Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Thyroid Cancer Advances and Environmental Factors
Discover the extraordinary journey of Dr. Ruth Decker, a leading thyroid and parathyroid surgeon whose unique blend of medical and legal expertise is transforming patient care. Explore how her roots in Sheboygan, education at Northwestern University and the University of Wisconsin, and a law degree from Washington University have shaped her innovative approach to surgery. Dr. Decker shares her secrets to demystifying complex procedures using a simple whiteboard, ensuring patients leave her office not just informed, but empowered to make the best decisions for their health.
Our conversation navigates the cutting-edge advancements in thyroid cancer treatment and diagnosis. Marvel at the power of ultrasound technology and the TI-RADS scoring system in revolutionizing cancer detection and management. Dr. Decker sheds light on the nuanced differences between papillary and anaplastic thyroid cancers, while also addressing the growing incidence of thyroid cancer and the critical need for diligent follow-up care. Her insights reveal both the promise and challenges of evolving treatment strategies in this dynamic field.
As we round out the episode, the discussion turns to the broader endocrine implications of weight and environmental factors. Dr. Decker explains how conditions like parathyroid disease, obesity, and hormonal disruptors are interlinked with rising rates of thyroid disease. Uncover how adipose tissue plays a pivotal role in overall health, influencing thyroid, prostate, and breast conditions. This episode offers a comprehensive understanding of the hormone-cancer connection and emphasizes the importance of education and primary care in tackling these complex health challenges.
Welcome to Doc Discussions. I'm Dr Jason Edwards and this is a podcast where I interview other physicians. I'm here with my good friend today, dr Ruth Decker. Ruth, how are you doing?
Speaker 2:I'm doing great and thanks for having me, dr Edwards, thank you.
Speaker 1:Ruth. Now for those of you who don't know, dr Decker is a thyroid surgeon. She's a general surgeon, but she specializes in thyroid and parathyroid surgeries. Is that accurate?
Speaker 2:Yeah, exclusively thyroid and parathyroid surgeries.
Speaker 1:Is that accurate? Yeah, exclusively thyroid and parathyroid. Yeah, and that's really important because, as we know, physicians who do a same surgery multiple times or they do it more times a year have better outcomes. I think specifically with thyroid cancer or thyroid surgeries it's 25 or more a year are known to have better outcomes.
Speaker 2:Yeah, that's correct, and because there's a lot of nuances and over time, then you're prepared because you've seen it before and you're just more comfortable because it's almost in your DNA.
Speaker 1:Yeah, you bet you bet We'll get into the nuts and bolts of thyroid surgery. But first, where are you from, Ruth? Originally I'm from Sheboygan, Wisconsin. Okay, and so is that in southern Wisconsin.
Speaker 2:No. It's north of Milwaukee. It's kind of mid. It's north of Milwaukee right on Lake Michigan.
Speaker 1:Okay, okay, so like south of Green Bay, north of Milwaukee.
Speaker 2:Correct.
Speaker 1:Okay, very good, I would assume it's a nice Midwestern city.
Speaker 2:Yeah, mostly blue collar. Yeah, we're near the bigger industries Kohler, Kohler of Kohler.
Speaker 1:Kohler the tool.
Speaker 2:Well, they have generators, they do bathtubs, toilets. Okay, gotcha, yeah, that's a big employer.
Speaker 1:Okay gotcha, Most of the stuff in Home Depot is going to be Kohler-like products.
Speaker 2:Yeah, most of the stuff in Home.
Speaker 1:Depot is going to be Kohler-like products.
Speaker 2:Yeah, maybe, maybe, yeah, and then where did you go to school at Undergrad? Yeah sure, I went to school at Northwestern.
Speaker 1:Very good.
Speaker 2:In Evanston Illinois.
Speaker 1:Sure.
Speaker 2:And I also got an MBA there.
Speaker 1:Okay.
Speaker 2:I attended medical school at the University of Wisconsin in Madison and then also completed a fellowship in thyroid surgery here at Barnes Hospital in St Louis. And following my medical training, I joined the faculty at the University of Michigan in Ann Arbor in the Division of Endocrine Surgery. I also had a research lab where I investigated the genetics of an inherited form of medullary thyroid cancer. My work was funded by the NIH, the American Cancer Society and the American College of Surgeons, from whom I received a National Faculty Award for my research. And then, in 1996, I returned to St Louis and came here to St Luke's and I got a law degree from Washington University.
