Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
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effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
OUR SPEAKER TODAY IS DR. JULIE
ANN SOSA, THE LEON
GOLDMAN CHAIR OF SURGERY,
UNIVERSITY OF CALIFORNIA
SAN FRANCISCO, WHERE SHE IS ALSO
A PROFESSOR IN THE DEPARTMENT OF
MEDICINE AND AFFILIATED FACULTY
FOR THE PHILIP R. LEE INSTITUTE
FOR HEALTH POLICY STUDIES.
OVER HER CAREER, SHE HAS
MENTORED MORE THAN 90 STUDENTS,
RESIDENTS AND FELLOWS, FOR WHICH
SHE WAS RECOGNIZED AS A FULL
MEMBER TO THE AMERICAN COLLEGE
OF SURGEONS, ACADEMY OF MASTER
EDUCATORS, IN 2020, AND WITH THE
DISTINGUISHED LECTURESHIP AWARD
IN 2017.
IN MY OPINION, THESE ACCOLADES
MAKE HER UNIQUELY SUITED FOR OUR
GREAT TEACHER GRAND ROUNDS
SERIES.
AFTER EARNING DEGREES FROM
PRINCETON AND OXFORD UNIVERSITY,
DR. SOSA EARNED HER
MEDICAL DEGREE FROM JOHNS HIGH JOHNS
HOPKINS SCHOOL OF MEDICINE AND
COMPLETED A RESIDENCY IN GENERAL
SURGERY.
HER TRAINING INCLUDED A
FELLOWSHIP IN CLINICAL RESEARCH
AS A ROBERT WOOD JOHNSON
CLINICAL SCHOLAR, SPECIALIST
TRAINING AT UNIVERSITY OF OXFORD
HOSPITALS, AND A FELLOWSHIP AT
JOHNS HOPKINS HOSPITAL IN
BALTIMORE, MARYLAND.
SHORTLY AFTER DR. SOSA CONTINUED
AT THE YALE UNIVERSITY SCHOOL OF
MEDICINE AS AN ASSISTANT
PROFESSOR OF SURGERY BEFORE
BEING PROMOTED TO DIRECTOR AND
LATER MOVED TO DUKE UNIVERSITY
SCHOOL OF MEDICINE AS A TENURED
PROFESSOR OF SURGERY AND
MEDICINE.
SHE MOVED TO HER CURRENT
POSITION AT UCSF IN 2018.
DR. SOSA'S RESEARCH FOCUSES ON
DEVELOPING TREATMENTS FOR
ADVANCED THYROID CANCER AND
UNDERSTANDING ENVIRONMENTAL
FACTORS THAT CAN RAISE A
PERSON'S RISK FOR THE DISEASE.
HER CLINICAL INTEREST IS IN
ENDOCRINE SURGERY WITH A FOCUS
IN THYROID CANCER.
SHE IS A NATIONAL INSTITUTES OF
HEALTH AND FOOD AND DRUG
ADMINISTRATION-FUNDED
INVESTIGATOR, AND AN AUTHOR OF
NEARLY 400 PEER REVIEWED
PUBLICATIONS AND 80 BOOK
CHAPTERS AND REVIEWS, ALL
LARGELY FOCUSED ON OUTCOMES
RESEARCH, HEALTHCARE DELIVERY,
HYPERPARATHYROIDISM AND THYROID
CANCER WITH A FOCUS ON CLINICAL
TRIALS.
SHE HAS AUTHORED OR EDITED SEVEN
BOOKS.
DR. SOSA HAS ALSO PUBLISHED
EXTENSIVELY ON PREDICTORS OF
OPTIMAL PATIENT OUTCOMES
FOLLOWING A VARIETY OF
CANCER-BASED PROCEDURES.
SHE IS AN EDITOR OF GREENFIELD
SURGERY SCIENTIFIC PRINCIPLES
AND PRACTICE.
DR. SOSA IS PRESIDENT-ELECT OF
THE AMERICAN THYROID ASSOCIATION
AND SERVES ON THE BOARD OF
DIRECTORS AND EXECUTIVE COUNCIL
OF THE ATA AND THE INTERNATIONAL
THYROID ONCOLOGY GROUP, AS WELL
AS THE PRACTICE GUIDELINES
COMMITTEE FOR THE ATA, THE
NATIONAL COMPREHENSIVE CANCER
NETWORK, AND THE AMERICAN
ASSOCIATION OF ENDOCRINE
SURGEONS.
DR. SOSA IS ALSO CHAIRING THE
COMMITTEE RESPONSIBLE FOR
WRITING THE NEXT ITERATION OF
DIFFERENTIATED THYROID CANCER
GUIDELINES FOR THE ATA.
THE TITLE OF DR. SOSA'S
PRESENTATION IS, SEEKING NEW
SOLUTIONS FOR OLD CHALLENGES,
ALWAYS WITH EVIDENCE AND
COURAGE.
PLEASE JOIN ME IN WELCOMING
TODAY'S GREAT TEACHER SPEAKER,
DR. JULIE ANN SOSA.
>> ALL RIGHT.
THANK YOU SO MUCH FOR THAT VERY
WARM INTRODUCTION,
AND ALSO THANK YOU
TO THE NIH AND THE NIH CLINICAL
CENTER FOR THIS INCREDIBLE HONOR
AND PRIVILEGE TO SPEAK WITH YOU
TODAY.
UNFORTUNATELY FROM
SAN FRANCISCO, ABOUT THYROID
CANCER AND ABOUT SCIENCE AND
INNOVATION MORE BROADLY, AND
FINALLY ABOUT THE IMPORTANCE OF
BRINGING COURAGE TO SCIENTIFIC
INVESTIGATION, AS WELL AS
BRINGING COURAGE INTO OUR
PERSONAL AND PROFESSIONAL LIVES.
AND I THINK WHEN IT COMES TO
CHALLENGING HOW WE HAVE DONE
THINGS AND HOW WE DO THINGS, WE
OFTEN FOCUS ON THE BODY OF
EVIDENCE WHEN WE IGNORE A LITTLE
BIT THAT YOU NEED COURAGE TO BE
ABLE TO DEPLOY THE EVIDENCE TO
CHALLENGE THE STATUS QUO.
SO HERE WE GO.
THESE ARE MY DISCLOSURES.
THEY PERTAIN TO MEDULLARY CANCER
AND ARE IRRELEVANT TO THE
DISCUSSION TODAY, WHICH WILL BE
LARGELY FOCUSED ON
DIFFERENTIATED THYROID CANCER.
SO I'M A SURGEON, AND BEING A
SURGEON AND A SURGEON SCIENTIST
DEFINITELY IMPACTS THE LENS THAT
I USE TO LOOK AT LIFE.
AND I LOVE TO READ, AND I READ
ALL KINDS OF THINGS, I READ
POETRY, AND I ALSO READ THE
CLASSICS.
AND AS I THINK ABOUT THE CLASSIC
PHILOSOPHERS, I SOMETIMES HAVE
WONDERED, WHAT IF THEY'D BEEN A
SURGEON, WHAT KIND OF SURGEON
WOULD THOSE PHILOSOPHERS HAVE
BEEN?
NOT SURE THAT'S CROSSED ANYONE
ELSE'S MIND, BUT IT'S CROSSED
MINE.
SO I THINK IF ARISTOTLE HAD BEEN
A SURGEON, AND HE WASN'T, HE
WOULD HAVE BEEN A CLINICAL
SURGEON.
AND WHY DO I SAY THAT?
I SAY THAT BECAUSE ARISTOTLE
SAID, QUOTE, WE ARE WHAT WE
REPEATEDLY DO.
EXCELLENCE, THEN, IS NOT AN ART,
BUT A HABIT.
AND THAT REALLY REFLECTS THE
MANTRA THAT MANY SURGEONS USE,
AND THAT IS PRACTICE MAKES
PERFECT.
WELL, IF THE PHILOSOPHER
SOCRATES BEEN A SURGEON, I THINK
HE WOULD HAVE BEEN AN ACADEMIC
SURGEON.
WHY DO I SAY THAT?
HE SAID, QUOTE, I KNOW THAT I
DON'T KNOW.
