Dr. Kristen Otto, a head and neck cancer endocrine surgeon from Moffitt Cancer Center, explains how shared decision-making can help to personalize care for people with thyroid cancer. Dr. Otto shares important questions you should always ask your care team before treatment, explains why you should always understand symptoms and side effects, and discusses the importance of regular communication with your care team.
Dr. Kristen Otto is a Head and Neck Endocrine Surgeon and an Associate Member in the Department of Head & Neck – Endocrine Oncology at Moffitt Cancer Center. Learn more about Dr. Otto.
Related Resources
Transcript
Katherine Banwell:
As we’ve been discussing, it’s really important to work with your healthcare team to identify what treatment would be best for you. So, Dr. Otto, I’m wondering how you define shared decision-making, and why is this critical to properly managing life with thyroid cancer?
Dr. Kristen Otto:
In most instances, surgery is the mainstay of treatment, and if we’re talking about surgery, of course, there’s always going to be a risk-benefit discussion to whether putting somebody under general anesthesia and taking out the thyroid gland is actually in their best interest and makes sense for them.
So, to me, understanding what is it like to live without your thyroid? Are you going to be good at taking your thyroid hormone supplementation after surgery? We also know that the thyroid gland sits near, in the neck, near structures that help control very functions like voice and swallowing. And so, if I would anticipate that there could potentially be any impact on a patient’s voice or the patient’s future ability to swallow, that also absolutely has to be part of the decision-making. Because even though we know that surgery is the best treatment for thyroid cancer, we know that thyroid cancer occurs in patients with lots of needs and other medical problems and other comorbidities. And so, we really do have to tailor that treatment to the patient, and make sure they understand what they’re signing up for.
Katherine Banwell:
All right. What key questions should patients be asking their healthcare team when considering treatment?
Dr. Kristen Otto:
I think it’s important to ask about stage. One of the things that we see frequently for patients who come to us for a second opinion is that there wasn’t a formal or thorough evaluation of staging of the tumor prior to recommendations for initial therapy. The classic example of this is somebody discovers a mass in the thyroid or a nodule in the thyroid, they get a biopsy, it’s cancer, and they get told, “Let’s go to surgery and take out your thyroid.” And they don’t remember to look comprehensively at the lymph nodes.
And so, if that happens, presumably, if there’s spread to lymph nodes and you just take out the thyroid, you’ve left disease behind. And so, patients can obviously be in a situation where they’re then having to play catch-up and have second operations and third operations to remove those lymph nodes, when in fact, those lymph nodes were there all along and could have been discovered if proper staging was done. So, I think staging is really important. We also talked about the fact that better outcomes are seen for patients and with surgeons who are considered high volume surgeons.
So, I think it’s always a fair question to ask your surgeon, “Well, how many of these do you do a year?” And if it’s three or five, that might be a red flag. Another thing I think is important for patients to ask is how their care will be integrated between the surgeon and the endocrinologist or the oncologist in the future. Because I think that it always is best for patients when they are able to work with true multidisciplinary teams, teams that speak to one another and have shared decision-making and adhere to sort of institutional guidelines and pathways for the treatment of the cancer.
Katherine Banwell:
Some patients are hesitant to speak up when it comes to their care choices. Why is it important for patients to share their preferences and treatment goals with their care team?
Dr. Kristen Otto:
So that they are concordant with what the surgeon or physician is recommending, for sure.
I mean, we can make recommendations all day long, but we’re not going to have satisfied, happy, healthy patients if we don’t ask what their needs and wants are. So, I would just encourage patients to never feel anxious or nervous to ask the questions that you’re thinking, because we really do want to know. As physicians, we want to know where your head is at and what is important to you, so that we can help serve that.
Katherine Banwell:
What symptoms or side effects should patients be aware of, and why is it important to communicate anything they’re experiencing with their care team?
Dr. Kristen Otto:
So, that’s a big question with a lot of discussion around it. So, in terms of symptoms that patients might experience when they’re first getting diagnosed with thyroid cancer, really honestly, many thyroid cancers are found by accident. We do imaging for some other reason. We do a CAT scan of the lungs because someone gets pneumonia, or we do a CAT scan of the spine because someone has a whiplash injury in a car accident.
And, lo and behold, we find a thyroid nodule, and that leads to the work-up. And so, I guess what I’m trying to get at is that many thyroid cancers are actually completely asymptomatic, silent. It’s only when thyroid cancer gets large that it starts to cause symptoms. Perhaps a mass you can feel in the neck, or a mass that might put pressure in the neck that somebody might experience if they try to swallow with their head turned, for instance. A lot of times, doctors and clinicians ask about things like voice changes in thyroid cancer, and I would argue that voice changes are actually quite rare as a result of thyroid cancer, and if they are seen, they should be taken very seriously. It would be an indicator of a very advanced, invasive thyroid cancer. So, voice changes aren’t as common. And then, in terms of what patients might expect in terms of symptoms or side effects as a result of treatment, the common things that we worry about.
So, the thyroid gland does sit up against the voice box in the neck, and behind the thyroid gland runs to important nerves, one on each side, that actually control the movement of the vocal cords. So, we always counsel patients that these nerves are at risk when we think about thyroid surgery. A change in voice after surgery, while never intentional or anticipated, is something that we would ask about. So, post-operative voice changes are important to look for. And then, the other thing we have to worry about in terms of a consequence of the surgery for thyroid cancer, is low calcium levels. And that is because the thyroid gland sits next to the little glands that control calcium levels, and those are called the parathyroid glands. They oftentimes can get a little bit swollen or bruised at the time of surgery such that they shut down and stop working, so patients can have low calcium temporarily, but that’s typically quite a temporary problem.
And there are some symptoms that go along with low calcium that we counsel patients to look for after surgery.
Katherine Banwell:
Dr. Otto, as we close out the program, what would you like to leave the audience with? Why are you hopeful?
Dr. Kristen Otto:
I think for thyroid cancer, the best thing to remember is these are highly predictable, highly responsive tumors, generally with quite good outcomes.
And we are just scratching the surface in terms of our understanding of the DNA and RNA alterations that lead to thyroid cancer, and we are now exploiting those things for treatments. So, even for the worst of the worst thyroid cancer, anaplastic thyroid cancer, we now are quite successful in treating these in many instances. So, there’s just a whole world of possibility for future management of these tumors.
Katherine Banwell:
That’s a very promising outlook to leave our audience with. Dr. Otto, thank you so much for joining us today.
Dr. Kristen Otto:
Thank you! Thank you for having me. I’m very appreciative.