Speaker 1:Very good.
Speaker 2:So I've been in the Midwest the whole time.
Speaker 1:And so not a lot of physicians have law degrees You're only the second one I've ever met and so how do you feel like that's influenced your practice?
Speaker 2:like that's influenced your practice. I think it.
Speaker 2:To me it has reinforced the importance of being very consistent in how you describe things to patients, yeah, so that when you actually operate, they have a feeling within that they have made the right decisions, that they've been given alternatives, and if you're consistent and I tend to use my whiteboard very generously, I draw pictures, I put down statistics and most patients come away actually stating that for the first time, they understand exactly why they're having surgery, and so I feel very comfortable in that approach. I don't, and even after surgery a time of discharge I stand at the bedside and I have very detailed written instructions for their post-operative care. However, I go through the instructions line by line myself.
Speaker 2:So, I don't delegate. I think it's important, and you have enough respect for patients, that you give them the time they need to understand why you're doing surgery which, when you think of I mean it's a very invasive correct. They're in a very fragile situation, they're under anesthesia, it can be very scary, and so you want them to feel that you care for them as a person as well as as a patient.
Speaker 1:Yeah, you know your whiteboard is legendary Patients talk to me about your whiteboard and a lot of people say Carl Rove stole it from you.
Speaker 2:And so.
Speaker 1:I don't know if that's true or not, but no, I mean, that's the tricky thing, Thyroid surgery, I mean, as you know, but to the audience members that is kind of a high real estate area in the neck.
Speaker 2:I mean you've got In a very small area, very small area.
Speaker 1:You've got the airway, the carotid artery, the jugular and the recurrent laryngeal nerve, which is a big deal for thyroid cancer. For those of you who don't know, it's a nerve that comes out of the neck down around the bronchus in the chest and then comes back up to innervate the vocal cords Correct and it's kind of on the backside of the thyroid gland Right. So when you resect the thyroid gland, if you're too aggressive you can clip those nerves and then people have a loss of voice, right.
Speaker 2:That's correct and part of it, and I do, in my description, give a percentage, that the injury is about 1%. But about 8% of patients can have a transient problem, not because the nerve has been severed okay, but because there might be a stretch injury, meaning the nerve is attached to the back of the thyroid. So when you rotate the gland the nerve comes up with it and then the sheath to the nerve becomes inflamed and that can cause a transient change in the voice. Of course, this is very disconcerting to patients and it does require reinforcement. This just takes time. You know, reinforcement, this just takes time. This will heal on its own. We do give the patient a high dose of decadron to try to decrease that swelling. So, yeah, this needs to be explained in detail because I, rather than just again delegating to another and explaining the anatomy to patients, and some pick up on it and they ask more questions about it, and even though one can use nerve monitoring, during surgery it still does not prevent those stretch phenomenon.
Speaker 2:Right, Because you've identified the nerve. The problem is not whether or not the nerve has been identified, but how much dissection has had to happen around the nerve. The problem is not whether or not the nerve has been identified, but how much dissection has had to happen around the nerve, especially if you're doing lymph node dissections. You're doing this dance around the nerve because they tend to hug the nerve, and so it's just a very fragile situation.
Speaker 1:Yeah, yeah, and you and I share a lot of patients. I don't see the majority of your patients, probably, but a fair amount of them have a higher risk thyroid cancer. Well, post-operatively, and it's actually. I can't recall any patients who've had any long-term damage off the top of my head.
Speaker 2:I mean you do a great job. Yeah, they do resolve. The other thing I want to point out is most patients are asymptomatic when they present.
Speaker 1:You bet yeah.
Speaker 2:So this is a very difficult situation. Plus, their thyroid levels are typically normal. And so you're coming to them and you're saying you need surgery. You know you have this biopsy and they feel no different. I mean, it's rare that the patient actually has hoarseness or difficulty swallowing. You know where they can sense yes, this has to happen. Most of the time they felt perfectly fine and here they're undergoing this surgery. So, again, it takes educating the patient of why this has to happen and, of course, as you know, it's all about probability. Rarely do we have 100% certainty that, yes, this patient has cancer, even though the diagnostics have improved and evolved to try to perfect the probabilities. To try to perfect the probabilities still you might have a situation where the probability suggests that they need the surgery, but yet on the final analysis that we get from the pathologist, we find it's a benign event.