AND ANOTHER SOCRATES QUOTE, TO
KNOW IS TO KNOW THAT YOU KNOW
NOTHING, THAT IS THE MEANING OF
TRUE KNOWLEDGE.
WELL, MANY PEOPLE SAY THERE IS
AN INTERNAL CONTRADICTION
BETWEEN BEING A CLINICAL SURGEON
WHERE PRACTICE MAKES PERFECT AND
BEING A SURGEON SCIENTIST, WHERE
YOU DEFINE A ROUTINE AND YOU
LOOK AND EMBRACE NOVEL TI.
WELL, LET'S TALK A LITTLE BIT
ABOUT THIS PHENOTYPE OF THE
SURGEON SCIENTIST.
STARTING WITH THE ARCH TYPE.
I WOULD SAY THE ARCH TYPE OF THE
SURGEON SCIENTIST, AS DEPICTED
HERE, WAS A MAN.
SCIENCE WAS PERFORMED
EXCLUSIVELY IN A WET LABORATORY.
AND ARE EXPECTATIONS OF SURGEON
SCIENTISTS WERE TO BE THE TRIPLE
THREAT TO BE AN EXCELLENT
CLINICIAN, A SUE PURLTIVE
RESEARCHER AND AN EFFECTIVE
EDUCATOR.
AN EXAMPLE OF SUCH AN ARCHETYPE
IS WILLIAM STEWART HALSTEAD WHO
WORKED, OF COURSE, AT JOHNS
HOPKINS HOSPITAL.
BUT I WOULD SAY THIS ARCHETYPE
OF THE SURGEON SCIENTIST IS
ANACHRONISTIC AND ARCANE.
THE MODERN ACADEMIC SURGEON DOES
NOT FIT ANY ONE PHENOTYPE.
SURE, IT COULD BE A BASIC
SCIENTIST BUT IT ALSO COULD BE A
CLINICAL RESEARCHER, A HEALTH
SERVICES RESEARCHER, EDUCATION
RESEARCHER, GLOBAL HEALTH
RESEARCHERS, FRANKLY, A MASTER
TEACHER, A MASTER CLINICIAN, OR
SOME COMBINATION OF THESE
THINGS, OF COURSE DEPICTED HERE
AS THE PROTOTYPE OF THE CHIMERA.
WHICH REMINDS ME FROM A COUPLE
OF YEARS BACK, THE PHENOMENON OF
THE BLUE VERSUS THE BROWN DRESS,
WHERE DIFFERENT PEOPLE LOOKED AT
THE SAME IMAGE AND BASED ON
THEIR RETINAL MAKEUP, SEE
DRESSES OF DIFFERENT COLORS.
SO I THINK THE MODERN SURGEON
SCIENTIST IS SOMEONE WHO COULD
BE ONE OF MANY PHENOTYPES, ALL
OF WHICH SHOULD BE HIGHLY VALUED
BY OUR ACADEMIC COMMUNITY.
IN THE END, A BOUQUET OF 12
WHITE FLOWERS MIGHT BE
BEAUTIFUL, BUT A BOUQUET OF 12
DIFFERENTLY COLORED FLOURS IS
ARGUABLY EVEN MORE BEAUTIFUL.
WHAT I THINK IS ESSENTIAL,
THOUGH, THE FOUNDATION OF
SCIENCE AND SURGICAL SCIENCE IS
THAT WE MUST BRING CREATIVITY,
DISCOVERY, AND INNOVATION TO
EVERYTHING WE DO, AND IS THAT IN
CONTRADICTION TO THE MANTRA OF
SURGERY THAT PRACTICE MAKES
PERFECT?
I DON'T THINK SO.
I THINK WE CAN BRING THESE TWO
WORLDS TOGETHER AS LONG AS IN
THE END, THE INNOVATION AND THE
DISCOVERY ULTIMATELY RETURNS TO
THE BEDSIDE AND IMPACTS IN A
POSITIVE WAY THE OUTCOME OF OUR
PATIENTS.
SO THERE MUST BE TRANSLATIONAL
IMPACT TO WHAT WE DO, AND TO BE
ABLE TO ACCOMPLISH THAT GREAT
FEAT, I WOULD ARGUE WE NEED BOTH
COURAGE AND EVIDENCE.
SO WHAT I'D LIKE TO DO IS TO
TELL A NARRATIVE AROUND THYROID
CANCER.
WE WILL BRING EVIDENCE AND
COURAGE TO WHAT WE DO, AND SINCE
THIS IS A GREAT TEACHERS GRAND
ROUNDS, I'M GOING TO PUT IN THE
EPICENTER OF OUR DISCUSSION A
LEARNER. THE ULTIMATE MESSAGE I WOULD
LIKE TO CONVEY TODAY IS THAT AS
A LEARNER, YOU CAN TRANSFORM
PRACTICE IF GUIDED BY MENTORSHIP
AND SPONSORSHIP.
SO LET'S START WITH SOME FACTS.
AND WE'LL START WITH
EPIDEMIOLOGY BECAUSE SINCE THE
BEGINNING OF THE PANDEMIC,
EPIDEMIOLOGY NOW REIGNS QUEEN OR
KING IN SCIENCE, AND THIS IS A
FIGURE THAT SHOWS THE
EPIDEMIOLOGY OF THYROID CANCER
IN THE UNITED STATES.
AND WHAT YOU SEE IS THAT THE
INCIDENCE OF THE DISEASE HAS
INCREASED BY MORE THAN THREE
FOLD OVER THREE DECADES.
AND THIS PHENOMENON HAS BEEN
SEEN IN ALL DEMOGRAPHIC
SUBTYPES.
ALL GENDERS, RACIAL, ETHNIC
SUBGROUPS AND IN THE YOUNG AND
IN THE OLD.
IN FACT, UNTIL 2020, I USED TO
SAY THERE WAS A PANDEMIC OF
THYROID CANCER IN THE WORLD,
BECAUSE SUM LAR OBSERVATIONS
HAVE BEEN MADE IN VIRTUALLY
EVERY DEVELOPED AND DEVELOPING
COUNTRY FOR WHICH THERE ARE
DATA.
I'VE NOW AMENDED THE USE OF THE
WORD PANDEMIC, AND I SAY JUST
EPIDEMIC.
SO WHAT IS GOING ON?
IT'S REALLY FASCINATING.
SO MANY PEOPLE HAVE TURNED TO A
SINGLE PIVOTAL STUDY TO TRY TO
EXPLAIN THIS RISE IN INCIDENCE.
THE STUDY WAS PUBLISHED IN JAMA
IN R6 BY WELCH AND DAVIES.
I'M JUST GOING TO QUICKLY WALK
YOU THROUGH THREE PIVOTAL IMAGES
FROM THAT PAPER.
STARTING IN THE UPPER LEFT-HAND
CORNER, WHERE YOU SEE INCIDENCE
OF ALL HISTOLOGIC SUBTYPES
RISING, BUT THE ENGINE FOR THE
RISE LARGELY APPEARS TO BE ONE
HISTOLOGIC SUBTYPE, PAPILLARY
THYROID CANCER, WHICH NOW
ACCOUNTS FOR MORE THAN 90% OF
NEW CASES.
THEN MOVING TO THE UPPER
RIGHT-HAND CORNER, YOU SEE
INCIDENT TUMORS BASED ON THE
SIZE OF THE TUMOR, AND YOU SEE
IT AS THE SMALLEST TUMORS, THOSE
LESS THAN 1 CENTIMETER IN SIZE,
WHICH WE CALL PAPILLARY THYROID
MICRO CARCINOMAS, THAT, AGAIN,
APPEAR TO BE THE ENGINE BEHIND
THE INCREASE IN INCIDENCE.
AND THEN FINALLY, THE MOST
IMPORTANT FIGURE FROM THAT WELCH
AND DAVIES STUDY, THE ONE IN THE
BOTTOM CENTER, WHERE YOU SEE
THIS RISE IN INCIDENCE AGAIN,
SUPERIMPOSED ON LEVEL MORTALITY.
LEADING THE AUTHORS TO CONCLUDE,
QUOTE, WE BELIEVE INCREASED
DIAGNOSTIC SCRUTINY IS THE MOST
LIKELY EXPLANATION FOR THE
APPARENT INCREASE IN INCIDENCE.
