Physicians are taught to make recommendations based on research and experience. But Marita Teng, MD, Professor of Otolaryngology – Head and Neck Surgery at Mount Sinai, often finds herself telling patients that decisions in thyroid cancer surgery are becoming as much personal as medical. The ‘right’ decision regarding whether to biopsy a thyroid nodule, or how much surgery to have, she explains, is different for every patient.
Marita Teng, MD, Professor of Otolaryngology – Head and Neck Surgery at Mount Sinai
This is particularly true in the field of thyroid cancer, where so much of the thinking and approach has changed in the last five years. The American Thyroid Association (ATA) published more than 100 new recommendations for the treatment of thyroid cancer in 2015. One of the most remarkable changes, and difficult decisions for patients, is determining what type of surgery to have.
“We are living in an age of information being at people’s fingertips and a culture where shared decision-making is more prevalent,” explains Dr. Teng. “Many times, there is not simply one right treatment path. Clinical outcomes are important, but decisions also depend on what feels right to the patient.”
Choosing between Total Thyroidectomy and Hemithyroidectomy
For decades, total thyroidectomy—a surgical procedure which removes the entire thyroid gland—was considered the gold standard treatment for most thyroid cancers. However, the latest ATA guidelines advocate that removing half of the thyroid gland, a procedure known as hemithyroidectomy, is as beneficial as having a total thyroidectomy in patients with well-differentiated cancerous growths measuring up to four centimeters.
“Some individuals who have thyroid cancer want the entire organ out of their body, so they do not have to worry about having problems with the other side. Other patients want to have as little surgery as possible. After I give these options to my patients, they frequently know exactly which one resonates with them,” explains Dr. Teng.
The Consideration of Thyroid-Stimulating Hormone Post Surgery
There are pros and cons to both hemi- and total thyroidectomy. One of the most important differences is the need for thyroid-stimulating hormone after surgery. The thyroid produces hormones that help regulate important body functions such as the heart rate and metabolism. When the entire thyroid is surgically removed, patients must take synthetic thyroid hormone for the rest of their lives. When half of the thyroid remains intact, close to 90 percent of patients can maintain normal thyroid function without medication.
“Some people shrug it off when I tell them they have to take medicine every day; others absolutely do not want to take a pill,” Dr. Teng says. “I also explain that some patients can be more difficult to regulate with medication than others. It really depends on how much that inconvenience strikes them.”
What Are the Risks of Thyroid Surgery?
The surgical risks of any thyroid procedure are small. But the likelihood of the rare complication, such as injury to the nerve that controls the voice, is cut in half with hemithyroidectomy because the procedure involves only one side as opposed to both. The recovery for both operations is about the same.
One potential downside to hemithyroidectomy, however, is that the remaining side will require monitoring and may potentially need to be removed later. In a small number of patients, a later biopsy finds cancer in the side that was thought to be unaffected.
“We can predict a fair amount before we operate. When I counsel patients, I try not to give them a recommendation that could bring them back to the operating room again,” explains Dr. Teng. “But by taking out the entire gland you never have to worry about that small chance you may need another thyroid operation.”
Dr. Teng says it is important that patients are informed, because implementing new guidelines into widespread practice can be a challenge. In fact, it takes an average of 17 years for an established medical guideline to become common practice. That means it could be be 2032 by the time these 2015 ATA guidelines are consistently followed throughout the country. Patients who were told total thyroidectomy was their only option often see her for a second opinion.
Mount Sinai Provides Patients with a Personalized Approach
“At Mount Sinai, we provide a personalized approach to every case and are up to date on current practice guidelines. We have a multidisciplinary team; for complex cases, our recommendations are evaluated carefully as a group of surgeons, endocrinologists, nuclear medicine specialists, and sometimes even medical and radiation oncologists. We are thankful to be able to engage our patients in this collaborative decision-making process,” says Dr. Teng.