Speaker 1:Yeah, yeah, I mean, life is probabilistic, right. Yeah absolutely Be weary of anybody who ever says always or never. Yeah, I mean that's the way we should talk, especially with informed consent, is to say high probability or low probability and try to give that probability if we can.
Speaker 2:Yeah, and to make that very clear, and it may not be in some cancers it may not be a one and done. We may have to go back and dissect more lymph nodes, you know, or for recurrent disease. So the patient needs to understand that as well. And maybe it was not detected initially with the current sensitivities of the imaging studies et cetera. So if they're prepared for that, it's important.
Speaker 1:Yeah, if you know it's a possibility, it's easier to accept when it happens.
Speaker 2:Yes.
Speaker 1:If you know it's a possibility, it's easier to accept when it happens. So, talking about imaging, the rate of thyroid cancer has increased over time, and there's some ideas of why that is.
Speaker 2:What are your thoughts on that? Well again, because many of the patients are asymptomatic, many of them come to me with. Well, I had this life screening at work.
Speaker 1:Okay.
Speaker 2:Or I had a carotid study, or I had a chest CT and it picked up this nodule. Yeah, that is the more common. And that is the more common Once in a while, depending again on the astuteness of the primary care that they will actually feel a thyroid nodule and then go on to order an ultrasound. And of course, ultrasound, I think, has been with us since the 1940s, but it has really been the mainstay for diagnosing thyroid nodules. It continues to be.
Speaker 1:Yeah, and ultrasound technology has obviously improved a fair amount too over that time. Right, you know especially my wife's an OB-GYN, and you know the ultrasound of the fetuses are incredible these days, yeah, yeah. And so that's helped. Yeah, so you're saying increased detection just from these scans? Incidentally, finding lesions is maybe one of the reasons that thyroid cancer is increasing and again.
Speaker 2:and if you talk about the legal implications of that, I think gone are the days where one can dismiss it.
Speaker 1:Yeah, correct yeah.
Speaker 2:You know. So the referrals, either for the thyroid FNA or to an endocrinologist or to a surgeon, to assume that. And then the follow-up. Let's say the initial biopsy was benign, but again you know that is not a hundred percent accurate and so there needs to be some follow-up. And that's the other thing to reinforce to patients. You know that even if the initial biopsy was okay, there needs to be follow-up, and even more pressing in these times where the treatment is actually less vigorous, I would say, than it used to be. Correct, okay, for small cancers, this puts a bigger burden on the physician for ensuring compliance, because let's say, you have a one centimeter papillary, many of those can now just be watched and operative treatment is not really recommended. But that patient has to commit to coming back and repeating the ultrasound. Okay, and even in some countries now it's even going to two centimeters.
Speaker 1:But you have to have a responsible patient. I mean, if we've all had patients who have kind of social situations that don't lend themselves to showing up for treatments and things like that, or maybe it's a personality and those people aren't a good candidate to watch or to deescalate the intensity of the treatment and we're seeing deescalation of care, like with rectal cancer. You know some patients will have a complete response to chemo radiation and not need surgery. But you have to follow very closely.
Speaker 1:It's more work on our end, but it saves the patient a surgery, Right? Yeah, no, I think that's. And yeah, there's plenty of patients that you see a nodule on the thyroid on a scan and you're like it's probably nothing, but you can't neglect it and five years later they come back with a gigantic mass on their neck. You're going to be held really culpable for that with a gigantic mass on their neck.
Speaker 2:you know you're going to be held culpable for that. And it's interesting because since, of course, now we have the TI-RADS scoring of these nodules, and so that is some protection or assurance. Again, you're dealing with probabilities correct yeah. Not absolutes, because patients may say, well, and some of those nodules are fairly, fairly large, but they're either cis or they're tr2, the scoring, and then you have to explain the scoring to the patient because then they don't understand why, why you know why this it's small. Why does this need to be biopsied?