THAT IS, IT IS ALL
OVERDIAGNOSIS.
WELL, ALL OF YOU KNOW THIS
FIGURE, FIGURE OF THE ICEBERG,
JUST A LITTLE BIT OF THE ICEBERG
ABOVE THE SURFACE OF THE WATER.
MOST OF IT BELOW THE WATER
LEADING PEOPLE TO SAY THE WHOLE
TRUTH IS OFTEN HIDDEN FROM VIEW.
NOW I DON'T WANT TO GET
POLITICAL TODAY, TODAY IS NOT
THE DAY TO GET POLITICAL, BUT I
WOULD TAKE THAT ICEBERG
METAPHOR1 STEP FURTHER AND SAY,
JUST AS THE ICEBERGS ARE MELTING
WITH CLIMATE CHANGE, SO, TOO,
MIGHT BE TRUTH, IN THE UNITED
STATES AND THE WORLD.
AND SO I HAVE TO SAY, I READ
THAT WELCH AND DAVIES STUDY AT
LEAST 70 OR 75 TIMES.
AND WHAT REALLY BOTHERED ME WAS
THAT LAST FIGURE, AND HERE IT IS
AGAIN ON THE LEFT, SHOWING
RISING INCIDENCE, NEW CASES,
SUPERIMPOSED ON A FLAT MORTALITY
TREND.
DEATHS.
AND WHAT BOTHERED ME IS THAT
BOTH THESE LINES ARE PUT ON THE
SAME ARITHMETIC Y SCALE.
WHAT WE KNOW IS THAT NEW CASES
IS A VERY LARGE NUMBER.
NOWADAYS IN EXCESS OF ABOUT 49
OR 50,000 NEW CASES OF THYROID
CANCER IN THE UNITED STATES EACH
YEAR.
FORTUNATELY, THYROID CANCER IS
AN INDOLENT DISEASE WITH
SURVIVAL AT A DECADE OF AT LEAST
95 TO 98%.
SO THERE IS AN OVERALL SCARCITY
OF DEATHS, AND DEATH IS A VERY
SMALL NUMBER.
SO WE'RE TAKING A VERY LARGE
NUMBER AND A VERY SMALL NUMBER
AND PUTTING THEM ON THE SAME
ARITHMETIC SCALE.
SO WHAT I WONDERED ABOUT IS, IS
IT NOT POSSIBLE THAT WITH THIS
ARITHMETIC SCALE, WE ARE
CAMOUFLAGING REAL CHANGES IN
MORTALITY THAT ARE BEING
DISGUISED BY THE Y AXIS.
SO I'M NOT A BIOSTATISTICIAN AND
I'M CERTAINLY NOT AN
EPIDEMIOLOGIST, BUT FORTUNATELY
I HAVE REALLY GOOD FRIENDS WHO
ARE, SO I CALLED UP MY FRIEND AT
THE NATIONAL CANCER INSTITUTE
AND I SAID, KARI, CAN YOU TAKE
THESE NUMBER, NEW CASES AND
DEATHS, AND PUT THEM ON A SEMI
LOG SCALE, SEND IT BACK TO ME?
WELL, IT TOOK HER ABOUT 30
MINUTES TO DO, AND SHE SENT ME
BACK THE FIGURE ON THE RIGHT.
AND THIS SUBSEQUENTLY WAS
PUBLISHED IN NATURE REVIEWS, AND
IT MAKES A VERY SIMPLE BUT VERY
IMPORTANT POINT.
AGAIN, WE SEE INCIDENCE RISING
WITH AN ANNUAL PERCENTAGE CHANGE
OF 5.6%.
BUT NOW, WE NO LONGER SEE
MORTALITY FLAT.
WE NOW SEE MORTALITY RISING,
WITH AN ANNUAL PERCENTAGE CHANGE
OF 0.8% PER YEAR, AND THIS
SHOULD RAISE THE EYEBROWS IN THE
AUDIENCE OF ONCOLOGISTS,
SURGICAL ONCOLOGISTS.
WHY?
BECAUSE WE ARE WINNING THE WAR
ON CANCER IN THE UNITED STATES
AND THE WORLD.
THERE ARE ONLY A FEW DIAGNOSES
WHERE WE ARE NOT IMPROVING
PATIENT SURVIVAL.
ONE IS HEPATOCELLULAR CARCINOMA,
AND NOW WE KNOW A SECOND IS
ACTUALLY THYROID CANCER.
AND WITH THAT SIMPLE BACK OF THE
ENVELOPE CALCULATION COMING FROM
A QUESTION ABOUT A Y AXIS, YOU,
TOO, CAN PUBLISH AN ARTICLE OR
STUDY IN THE JOURNAL JAMA.
AND HERE IS DR. KETAHARA'S AND
MY STUDY REVISING THE WORK OF
WELCH AND DAVIES PUBLISHED IN
2017.
AND ESSENTIALLY WHAT WE DID IS
TO REDO THE WELCH AND DAVIES
STUDIES WITH TWO SIMPLE CHANGES.
LIKE WELCH AND DAVIES, WE
GARNERED OUR INCIDENCE DATA FROM
THE SEER 9 DATABASE WITH MORE
THAN 77,000 PATIENTS WITH
THYROID CANCER.
MANY OF YOU MAY HAVE USED THIS
DATABASE.
REPRESENTS ABOUT 10% OF THE U.S.
POPULATION AND CONTAINS A LOT OF
VERY VALUABLE DEMOGRAPHIC,
PATHOLOGIC AND CLINICAL
VARIABLES, ALL OF WHICH CAN
CONTRIBUTE TO SURVIVAL.
OUR THYROID CANCER MORTALITY
LIKE WELCH AND DAVIES CAME FROM
THE DEATH CERTIFICATE
INFORMATION FROM THE NATIONAL
CENTER FOR HEALTH STATISTICS.
BUT THEN WE CHANGED THE FIRST
THING FROM WELCH AND DAVIES, AND
THAT IS INSTEAD OF USING
MORTALITY, WE USED
INCIDENCE-BASED MORTALITY.
WHY?
BECAUSE IBM IS PROBABLY THE
SUPERIOR OUTCOME WHEN YOU ARE
LOOKING AT AN INDOLENT DISEASE
LIKE THYROID CANCER, WHERE THERE
IS A PAUCITY OF OUTCOME EVENTS,
SPECIFICALLY MORTALITY.
LIKE WELCH AND DAVIES, WE
CALCULATED AGE-ADJUSTED RATES
AND ANNUAL PERCENTAGE CHANGES
FROM JOINPOINT REGRESSION
ANALYSES.
THEN WE CHANGED THE SECOND THING
FROM WELCH AND DAVIES STUDY, AND
THAT IS WE CHANGED THE Y AXIS
FROM THE DATA WE PRESENT FROM AN
ARITHMETIC SCALE TO A SEMI LOG
SCALE.
AND LET'S LOOK AT WHAT WE FOUND.
STARTING WITH INCIDENCE.
AND I'M GOING TO, FOR THE
PURPOSES OF TIME, JUST FOCUS ON
PAPILLARY THYROID CANCER.
IT MAKES IT A MORE HOMOGENEOUS
PRESENTATION, AND AGAIN, THIS IS
MORE THAN 90% OF INCIDENCE
CASES.
FIRST WE LOOK AT INCIDENCE BASED
ON STAGE OF DISEASE.
AND YOU SEE LOCALIZED DISEASE,
THAT IS, DISEASE CONFINED TO THE
THYROID RISING AT 4.6% PER YEAR
ANNUAL PERCENTAGE CHANGE.
BUT THEN WE SEE SOMETHING
SURPRISING, AND THAT IS THE
INCIDENCE OF REGIONAL, MEANING
METASTATIC TO CERVICAL LYMPH
NODES, AND DISTANT DISEASE, ALSO
INCREASING.
THIS SHOULD NOT BE HAPPENING IF
ALL WE'RE TALKING ABOUT IS
SUBCLINICAL DISEASE, AND THIS IS
ALL OVERDIAGNOSIS.
