One-Stop Thyroid Shop

April 10, 2015

One of the worst parts of being evaluated for a possible medical problem is the waiting part—waiting for appointments, waiting for tests to be scheduled, waiting for test results and a diagnosis.

Patients with thyroid nodules, lumps on the thyroid gland that are sometimes cancerous, are almost always successfully treated. Traditionally, however, there's considerable lag time between suspecting something is wrong with your thyroid and getting that something taken care of. And the lag time equates to worry time.

But endocrine surgeon and thyroid pro Melanie Goldfarb, MD, wants to eliminate as much worry time as possible. She recently launched the Thyroid Nodule Clinic at the John Wayne Cancer Institute at Providence Saint John’s Health Center so that patients can have their diagnosis and treatment plan in one day, rather than having multiple tests over a period of weeks, common at other facilities. 

“It is so much more convenient and less stressful for patients to know what’s going on and what we’re going to do about it almost immediately.” – Dr. Melanie Goldfarb

"We envision this as a 'one-stop shop' for thyroid nodules," explains Dr. Goldfarb. Instead of scheduling multiple tests with multiple doctors (endocrinologist, radiologist, endocrine surgeon, etc.), most diagnoses and treatment plans can be handled with one visit to the Thyroid Nodule Clinic.

That means if a patient is referred for a suspicious lump and the doctor decides a biopsy is in order, you get it done and know the preliminary results the very same day. In fact, you generally walk out with a complete treatment plan.

"It is so much more convenient and less stressful for patients to know what’s going on and what we’re going to do about it almost immediately," says Dr. Goldfarb, "especially since getting referred for a potential thyroid problem is fairly common."

The thyroid is a butterfly-shaped organ in the front of the neck. It produces the thyroid hormones that regulate the body’s metabolism, including heart rate, body temperature and weight. Thyroid disorders affect far more women than men, but nobody is immune.

Dr. Goldfarb says the most common patient referred to the clinic is a middle-aged woman who has a nodule that is found during a routine physical exam. No surprise. Roughly 50% to 70% of middle-aged women have thyroid nodules, and 20-30% of women in their 30s have them, says Dr. Goldfarb. The vast majority of nodules are benign.

"Only 5% to 10% of the nodules even end up being cancer," says Dr. Goldfarb. That said, since 1970 there has been a steadily increasing rate of thyroid cancer diagnosis. The increase is likely due to a combination of factors, says Lisa Moore, MD, one of the local endocrinologists who refers patients to Dr. Goldfarb.

"We think a lot has to do with the increased awareness of thyroid disorders and thyroid cancer," says Dr. Moore. In addition, CT and MRI scans have become more common.

"Lots of times patients will be getting these scans for reasons completely unrelated to the thyroid, but a doctor will notice a small nodule and that’s how they’re referred to us," explains Dr. Moore. Quite often patients have no symptoms and haven’t felt the nodule at all.

“Only 5% to 10% of the nodules even end up being cancer.”

In her clinic, Dr. Moore also treats conditions relating to how the thyroid is functioning, such as hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid). Sometimes patients suspect their thyroid is underactive or overactive because they have symptoms such as fatigue, weight gain or intolerance to cold (hypothyroidism) or sudden weight loss, hair loss, dry skin, sweating or anxiety/irritability (hyperthyroidism).

Goiter, an enlarged thyroid that protrudes from the neck, is another disorder. It can be caused by a diet deficient in iodine, but in the United States it’s most often caused by a defect that causes hormones to fluctuate.

Some thyroid nodules require surgery. Each patient is treated individually, but in general, Dr. Goldfarb says that characteristics likely pushing her to recommend surgery are large nodule size (larger than four centimeters), very worrisome ultrasound characteristics, a suspicious thyroid biopsy, or compressive symptoms such as problems swallowing or breathing caused by the nodule. Many nodules however, can be watched with screening ultrasounds to see if they grow over time.

"We’re really more apt to take a highly individual approach these days," explains Dr. Moore. "Many conditions will require medication, and some nodules will require surgery—but definitely not all."

Typically, exploration into a thyroid condition will include a physical exam, an ultrasound, a blood test and, if a nodule is present, a biopsy. "Fortunately thyroid cancer is a very slow-growing cancer, and therefore it doesn’t spread to other parts of body as rapidly as many cancers," says Dr. Goldfarb. "But of course, you do need to treat it."

Depending on the extent of the cancer, doctors will determine if a patient needs a total thyroidectomy or a partial thyroidectomy. Sometimes lymph nodes in the neck are also removed. After surgery, patients are often able to go home the same day, though some do spend the night.

"Even with surgery, you’re able to go back to normal activities almost right away. You might have a slight sore throat," says Dr. Goldfarb, who prefers to prescribe ice cream for that. Patients are then prescribed daily thyroid medication, which may need to be adjusted over time.

Up until just a few years ago, all thyroid cancer patients also underwent radioactive iodine treatment some weeks post-surgery. Recent American Thyroid Association guidelines, however, establish that patients who have small, confined cancers don’t benefit from the extra treatment.

Now only patients whose cancer has spread to their lateral lymph nodes or those with unfavorable tumor characteristics will likely require radioactive iodine treatment which works by to destroying any remaining thyroid tissue.

The temporary side effects aren’t a cakewalk; they can include neck pain, nausea and taste changes. Plus you have to remain six to eight feet from other people for a short amount of time.

And again, the exciting part is the cure rate. The two most common types of thyroid cancer—papillary and follicular—have a more than 97% long-term cure rate if treated appropriately.

"Our goal, too, with the Thyroid Nodule Clinic is not only to give appropriate care but give very swift care. We think it’s important; it gives our thyroid patients enormous peace of mind," says Dr. Goldfarb.

Pregnant Women May Want to Have Thyroid Test

Right now pregnant women aren’t universally screened for thyroid disorders. However, hypothyroidism can be dangerous to developing fetuses. Current recommendations say that women with thyroid disease or those at risk for thyroid disease (for example, if it runs in the family) should be screened.

A study published in the journal Thyroid in October 2014, however, concluded that if thyroid blood testing during pregnancy became standard, 25,000 pregnant women in the United Stated would be diagnosed and adequately treated each year. The study authors say that it’s entirely reasonable to ask your doctor to screen your thyroid if you are age 30 or older, have a prior history of abnormal thyroid function or are experiencing any symptoms of overactive or underactive thyroid. Also, any pregnant woman who has had prior head and neck radiation (often used to treat certain cancers) should request a thyroid screening test.

Written by Victoria Clayto

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