Speaker 1:etc. So the tirads is kind of similar to the birads which is used in breast, and that's when the radiologist gives an assessment of what's the likelihood of the lesion to be a cancer.
Speaker 2:Right, right, and the whole point is the feeling that thyroid cancers were being over-treated at a time when the incidence was increasing.
Speaker 1:Yeah, and the cure rate for thyroid cancer is really high for most thyroid cancers.
Speaker 2:Right, but the other thing is, what about the patient that said, well, I heard, this is really a good cancer. Yeah, what is the answer to that?
Speaker 1:So, I mean, this is my take on it. So for a papillary thyroid cancer the cure rate is really high. It's like 99%, right, Right.
Speaker 2:But if they're treated, if they're treated, yeah, okay.
Speaker 1:Now, psychologically I try not to downplay any cancer to a patient because psychologically they hear cancer. It makes them examine their own mortality. Mentally and emotionally they don't feel how they feel is not commensurate with the probability of cure. You know they feel horrible when they have it. One of the weird things about thyroid is the best. It's papillary thyroid cancers about the cancer with the highest probability of cure, and a plastic thyroid cancer, which is a more aggressive, is the absolute worst cancer you can get.
Speaker 1:It has the fastest mortality rate, I think it's six months. And so it's just weird one gland can have the best and worst cancer with regard to cure rate.
Speaker 2:And the anaplastic. The progenitor of that is papillary. Yeah, so I've had patients that had within the same gland. You would see this progression within the gland, where they would start out with normal papillary and then it would watershed area where it was de-differentiating, and then there was an area of anaplastic frankly anaplastic and fortunately that doesn't happen very often. But, yeah, usually when it's consumed with all anaplasia, then the mortality is usually, though, from recurrence of distant disease, not from treatment of the primary, is my understanding.
Speaker 1:And the treatment of the primary is really difficult to do a complete thyroidectomy because the tissue goes down into the chest, as you know, and so it's hard to get it all. And then we use chemoradiation and that's a horrendous treatment, but fortunately we don't see a lot of those.
Speaker 2:I think I've had a couple and this might have been prior to your time here where we did have survival of 12 months or more, you know what.
Speaker 1:There's one patient who's cured of it. Was it a woman? No, it was not.
Speaker 2:It was not okay.
Speaker 1:But it's a difficult treatment and that's rare. I mean, that's super rare.
Speaker 2:Yeah.
Speaker 1:But we you know.
Speaker 2:I think it's interesting because that is the one cancer where you actually need to you know, within a week need to you know within a week have a complete plan between the surgeon, the radiation oncologist, the chemotherapy, the medical oncologist, and you have to come up, you know, core biopsy, what are the tumor markers?
Speaker 1:Very different from the other cancers, because time is critical in that situation. Yeah, that's you know, fortunately we don't see those very often. That situation, yeah, yeah, that's you know, fortunately we don't see those very often. And so the so and then can you talk to me about parathyroid disease. So that's, you know, way out of my wheelhouse and so but. But I know it has to do with calcium regulation and whatnot. But can you go into that a little bit for me?
Speaker 2:Yeah, it's interesting because I would say, when you talk about the evolution of a career, it seems like I'm seeing quite more parathyroid disease.
Speaker 1:Is that?
Speaker 2:right, Right, and it used to be, I would say, see 10 women for one male. But it seems to be more common now in the male population as well, and of course the male population as well, and of course the treatment for that the mainstay is surgical, obviously, and we've had some better resolution as far as imaging the SPECT imaging, the parathyroid nuclear imaging.
Speaker 2:That has it, and now the 4D CT scanning A patient I did this morning. The Sestamib nuclear scan did not show an abnormality. The ultrasound did not show an abnormality, but the 4DCT did, and that's exactly where the adenoma rested. Parathyroid cancer is very, very rare, Thank God.
Speaker 1:But parathyroid disease is different than parathyroid cancer. Right.
Speaker 2:Yeah, and of course the implications. There is the bone deterioration, risk of kidney stones. And again, some patients have soft findings. They don't have kidney stones, they don't have osteoporosis, but they're very tired you know and you know, we pursue operative resolution for those that desire it. Some patients don't, and a part of that also depends on the primary care, because years prior patients would be referred for maybe they waited until calcium was 12 or so.