NOW WE LOOK AT INCIDENCE BASED
ON THE SIZE OF THE TUMORS, AND
AS WELCH AND DAVIES SHOWED,
THESE PAPILLARY THYROID
CARCINOMAS LESS THAN
1 CENTIMETER IN SIZE RISING
RAPIDLY AT A RATE OF 9.3% PER
YEAR, BUT WE ALSO SEE TUMORS OF
ALL SIZES INCREASING IN
INCIDENCE, INCLUDING TUMORS OVER
4 CENTIMETERS IN SIZE AT A RATE
OF 6.1% PER YEAR.
THESE ARE ABOUT THE SIZE OF A
GOLF BALL.
NO ONE WOULD CLAIM THAT THESE
LARGE TUMORS ARE OVERDIAGNOSED.
AND THEN SWITCHING TO
INCIDENCE-BASED MORTALITY, WHERE
WELCH AND DAVIES HAD SEEN LEVEL
MORTALITY RATES OVER TIME, WE
NOW HAVE SEEN RISING MORTALITY
TRENDS OVER TIME FOR ALL STAGES
OF THYROID CANCER, AND FOR
TUMORS OF ALL SIZES, INCLUDING
TUMORS LESS THAN 2 CENTIMETERS
IN SIZE.
AT A RATE OF 6.8% PER YEAR.
POTENTIALLY LENDING CREDENCE
THAT THERE IS A FUNDAMENTAL
CHANGE IN THE BIOLOGIC PROFILE
OF THE DISEASE, PERHAPS RELATED
TO THE MOLECULAR UNDERPINNINGS
OF IT.
SO WHAT WERE OUR CONCLUSIONS?
LIKE WELCH AND DAVIES, WE AGREE,
AVERAGE INCREASE OF 3.6% OVER A
THREE-DECADE PERIOD AFFECTING
ALL SUBGROUPS ESPECIALLY FOR
PAPILLARY THYROID CARCINOMA.
BUT IN ADDITION TO WELCH AND
DAVIES WHO THOUGHT MORTALITY WAS
FLAT, WE FOUND INCIDENCE BASED
MORTALITY RISE BY MORE THAN 15%
OVER THIS PERIOD, IMPACTING ALL
DEMOGRAPHIC SUBGROUPS, AND AGAIN
ESPECIALLY TRUE FOR PAPILLARY
THYROID CARCINOMA.
SO YES, I DO AGREE WITH WELCH
AND DAVIES THAT OVERDIAGNOSIS IS
A LARGE PART OF THE EXPLANATION
OF THE EPIDEMIOLOGIC PHENOMENON
THAT WE SAW BUT IT IS NOT THE
ONLY EXPLANATION.
AND I WOULD ARGUE THAT WE ARE
DOING OURSELVES AND MORE
IMPORTANTLY OUR PATIENTS A
DISSERVICE IF WE DISTRACT
ATTENTION FROM A DISEASE WHERE
WE ARE POTENTIALLY LOSING, NOT
GAINING GROUND.
THAT'S ALL WELL AND GOOD, BUT
WHAT DO YOU THINK IS GOING ON,
AND I THINK THERE ARE
POTENTIALLY OTHER EXPLANATIONS
FOR WHAT IS GOING ON.
ONE OF THE IMPORTANT ONES IS
OVERWEIGHT AND OBESITY.
I THINK ALL OF YOU WILL BE
FAMILIAR WITH THE FIGURE ON THE
RIGHT, SHOWING INCREASING
PREVALENCE OF OVERWEIGHT AND
OBESITY AMONG ADULT AMERICANS.
BUT WHAT MANY OF YOU MAY NOT
KNOW IS THAT OVERWEIGHT AND
OBESITY BOTH APPEAR TO BE
ASSOCIATED WITH THIS RISE IN
INCIDENCE OF THYROID CANCER IN
RED, SHOWING THE THYROID CANCER
INCIDENCE THAT WE BELIEVE IS
ATTRIBUTABLE TO OVERWEIGHT AND
OBESITY, BUT WHAT IS REALLY
STRIKING IS THE FIGURE ON THE
RIGHT, WHERE WE BELIEVE
OVERWEIGHT AND OBESITY NOW
POTENTIALLY EXPLAIN MORE THAN
HALF OF INCIDENT CASES OF THE
MOST ADVANCED DISEASE.
THAT IS TUMORS OVER
4 CENTIMETERS IN SIZE.
AND THIS IS A STUDY I PUBLISHED
TOGETHER WITH DR. KETAHARA IN
THE JOURNAL OF THE NATIONAL
CANCER INSTITUTE.
WELL, FORTUNATELY THAT PART OF
THE DISEASE THAT WE UNDERSTAND
BETTER, THAT THAT IS RELATED TO
OVERDIAGNOSIS, WE HAVE GOTTEN
BETTER CONTROL.
HOW?
WITH CLINICAL PRACTICE
GUIDELINES, DISCOURAGING
SURVEILLANCE AND SCREENING OF
THYROID NODULES.
THE U.S. PREVENTIVE SERVICES
TASK FORCE HAS RECOMMENDED
AGAINST SUCH.
AND WE'VE ALSO CHANGED THE
NOMENCLATURE OF THYROID CANCER,
SUCH THAT YOU CAN SEE JUST OVER
THE LAST COUPLE OF YEARS, WE
HAVE BEGUN TO START TO,
QUOTE-UNQUOTE, FLATTEN THE
CURVE.
WELL, WHERE ARE WE TODAY, THEN,
AS COMPARED TO 20 OR 30 YEARS
AGO WITH REGARD TO THE
MANAGEMENT OF THYROID CANCER?
AND I'M A LITTLE FACETIOUS HERE,
BUT IT'S LIKE THE PROCESS OF
EVOLUTION.
WHAT WE ARE DOG DOING AND WHAT WE
ARE THINKING TODAY IN SOME WAYS
VERY MUCH RESEMBLES WHERE WE
WERE A LONG TIME AGO.
THESE ARE THE GUIDELINES THAT
DRIVE THE MANAGEMENT OF THYROID
CANCER IN THE UNITED STATES AND
PROBABLY THE WORLD.
THEY WERE LAST PUBLISHED IN 2015
BY THE ATA.
WHENEVER I TALK ABOUT
GUIDELINES, THEY ALWAYS SAY
FIRST UNDERSTAND WHO WROTE THE
GUIDELINES.
WHY?
BECAUSE ALL OF US BRING IMPLICIT
BIASES TO WHAT WE DO AND HOW WE
THINK.
SO THESE WERE THE FOUR AUTHORS
OF THOSE GUIDELINES PERTAINING
TO SURGERY.
THE ETA IN MANY WAYS IS VERY
EQUITABLE AND FAIR AND THAT IS
WONDERFUL.
TWO OF US WERE
OTOLARYNGOLOGISTS, ON THE LEFT.
TWO OF US WERE ENDOCRINE
SURGEONS ON THE RIGHT, TWO OF US
ON TOP HAD BEEN ON PRIOR
GUIDELINES, TWO OF US WERE
NEWBIES.
I WOULD SAY WE ARE STILL
STRUGGLING WITH GENDER EQUITY IN
THE THYROIDOLOGY COMMUNITY.
WELL, THE CURRENT GUIDELINES IN
MANY WAYS ARE NOT SO NOVEL IN
THAT THEY REFLECT PRINCIPLES AND
TENETS THAT SHOULD BE THE
UNDERPINNING OF ALL
CANCER-RELATED GUIDELINES.
WE WANT TO IMPROVE SURVIVAL, WE
WANT TO REDUCE THE RISK OF
RECURRENCE AND METASTATIC
SPREAD, LONG TERM SURVEILLANCE.
SO WHAT IS REALLY UNIQUE ABOUT
CURRENT GUIDELINES AND THESE
GUIDELINES IS THAT FOR THE FIRST
TIME, WE REALLY STRIVE TO
MINIMIZE TREATMENT-RELATED
MORBIDITY, AND IS THAT SUCH A
NOVEL CONCEPT?
I DON'T THINK SO.
IT'S WHAT WE DO EACH AND EVERY
DAY IN OUR CLINICS, AS
CLINICIANS.
WE WANT TO ON ONE HAND AVOID THE
OVERTREATMENT OF INDOLENT
DISEASE, BUT AT THE SAME TIME,
AVOIDING UNDERTREATMENT OF
CLINICALLY SIGNIFICANT CANCERS,
AND HOW DO WE DO IT?
