, or rarely, coughing up blood. But the vast majority of patients are actually asymptomatic at the time of diagnosis.

Interviewer: So what should somebody do if their physician had done some other tests and discovered that they actually do have a thyroid nodule?

Dr. Monroe: The first thing that's important to realize is that thyroid nodules are incredibly common. They increase with age and, in fact, if you look with sensitive measures like ultrasound, over 50% of people will have thyroid nodules by the age of 50 or 60. So an incredibly common condition.

Interviewer: So it doesn't mean cancer?

Dr. Monroe: It does not mean cancer. In fact, the risk of cancer in any individual with thyroid nodules is actually quite low, somewhere in the range of 5 to 10%.

Interviewer: So that's kind of nice to hear.

Dr. Monroe: Yes. So I think it's nice. Now, as of right now we don't have great ways of differentiating them other than characteristics on the ultrasound and by biopsy. So for patients who are diagnosed with a thyroid nodule most will be referred to an endocrinologist or a surgeon who specializes in thyroid cancer for evaluation of the characteristics of the nodule as well as their thyroid gland function.

The testing typically begins with measurement, a blood test to measure your thyroid function, and then, in most cases then an ultrasound. There are very specific criteria that have been laid out that demonstrate which nodules harbor an increased risk of thyroid cancer and which nodules should be biopsied, so not all nodules need to be biopsied. Those that are larger in size or have worrisome characteristics by ultrasound, the next step is to then attain a fine needle aspiration, which is a small biopsy with a needle that can be done in clinic.

Interviewer: So a nodule doesn't necessarily mean cancer. If it is diagnosed and it is determined that there is cancer going on, what would be the steps after that? What's the treatment look like?

Dr. Monroe: The treatment for thyroid cancer typically involves surgery. Depending on the size and location of the cancer within the thyroid, that may involve removing either half or the entire thyroid gland. Occasionally, removal of regional lymph nodes is required if the cancer has spread to the lymph nodes or if there's a particularly high risk of cancer spreading to the lymph nodes.

Once surgery is over, a select group of patients that are at higher risk may need additional therapies. The most common of those is radioactive iodine, which is a pill that can be taken afterwards that has radiation tagged to an iodine molecule. Now the thyroid is a little bit unique in that it takes up this iodine and can concentrate the radiation to kill any remaining thyroid cancer. That's really only used in patients that are deemed higher risk for the cancer coming back afterwards.

Interviewer: And what's life look like after thyroid cancer treatment?

Dr. Monroe: The good news is that if we look at all the different shades of thyroid cancers, the most common thyroid cancer rates of survival are excellent. Survival rates at 5 and 10 years are well above 95%. Survival is great. The unfortunate thing is that we don't really have a lot of data on what sort of health problems people have after treatment, so that remains an unanswered question. But in the vast majority of cases, patients are able to go back to their normal life and function normally.

Interviewer: So for the most part, quality of life after the treatment

Dr. Monroe: Yeah, as far as I know--

Interviewer: Is normal, unaffected?

Dr. Monroe: Yeah.

Interviewer: Any final thoughts? Anything you wish I would have asked or anything you feel compelled to say?

Dr. Monroe: I think the important thing to realize is that, because survival is so good, nodules are so common, thyroid cancer is not something we recommend screening for. In fact, if we look at countries that have started screening for thyroid cancer, we see some really interesting findings. So if we look at South Korea, for instance, they started a screening program for cancers in the '90s and, as part of that, many hospitals offer ultrasound based thyroid screening. And what they have found is that thyroid cancer has now become the most common malignancy in that country, far surpassing any other cancers.

The interesting thing about it is the number of people who die of thyroid cancer has remained unchanged. So I think it's really important when we talk about screening for these cancers is that to realize that one, these cancers are actually very common, and two, they are unlikely to affect a person significantly during their lifetime. There's general though that, in many cases, the risks of screening and all the testing and biopsies that need to go into finding these nodules probably outweighs any benefit.

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