Speaker 2:And now that's not true. A lot of the patients I see have are in the upper limits of normal, or actually within the range of 10 to 11. And do you?
Speaker 1:ever see any patients with mental issues.
Speaker 2:Yeah. Chronic fatigue yeah, Loss of focus.
Speaker 1:Yeah.
Speaker 2:They have, they can't seem to they memory problems. Some people have depression. Yeah, so yeah, and but they, and insomnia is common From medical school.
Speaker 1:I remember the moans, groans and stones it was psychological moans groans from bone pain and then kidney stones.
Speaker 2:Yeah, and of course in the dialysis patient a recent woman that I did. She had terrible bone groans and puritis generalized and she didn't realize it was due to this calcium issue and she was instantly cured of that post-op.
Speaker 1:Yeah, she was so grateful.
Speaker 2:I mean it was a major lifestyle. It's immediate. I mean the bone can be immediate. The next day it's gone. How wonderful, yeah, so those are the happy campers, yeah.
Speaker 1:And so we've talked about, you know, the thyroid disease and thyroid cancer, the rate going up because of increased detection. What other things do people think are contributing to that?
Speaker 2:Well, I think, more and more the literature is suggesting that, because there's actually, you know, endocrine receptors, as you know on the thyroid gland including estrogen et cetera, and that things environmentally that are hormonal disruptors are increasing the incidence and growth of thyroid nodules.
Speaker 1:And this would be like chemicals and microplastics and stuff like that.
Speaker 2:Right and I have like, for instance it's not only that, it's increased weight, so obesity.
Speaker 1:Sure.
Speaker 2:Because it increases the inflammatory state of the body. The adipose tissue is actually considered now an organ in and of itself.
Speaker 1:Okay.
Speaker 2:And the disruptors from an increase in that tissue may also be affecting not only thyroid, but prostate and breast yeah, I believe yeah and so that literature. Because the thing is, as our population has a, b, as you have an increase in obesity, you're finding an increase in thyroid cancers, and so the question is is there some relationship and that, and what are the mediators of that right?
Speaker 1:Yeah, for sure. I actually was involved in a study where we would harvest fat cells and then spin down stem cells out of mature adipose cells. And stem cells have a ton of hormones in them, and so does adipose tissue. So you've got all these hormones floating around sheerly because of the adipose tissue and you don't know. You know, is the thyroid cancer causing the obesity? Is the obesity causing thyroid cancer? Probably the latter, but that's the tricky thing with science is trying to figure out which way the arrow is pointing. Yeah, which came?
Speaker 2:first yeah, but you know. The other thing is, you know, although the link between smoking and lung cancer is very solid, Very solid. Some of these others. I mean, you know, as a surgeon would you say, well, you need to lose weight. I mean that's not going to be the resolution of the problem that's before me, no, no, the resolution of the problem that's before me, no, no, you know. So that would be more general education, maybe at the primary care level.
Speaker 1:Yeah.
Speaker 2:And it probably will happen, you know, as more information becomes available.
Speaker 1:Yeah, we definitely think that the diet is contributing to colon cancer. I mean, that's, that's, that's, you know, less fiber in the diet. In general Right and and and then we know that more fat on the body increases estrogen levels, which can increase endometrial cancer, which we've known for a long time and contribute to breast cancer too you know it's interesting.
Speaker 2:It's interesting too because they they say that um once puberty um appears, is when the incidence of thyroid problems appears in women.
Speaker 1:Okay.
Speaker 2:And now you don't see that in men, you don't see that kind of, and then that increases until the postmenopausal stage.
Speaker 1:Yeah, it's kind of 20 to 55, right I mean it's like somewhere in there where it's the high point for thyroid cancer, which kind of is consistent with the hypothesis that it's driven by hormones to some extent. Right yeah, Right yeah, it's very interesting. Well, Ruth, I want to appreciate all the good care that you've given our mutual patients over the years. You are an absolute expert in thyroid and parathyroid surgery and your results speak for themselves. Thanks so much for coming on the podcast.
Speaker 2:You're welcome.