WELL, WE HAVE TO WEIGH THE RISKS
OF MISDIAGNOSIS.
INCREASINGLY THE PATIENT IS AT
THE EPICENTER OF DECISION HAD
BEEN MAKING.
OF COURSE THERE ARE THE
OMNIPRESENT MEDICAL-LEGAL
CONSIDERATIONS AND WE ALWAYS
HAVE TO CONSIDER COST.
WELL, LET'S WORK OUR WAY THROUGH
THE GUIDELINES AND EVIDENCE AND
MAYBE CHALLENGE SOME OF THE
EVIDENCE THAT HAS BEEN CITED
UNTIL RECENTLY.
AND WE'RE GOING TO GO FROM SMALL
TO LARGE, INSIDE TO OUTSIDE THE
THYROID.
STARTING WITH THOSE TINY TUMORS,
I'VE TALKED ABOUT THEM NOW A
COUPLE OF TIMES, THESE PAPILLARY
THYROID MICRO CARCINOMAS LESS
THAN 1 CENTIMETER, RISING THE
FASTEST IN INCIDENCE.
AND IN 2014, THERE WAS A REALLY
PROVOCATIVE COMMENTARY PUBLISHED
BY TWO THYROIDOLOGISTS IN THE
JOURNAL THYROID, ASKING WHETHER
THE IDENTIFICATION AND
ERADICATION OF ALL OF THESE TINY
TUMORS IS REALLY A WORTHWHILE
GOAL, OR IF, RATHER, WE MAY NOT
WANT TO REMOVE THEM SURGICALLY
BUT RATHER LEAVE THEM IN AND
ACTIVELY SURVEIL THEM.
AND WHENEVER I GO BACK AND READ
THIS COMMENTARY, I ALWAYS SAY,
IF WE'RE GOING TO NOT REMOVE BUT
ACTIVELY SURVEIL, WE'D BETTER DO
IT MORE FASTIDIOUSLY THAN THE
EDITORS OF THE JOURNAL THYROID,
WHO MISSPELLED MICROPAPILLARY
THYROID CANCER.
SO A CAUTIONARY NOTE AROUND
ACTIVE SURVEILLANCE.
WELL, ARE THERE ANY DATA TO
SUGGEST WE CAN ACTIVELY SURVEIL
THESE TINY TUMORS?
WE'RE BUILDING SOME BODY OF
EVIDENCE HERE IN THE UNITED
STATES, BUT REALLY THE LARGEST
BODY OF WORK HAS COME FROM JAPAN
IN THE ETO RESEARCH GROUP.
THEY'VE PUBLISHED CYRIL SERIALLY ON A
COHORT OF PATIENTS THAT NOW WELL
EXCEEDS 1200 PATIENTS.
THIS IS MY FAVORITE STUDY FROM
THAT SERIES FROM 2014 LOOKING AT
1235 PATIENTS FOLLOWED FOR A
MEAN OF 75 MONTHS DIVIDED INTO
THREE AGE GROUPS, AND BASICALLY
ALL OF THESE PATIENTS HAD
PAPILLARY THYROID MICRO
CARCINOMAS AND THE TUMORS WERE
NOT REMOVED BUT FOLLOWED,
LOOKING FOR NODAL METASTASIS OR
PROGRESSION OF CLINICAL DISEASE
TO A TUMOR SIZE 1.2 CENTIMETERS
OR GREATER.
AND WHAT THE AUTHORS FIND IS
REALLY EXTRAORDINARY.
AT A DECADE, 10 YEARS, JUST 8%
OF THESE PATIENTS EXPERIENCED
ANY ENLARGEMENT OF THEIR TUMORS,
AND LESS THAN 4% OF THESE
PATIENTS DEVELOPED NODAL
METASTASES.
WHEN THE PATIENTS WERE DIVIDED
UP INTO AGE GROUPS, WHAT YOU SEE
IS THAT THE PROPORTION OF
PATIENTS WHO HAD THE MOST
PROGRESSION OF DISEASE WERE THE
YOUNGEST PATIENTS SHOWN IN THE
DOTTED LINE ON THE LEFT AND IN
THE RIGHT, AND IT WAS LOWEST
PROGRESSION FOR THE OLDEST
PATIENTS SHOWN IN THE SOLID
LINE, INDEED ON MULTIVARIATE
REGRESSION ANALYSIS, YOUNG AGE
WAS AN INDEPENDENT PREDICTOR OF
PROGRESSION.
LEADING THE AUTHORS TO CONCLUDE
THAT OLDER PATIENTS ARE PROBABLY
THE BEST PATIENTS TO ACTIVELY
SURVEIL OR OBSERVE RATHER THAN
OPERATE ON.
BUT EVEN IN YOUNG PATIENTS,
WHERE THERE IS THE MOST
PROGRESSIVE DISEASE, THERE
APPEARS TO BE PLENTY OF TIME TO
FOLLOW PATIENTS AND THEN RESCUE
PATIENTS WITH DELAYED SURGERY
AND WITHOUT AN IMPACT ON
SURVIVAL.
SO A LOT OF PEOPLE SAID, WELL,
LET'S EMBRACE ACTIVE
SURVEILLANCE IN THE UNITED
STATES.
LET'S JUST START DOING IF IT
WORKS IN JAPAN.
AND I'M SOMEONE WHO ALWAYS TAKES
A CAUTIONARY -- BEFORE WE DO
SOMETHING NEW, LET'S SEE WHAT
WE'RE DOING RIGHT NOW.
SO THIS IS THE STUDY FROM OUR
RESEARCH GROUP COMPARING
SURVIVAL AT A POPULATION LEVEL
FOR PATIENTS WITH PAPILLARY
THYROID MICRO CARCINOMAS TO THE
GENERAL U.S. POPULATION.
AND WHAT YOU SEE IS THAT IF
ANYTHING, PATIENTS WITH
PAPILLARY THYROID MICRO
CARCINOMAS, THEY LIVE LONGER
THAN THE AVERAGE AMERICAN.
WELL, A LOT OF PEOPLE SAY, HOW
IS THAT POSSIBLE?
HOW CAN YOU HAVE THYROID CANCER
AND LIVE LONGER THAN SOMEONE
WITH NO CANCER?
AND OF COURSE IF YOU HAVE A TWO
OR THREE OR FOUR-MILLIMETER
CANCER DISCOVERED AND TREATED IN
YOUR THYROID, YOU ALMOST
CERTAINLY HAVE BETTER HEALTHCARE
AND BETTER ACCESS TO HEALTHCARE
THAN THE AVERAGE AMERICAN, WHICH
MAY WELL CONVEY A SURVIVAL
ADVANTAGE.
WELL, RIGHT NOW IN THE UNITED
STATES, PEOPLE WITH THESE TINY
TUMORS ARE BEING OVERTREATED FOR
THEIR DISEASE.
NEARLY THREE QUARTERS OF THEM
ARE UNDERGOING TOTAL THYROID
THYROIDECTOMY, WHEN THE
RECOMMENDATIONS CURRENTLY ARE
FOR THYROID LOBECTOMY.
A LOT OF PEOPLE SAY WAIT A
MINUTE, JULIE ANN, YOU'RE
MISREPRESENTING THIS.
THESE ARE ACTUALLY PEOPLE WHO
ARE HAVING TOTAL THYROIDECTOMIES
BECAUSE THEY HAVE MULTINODULE
GOITER, GRAVES' DISEASE, OTHER
REASONS TO HAVE THEIR WHOLE
THYROID TAKEN OUT, AND ONLY ON
THE SURGICAL HISTOPATHOLOGY IS
THE TINY CANCER IDENTIFIED.
SO IT WAS NOT THE REASON FOR THE
SURGERY.
BUT I WOULD SAY, UH-UH.
WHY DO I SAY THAT?
BECAUSE THESE PATIENTS NOT ONLY
HAD THEIR WHOLE THYROID REMOVED
FOR A TINY, TINY CANCER, BUT A
THIRD OF THEM GO ON TO ALSO
UNDERGO ADJUVANT RADIOACTIVE
IODINE.
SO WHAT DO THE GUIDELINES
CURRENTLY RECOMMEND IN THE
UNITED STATES?
