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Doctors are seeing more patients with thyroid cancer in the last 30 years, as data from the American Cancer Society show. Thyroid cancer is the fastest-growing cancer diagnosis in the United States. The vast majority of these cases are papillary thyroid cancers, which are more common in adults between the ages of 30 and 50 and more common in women than men.
For many years, we’ve handled these cases the same way:
- A growth, or nodule, appears on a patient’s thyroid
- We perform a biopsy, which involves taking a sample of the nodule’s tissue
- If the biopsy confirms that the nodule is cancerous, we recommend surgery, which can involve removing either part or all of the thyroid
But in the last five to 10 years, we’ve found that patients whose thyroid nodules aren’t considered aggressive both clinically and cytologically tend to have a low risk of symptoms or death over long periods of time. As we find more of these small, slow-growing thyroid nodules, researchers have begun to study whether it’s better in these cases to practice active surveillance, also known as watchful waiting.
As of August 2017, there are several clinical studies measuring outcomes for patients with low-risk thyroid cancer who decide to closely monitor their cancer instead of having surgery. But prospective, controlled trials will take years or decades to show their full results. In the meantime, I recommend surgery for the majority of my patients who have low-risk thyroid cancer.
LISTEN: Dr. Burman discusses low-risk thyroid cancer further on the Medical Intel podcast.
The advantages of thyroid surgery
Surgery is the standard treatment for thyroid nodules that we identify as being cancerous, and surgery has a high chance of successfully treating the patient’s cancer. For small nodules, our surgeons may be able to perform a lobectomy, which involves removing only part of the thyroid. For aggressive, larger cancers, we may need to consider a total thyroidectomy, in which we remove the entire thyroid.
We have to consider each patient’s health before recommending surgery. Any surgical procedure involves risks, and patients who are younger and healthier tend to recover more quickly after surgery. Thyroid surgery, even in experienced hands, can rarely lead to several possible complications to include:
- Hoarseness or voice changes
- Neck pain
- Trouble breathing or swallowing
- Low serum calcium
One of the most important considerations for patients with thyroid nodules is the experience level of their surgeon. Just like any skill, the more you do something, the better you tend to become at doing it. In a February 2017 study, researchers looked at surgical outcomes of patients who had a total thyroidectomy, or a removal of the entire thyroid. Patients whose surgeons didn’t perform many thyroidectomies were more likely to have longer hospital stays and complications after surgery as compared to patients whose surgeons were more experienced.
When indicated, I can confidently recommend thyroid surgery for my patients in part because of our thyroid surgery team’s vast experience. Our three thyroid surgeons perform around 600 thyroid surgeries each year, which means patients are more likely to have shorter hospital stays and better outcomes after surgery.
In addition, we discuss our most complicated thyroid cases at a regular team conference, where we can gather input from other specialists and get insights to share with our patients. This helps us make sure we’re giving patients all the options, so we can make informed decisions about their care.
Why might someone want to wait on thyroid cancer surgery?
We diagnose more cases of papillary thyroid cancer today in part because of improved imaging technology, such as thyroid ultrasounds. Most thyroid cancer is slow-growing and doesn’t cause pain or difficulty right away for patients.
Most #thyroidcancer is slow-growing and doesn’t cause pain or difficulty right away for patients. via @MedStarWHC
Active surveillance involves regular monitoring of thyroid nodules. Patients with small nodules can come back every three to six months for a thyroid ultrasound, and the doctor can track that nodule’s growth over time. If the nodule has grown at least 20 or 30 percent in six months, the surgeon and patient can re-evaluate whether surgery is a good option. A thyroid fine needle aspiration (FNA) is recommended for thyroid nodules at least about 1-1.5 cm or larger.
A potential reason to wait on surgery is if the patient has other health conditions that could make surgery and recovery more challenging. For example, a patient in their 80s who has heart disease is likely to have more trouble recuperating after thyroid surgery than an otherwise healthy patient in their 30s.
These are valid considerations, and doctors should discuss them with their patients. Though I tend to recommend surgery for my patients with low-risk thyroid cancer (e.g., thyroid nodules larger than 1-1.5 cm and/or that have an FNA suspicious or diagnostic of thyroid cancer it’s a decision both the patient and their doctor should weigh carefully. Make sure to discuss the advantages and disadvantages of surgery, as well as your risks if you decide to wait. Ask about the surgeon’s experience performing this kind of procedure. And don’t be afraid to ask for a second opinion.