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Is That Thyroidectomy Really Necessary?

The incidence of thyroid cancer is rapidly rising in the United States, and with it, the number of thyroidectomies. But are all these surgeries really necessary?

Ashok R. Shaha, MD

Ashok R. Shaha, MD, attending surgeon at Memorial Sloan Kettering Cancer Center in New York, broached the subject in his Sunday session, “Controversies in the Management of Thyroid Nodules.” Although the numbers of thyroid cancer cases are rising, he said the majority of the cases are actually microcarcinomas, which have a survival rate of 99 percent. In which case, he wondered aloud, do we even need to call it cancer?

He stressed that most people who have thyroid cancer don’t know it. “Six percent of the population in the U.S. is living with thyroid cancer. That’s 20 million people. About 19.5 million of those are living happily without the knowledge that they have the disease.”

The controversial part of thyroid nodule management involves the diagnostic workup and the extent of surgery, he said. He urged doctors to pay more attention to patient history and physicals as these seem to be a “forgotten art.” Other elements of routine evaluation include indirect laryngoscopy, TFTs, and blood workup, while further tests may require a thyroid scan, sonogram, CT scan, MRI, and needle aspiration.

Age is the most prognostic factor when it comes to diagnosing thyroid cancer. “The younger the patient, the less worried I am,” he said, adding that there is no stage 3 or stage 4 cancer in patients under age 45. Other prognostic factors include a history of radiation to the neck area and sex, as thyroid disease is more common in women, while thyroid cancer is more common in men.

Dr. Shaha questioned whether surgery is required as often as it is performed. Just because you can do a successful thyroidectomy doesn’t mean you should, he said, advocating a conservative approach. Quality of life and possible complications from thyroid surgery should be the center of all discussions of thyroid cancer, especially with papillary microcarcinomas.

For example, in a young female patient, a total thyroidectomy would result in her having to take thyroid medications for the rest of her life. Instead, doctors could take the position of active surveillance, because in many cases, whether you operate or not, the outcome will be the same.

Despite the advantages of the conservative approach, he said there is still an increasing incidence of total thyroidectomies. Among the reasons for this is what he called “Dr. Google.” Thanks to their ability to search their conditions and treatment options on the internet, he said, patients come to their appointments prepared. He likened appointments to thyroid confrontations rather than consultations, as patients come in expecting thyroidectomies and advocate for them even against the doctor’s recommendation.

“The word ‘cancer’ is very disturbing to a patient and the patient’s family,” he said. “You have to spend a lot of time conveying the message to the patient that they’re living with thyroid cancer that is not lethal.” To this end, Dr. Shaha said he would like to change the name of these from microcarcinomas to “papillary micro-tumors.” It would help ease patients’ minds and keep them from thinking they automatically need a thyroidectomy, or even surgery at all.