THYROID LOBECTOMY IS THE
OVERWHELMING RECOMMENDATION, BUT
THE GUIDELINES FOR THE FIRST
TIME INTRODUCE THE WORD "IF.
"IF SURGERY IS CHOSEN.
MEANING THE DOOR WAS OPENED A
CRACK TO PERMIT THE APPLICATION
OF ACTIVE SURVEILLANCE IN VERY
SPECIFIC CIRCUMSTANCES.
WELL, LET'S SWITCH GEAR AND GO
ONE SIZE UP AND TALK ABOUT THE
BREAD AND BUTTER OF THYROID
CANCER PRESENTATION, WHICH IS A
LOW RISK DIFFERENTIATED THYROID
CANCER.
1 TO 4 CENTIMETERS IN SIZE,
CONFINED TO THE THYROID, THAT
HAS NOT SPREAD OUTSIDE THE
THYROID OR METASTASIZED TO LYMPH
NODES.
THIS IS THE AGE-OLD DEBATE,
TOTAL THIGH ROADECTOMY VERSUS
LOBECTOMY, THE REMOVAL OF HALF.
THOSE WHO ARGUE FOR TOTAL
THYROIDECTOMY SAY THERE'S OFTEN
BILATERAL AND MULTIFOCAL
DISEASE.
WE MAY WANT TO GIVE RADIOACTIVE
IODINE AFTER SURGERY AND FOR
THAT, YOU WANT YOUR WHOLE
THYROID REMOVED.
AND ZEROING OUT THE THYROID
GLOBULIN LEVEL OF TUMOR MARKER
IS DONE WITH TOTAL
THYROIDECTOMY, MAKING BIOMARKERS
A USEFUL ADJUNCT.
THOSE WHO COUNTER AND ARGUE FOR
LOBECTOMY SAYS WHO WANTS
SUPPLEMENTATION LET ALONE
THYROID HORMONE REPLACEMENT?
IT'S AN INDOLENT DISEASE WITH AN
EXCELLENT PROGNOSIS, AND BIGGER
SURGERY IMPLIES MORE
COMPLICATIONS.
WELL, UNTIL VERY RECENTLY, WE
PERFORMED TOTAL THYROIDECTOMY
FOR ALL OF THESE PATIENTS.
WHY DID THE AMERICAN THYROID
ASSOCIATION RECOMMEND THAT?
AGAIN, IT'S AMAZING HOW LITTLE
EVIDENCE THERE IS FOR MANY OF
THE THINGS THAT WE THINK ARE
STANDARD PRACTICE.
IT WAS A SINGLE STUDY PUBLISHED
BY BILIMORIA ET AL. IN 2007
LOOKING AT MORE THAN 52,000
PATIENTS FROM THE NATIONAL
CANCER DATABASE.
AND I'M JUST GOING TO CUT TO THE
CHASE.
HERE'S THE PIVOTAL FIGURE FROM
THAT ARTICLE COMPARING PATIENTS
WHO UNDERGO LOBECTOMY TO TOTAL
THYROIDECTOMY.
AND WHAT YOU SEE IS IF YOU
UNDERGO A LOBECTOMY, YOU ARE 31%
MORE LIKELY TO DIE THAN IF YOU
HAD UNDERGONE TOTAL
THYROIDECTOMY FOR YOUR LOW RISK
DIFFERENTIATED THYROID CANCER.
PRETTY COMPELLING, AND THE
REASON WHY THE ATA MADE THE
RECOMMENDATION IT DID.
BUT THEN AFTER THAT BILIMORIA
STUDY WAS PUBLISHED, YOU , A FEW
PEOPLE SCRATCHED THEIR HEADS AND
SAID WELL, THERE ARE SOME
VARIABLES THAT SEEM TO HAVE BEEN
MISSING FROM THAT NATIONAL
CANCER DATABASE, AND THEN IN
2010, MENDELSOHN LOOKED AT MORE
THAN 22,000 PATIENTS IN A
DIFFERENT DATASET, BUT WAS
UNABLE TO DEMONSTRATE A SURVIVAL
ADVANTAGE WITH TOTAL
THYROIDECTOMY.
SO SOMETIMES THE BEST SCIENCE
DOES NOT COME FROM ASKING A NEW
QUESTION, RATHER, IT COMES FROM
ASKING AN OLD QUESTION BUT IN A
NEW WAY.
SORT OF LIKE DR. KETAHARA AND I
DID AROUND THE EPIDEMIOLOGY OF
THIS EPIDEMIC OF THYROID CANCER.
SO THIS IS A STUDY AGAIN
PUBLISHED BY OUR RESEARCH GROUP
BUT THIS TIME LED BY A LEARNER.
THIS IS DR. MOHAMED ADAM WHEN HE
WAS A THIRD YEAR RESIDENT AT
DUKE UNIVERSITY.
WHAT WE DID IN THIS STUDY WAS
ESSENTIALLY REDO THE BILIMORIA
STUDY BUT WITH AN EMBELLISHED
DATASET.
SO LIKE BILIMORIA, WE USED THE
NATIONAL CANCER DATABASE
COMPARING SURVIVAL FROM TOTAL
THYROIDECTOMY TO THYROID
LOBECTOMY, BUT THIS TIME,
ENRICHING THE DATASET FOR MANY
VARIABLES THAT WERE MISSING FOR
BILIMORIA BUT BY WHICH COULD WELL
IMPACT SUR VIE. WE HAD MORE THAN
61,000 PATIENTS, LOBECTOMY ON
THE LEFT, TOTAL THYROIDECTOMY ON
THE RIGHT.
HERE YOU'LL SEE DEMOGRAPHIC
VARIABLES.
P VALUES THAT ARE STATISTICALLY
SIGNIFICANT BUT I WOULD ARGUE
NOT CLINICALLY SIGNIFICANT, BUT
THESE DEFINITELY ARE.
AND ALL OF THESE VARIABLES HAD
BEEN MISSING FOR BILIMORIA,
PRESENT FOR US AND DEFINITELY
RELEVANT TO SURVIVAL.
NOT REALLY -- IT'S SURPRISING,
MORE MULTIFOCAL DISEASE, MORE
EXTRA THIGH THYROIDAL EXTENSION, AND
MORE POSITIVE SURGICAL MARGINS
IN THE TOTAL THYROIDECTOMY
GROUP.
BUT WHEN WE TOOK THIS ENRICHED
DATASET AND REPLICATED THE
ANALYSES OF BILIMORIA, THE
SURVIVAL ADVANTAGE OF TOTAL
THYROIDECTOMY DISAPPEARED.
AND SURVIVAL IS COMPARABLE FOR
TOTAL THYROIDECTOMY AND
LOBECTOMY.
SO HERE ARE GUIDELINES FROM THE
ATA RECOMMENDING TOTAL
THYROIDECTOMY FOR THE
OVERWHELMING MAJORITY OF
PATIENTS WITH LOW RISK DISEASE,
AND HERE ARE THE 2015 GUIDELINES
WHERE TOTAL THYROIDECTOMY OR
THYROID LOBECTOMY ARE EQUIVALENT
WITH REGARD TO SURVIVAL, AND,
THEREFORE, BOTH ARE TREATMENT
OPTIONS FOR PATIENTS.
IN THE END, SHOULD I MAKE THIS
DECISION OR RECOMMENDATION?
I DON'T THINK SO.
I THINK ALL OF US, IF WE'RE GOOD
CLINICIANS, WISE CLINICIANS, WE
PRESENT THE RISK AND BENEFITS OF
BOTH TREATMENT ALTERNATIVES TO
OUR PATIENTS, AND WE ALLOW THE
PATIENTS TO EXERCISE THEIR
PREFERENCES BASED ON THEIR
VALUES.
BUT AGAIN, GUIDELINES
TRANSFORMED BY A LEARNER DOING
IMPACTFUL RESEARCH BASED ON AN
OLD QUESTION ANSWERED IN A NEW
WAY.
WELL, LET'S NOW CHANGE GEARS
AGAIN AND WE'RE GOING TO HOP
OUTSIDE THE THYROID, AND WE'RE
GOING TO TALK ABOUT THE LYMPH
NODES AROUND THE THYROID THAT
MIGHT CONTAIN METASTATIC
DISEASE.
JUST A QUICK PRIMER.
THIS IS THE STATE YOUR STATE YOUR STAGES SYSTEM FOR
DIFFERENTIATED THYROID CANCER.
IT'S QUIRKY AND WEIRD.
THIS IS THE AJCC STAGING SIM
CYST TEM.
WHAT YOU NEED TO KNOW IS A
SIMPLE THING.
IF YOU ARE YOUNG, THIS IS THE
SEVENTH EDITION, WE'RE NOW ON
THE EIGHTH EDITION.
BUT IF YOU'RE YOUNG, THEN UNDER
45 YEARS, NOW WITH THE EIGHTH
EDITION, UNDER 55 YEARS, YOU CAN
ONLY BE STAGE ONE I OR STAGE II,
BASED ON WHETHER YOU HAVE EXTRA
CERVICAL METASTASES.
SO DISTANT METASTATIC DISEASE.
IF YOU'RE OVER 45 IN THE SEVENTH
EDITION, IN THE EIGHTH EDITION,
OVER 55, YOU CAN BE STAGE I, II,
III OR IV.
SO WHAT'S THE BIG DIFFERENCE?
IF YOU ARE YOUNG AND YOU HAVE
METASTATIC DISEASE IN THE NECK,
WE DO NOT TREAT YOU DIFFERENTLY
FROM NOT HAVING METASTATIC
DISEASE, BUT IF YOU ARE OLDER,
WE UPSTAGE YOU FOR THE NODAL
METASTASES.
SO I'LL JUST TELL YOU, THIS IS
SUPER QUIRKY.
THERE IS NO OTHER CANCER STAGING
SYSTEM THAT DEPLOYS AGE IN THIS
WAY.
SO I SCRATCHED MY HEAD AND SAID,
WHY DO WE DO SOMETHING
DIFFERENTLY FOR THYROID CANCER
THAN EVERY OTHER SOLID TUMOR
UNKNOWN TO MAN?
SO I TERNED TO MY MENTEE LEARNER
AND ACADEMIC SURGEON
EXTRAORDINARIE KNOW HAMED ADAM,
AGAIN A THIRD YEAR WHEN HE DOES
THIS STUDY WITH AN IMPACT FACTOR
OF NEARLY 30.
AND WHAT WE ASKED IS A SIMPLE
QUESTION.
DO LYMPH NODE METASTASES IN
YOUNG PEOPLE REALLY MEAN
NOTHING?
OR DO THEY, IN FACT, IN
CONTRADICTION TO STAGING
SYSTEMS, IMPACT SURVIVAL, AND IF
THEY DO, DOES THE VOLUME OF
METASTATIC DISEASE HAVE
RELEVANCE?
SO TO ANSWER THAT QUESTION,
DR. ADAM AND OUR RESEARCH GROUP
LOOKED AT TWO LARGE POPULATION
LEVEL DATABASES, THE NATIONAL
CANCER DATABASE AND SEER.
I'VE SHOWN YOU BOTH OF THESE
STUDIES BEFORE.
THEY CONTAIN A LOT OF
DEMOGRAPHIC, CLINICAL AND
PATHOLOGIC VARIABLES, ALL OF
WHICH CAN PREDICT SURVIVAL, AND
AGAIN WHEN PREDICTED SURVIVAL IS
OUT COME BECAUSE THAT IS WHAT
STAGING SYSTEMS ARE TO COULD,
NOT PREDICT RECURRENT OR
PERSISTENT DISEASE.
VERY SIMPLE STUDY DESIGN.
OUR FOCUS WAS ON YOUNG PATIENTS,
SO WE USED THE SEVENTH EDITION,
LESS THAN 45 YEARS OF AGE, AND
WE DIVIDED THESE PATIENT INTO
TWO GROUPS.
THOSE WHO HAD CERVICAL LYMPH
NODE METASTASES AND THOSE WHO
DID NOT HAVE CERVICAL LYMPH NODE
METASTASES.
WE DID UNADJUSTED AND ADJUSTED
SURVIVAL ANALYSIS, AND THEN WE
DID SOMETHING COOL, AND THIS IS
WHY YOU ALWAYS WANT TO HAVE
BIOSTATISTICIANS AS MEMBERS OF
YOUR RESEARCH TEAM, AND THAT IS,
WE DEPLOYED RESTRICTIVE CUBIC
SPLINES.
NOW IF YOU'RE NOT ALREADY ASLEEP
FROM MY PRESENTATION, AND I HOPE
YOU'RE NOT, PLEASE WAKE UP FOR
THIS, BECAUSE THIS IS A REALLY
COOL TOOL TO HAVE IN YOUR
TOOLKIT IF YOU DO HEALTH
SERVICES RESEARCH.
SO WHETHER YOU KNOW IT OR NOT,
WHEN YOU DO MULTIVARIABLE
REGRESSION ANALYSIS, THERE IS AN
ASSUMPTION OF A LINEAR
ASSOCIATION BETWEEN YOUR
DEPENDENT AND YOUR INDEPENDENT
VARIABLES.
SO WHAT DOES THAT MEAN?
SO I'M KIND OF SIMPLE SO LET'S
KEEP IT SIMPLE.
SO YOU'RE DRIVING SUPER FAST ON
THE HIGHWAY AND YOU HEAR A SIREN
BEHIND YOU BECAUSE YOU ARE GOING
TOO FAST.
THE POLICE ARE THERE SO YOU SLAM
ON THE BRAKES.
WHAT WE KNOW IS THAT THE FASTER
YOU WERE TRAVELING, THE LONGER
IT TAKES TO STOP.
SO THAT'S A LINEAR ASSOCIATION.
WELL, I'M FROM CANADA, I'M FROM
MONTREAL, AND IN MONTREAL, WE
TALK ABOUT TWO THINGS: COLD AND
COLDER.
AND SO THESE ARE THE SEASONAL
TEMPERATURES IN MONTREAL OVER
THE COURSE OF A YEAR.
NOT SURPRISINGLY, IN THE WINTER,
IT IS COLD, AND IN THE SUMMER,
IT IS LESS COLD.
BUT YOU CANNOT FIT THE SEASONAL
VARIATION IN TEMPERATURE TO A
STRAIGHT LINE.
SO THERE IS A NON-LINEAR
ASSOCIATION HERE, AND A
REGRESSION ANALYSIS WOULD BE
POORLY SERVED.
SO WHAT DO RESTRICTIVE CUBIC
SPLINES DO?
THEY RELAX THE LINEARITY
ASSUMPTION THAT IS OTHERWISE
MADE IN MULTIVARIABLE REGRESSION
ANALYSIS.
AND I'LL SHOW YOU HOW WE
DEPLOYED IT.
BUT LET'S START WITH OUR
SURVIVAL ANALYSIS, AND PLEASE
SEE HERE, WE ARE PREDICTING
DEATH, NOT SURVIVAL.
AND WE ARE COMPARING YOUNG
PATIENTS WHO DO NOT HAVE
CERVICAL LYMPH NODE METASTASES
SHOWN IN THE SOLID LINE TO THOSE
WHO DO HAVE CERVICAL LYMPH NODE
METASTASES SHOWN IN THE DOTTED
LINE.
AND WHAT YOU SEE IS THAT IF YOU
ARE YOUNG AND YOU HAVE CERVICAL
LYMPH NODE METASTASES, YOU ARE
MORE LIKELY TO SUCCUMB TO YOUR
DISEASE THAN IF YOU DON'T.
THIS FLIES IN THE FACE OF
CURRENT STAGING SYSTEMS,
STATISTICALLY AND CLINICALLY
SIGNIFICANT.
WE THEN CHANGED FROM THE NCDB TO
SEER, AND WE COME TO EXACTLY THE
SAME CONCLUSION, PERHAPS EVEN A
BIGGER DIFFERENCE IN SURVIVAL
BETWEEN THOSE WITH AND THOSE
WITHOUT CERVICAL LYMPH NODE
METASTASES.
AND THE VOLUME OF CERVICAL LYMPH
NODE METASTASES MATTERS.
WHAT WE FOUND USING RESTRICTIVE
CUBIC SPLINES IS THAT EVERY
INCREMENTAL METASTATIC LYMPH
NODE UP TO THE NUMBER 6 CONFERS
A DECREMENT IN SURVIVAL.
AND AFTER 6, THERE IS NO
ASSOCIATION.
SO WHAT DID WE CONCLUDE FROM
THIS IMPORTANT STUDY ?L CERVICAL
LYMPH NODE METASTASES DO APPEAR
TO BE ASSOCIATED WITH
COMPROMISED SURVIVAL AMONG YOUNG
PATIENTS.
UNFORTUNATELY IN THE SEVENTH AND
THE EIGHTH EDITION, YOUNG
PATIENTS WITH NODAL METASTASES
ARE BEING UNDERSTAGED.
AND IF YOU ARE UNDERSTAGED FOR
YOUR DISEASE, YOU ARE ALMOST
CERTAINLY ALSO BEING
UNDERTREATED FOR YOUR DISEASE.
NOW, I'M NOT STRONG AND POWERFUL
LIKE THE AJCC/UICC, BUT I CAN
CHANGE WHAT I DO IN MY PRACTICE.
AND THE IMPLICATIONS OF THESE
RESEARCH FINDINGS FOR OUR
CLINICAL GROUP IS THAT WE MORE
RIGOROUSLY PREOPERATIVELY SCREEN
YOUNG PATIENTS LOOKING FOR LYMPH
NODE METASTASES, AND IF WE FIND
THEM, WE PERFORM SIMULTANEOUS
LIMB FAD NECT
LYMPHADENECTOMY.
THE FINAL STUDY I WANT TO
PRESENT ABOUT CHANGING WHAT WE
DO IS NOT A CASE OF WHERE LESS
IS MORE, BUT RATHER WHERE MORE
IS MORE, AND WE'RE GOING TO GO
FULL CIRCLE BACK TO ERRS STO
TELL AND ARISTOTLE
AND THE CLINICAL SURGEON AND
MORE IS BETTER.
AND THIS IS THE ASSOCIATION
BETWEEN SURGEON EXPERIENCE AND
PATIENT OUTCOMES, PRACTICE MAKES
PERFECT, AND A FINAL EXAMPLE OF
HOW DR. ADAM, AS A LEARNER, HAS
TRANSFORMED HOW WELL THINK IN
OUR THYROIDOLOGY COMMUNITY.
SO AS MANY OF YOU KNOW, THERE IS
A LARGE BODY OF EVIDENCE IN
SURGERY AND IN OTHER FIELDS THAT
DEMONSTRATES THE MORE YOU DO OF
SOMETHING, ON AVERAGE, THE
BETTER YOU ARE AT DOING IT.
AND THIS HAS BEEN SHOWN FOR A
NUMBER OF DIFFERENT SURGICAL
PROCEDURES AND DIAGNOSIS,
INCLUDING THYROIDECTOMY.
BUT WHEN YOU LOOK AT THE
LITERATURE, IT'S VERY
INTERESTING.
YOU FIND THAT DIFFERENT AUTHORS
HAVE DEFINED VOLUME THRESHOLDS
DIFFERENTLY, BUT NO ONE HAS
TREATED SURGEON VOLUME AS THE
CONTINUOUS VARIABLE THAT IT IS.
I DO FIVE CASES A YEAR, SHE DOES
10 CASES A YEAR, HE DOES 15
CASES A YEAR.
IT'S A CONTINUOUS, NOT A
CATEGORICAL VARIABLE.
SO WHAT WE DID IN OUR RESEARCH
GROUP IS FOR THE FIRST TIME,
LOOK AT SURGEON VOLUME AS A
CONTINUOUS VARIABLE, TRYING TO
UNDERSTAND A THRESHOLD.
IS THERE A THRESHOLD EFFECT AS
THERE WAS WITH THE NUMBER OF
LYMPH NODES AND THE RISK OF
SURVIVAL THAT IS ASSOCIATED WITH
IMPROVEMENT IN PATIENT OUTCOMES.
SO HERE IS ANNUAL SURGEON VOLUME
OF TOTAL THYROIDECTOMY AT THE
POPULATION LEVEL.
IT RANGES FROM 1 TO 157 TOTAL
THYROIDECTOMIES A YEAR FOR
THYROID SURGEONS.
WE THEN TOOK OUR RESTRICTIVE
CUBIC SPLINES, LOOKING TO SEE IF
THERE IS A THRESHOLD.
AND WHAT WE FOUND IS SOMETHING
VERY INTERESTING AND NO VILLE,
AND THAT IS, EACH INCREMENTAL
THYROID OPERATION THAT A SURGEON
DOES UP TO THE NUMBER 25, ON
AVERAGE, APPEARS TO CONFER AN
OUTCOMES ADVANTAGE TO THEIR
PATIENT, BUT AFTER 25
THYROIDECTOMIES A YEAR, THERE IS
NO ASSOCIATION BETWEEN SURGEON
VOLUME AND PATIENT OUTCOMES.
AND IT'S INTERESTING, IF YOU GO
BACK AND LOOK AT THE LITERATURE,
WHERE PEOPLE HAVE USED DIFFERENT
CUT POINTS AS CATEGORICAL CUT
POINT VARIABLE DEFINITIONS,
NOBODY HAD USED THE NUMBER 25,
WHICH IS EVIDENCE-DRIVEN.
SO NOW FOR THE FIRST TIME, WE
HAVE THE DEFINITION OF WHAT A
HIGH VOLUME THYROID SURGEON IS,
WE THEN REDEFINE LOW AND HIGH
VOLUME BASED ON THAT CUT POINT,
AND WHAT YOU SEE IS SOMETHING
DRAMATIC.
IF YOU HAVE SURGERY BY A LOW
VOLUME SURGEON, YOU'RE 55% MORE
LIKELY TO HAVE A COMPLICATION,
AND SIGNIFICANTLY LONGER LENGTH
OF STAY AS A RESULT, AND HIGHER
COSTS.
NOW, I UNDERSTAND ASSOCIATION IS
NOT CAUSATION.
BUT HERE IS THE DOSE-RESPONSE
CURVE FOR VOLUME AND OUTCOMES.
YOU SEE HOW BEAUTIFULLY THE TWO
ARE ALIGNED.
PERHAPS THE MOST SHOCKING DATA
THAT I AM SHOWING YOU TODAY AND
DISCOURAGING IS THAT MORE THAN
HALF OF SURGEONS DOING THYROID
OPERATIONS IN THE UNITED STATES
TODAY DO JUST ONE PER YEAR.
WHAT'S IMENT PUBLICATION OF
THAT?
THE IMPLICATION IS THAT THE
MAJORITY OF PATIENTS IN THE
UNITED STATES UNDERGOING THYROID
SURGERY ARE UNDERGOING SUCH
SURGERY BY LOW VOLUME SURGEONS
AND, THEREFORE, ARE BEING
EXPOSED TO ADDITIONAL RISK.
IS THIS IMPORTANT?
IT SURE IS.
IT'S IMPORTANT BECAUSE THYROID
SURGERY IS ONE OF THE 10 MOST
COMMONLY PERFORMED OPERATIONS IN
THE UNITED STATES.
AND WHEN DR. ADAM PUBLISHED HIS
STUDY IN THE ANNALS OF SURGERY,
YOU THINK, WHO SAW THAT?
I'LL TELL YOU WHO SAW IT.
"THE NEW YORK TIMES" SAW IT,
HERE IS THEIR ARTICLE ON THE
LEFT, AND HERE IS "THE
WASHINGTON POST'S" COVERAGE OF
THIS SCIENCE.
INCREDIBLY IMPACTFUL.
AND PERHAPS AS A RESULT OF THE
MEDIA COVERAGE, BLUE CROSS AND
BLUE SHIELD CALLED ME ABOUT A
MONTH AFTER PUBLICATION TO SAY,
SHOULD WE BE CHANGING HOW WE
REFER PATIENTS FOR THYROID
SURGERY AND PERHAPS JUST AS
IMPORTANTLY, HOW WE REIMBURSE
THYROID SURGERY.
SO WHERE WOULD I LIKE TO LEAVE
YOU?
I THINK THE FIRST IS TO
UNDERLINE THE IMPORTANCE OF
EVIDENCE.
EVIDENCE FROM HEALTH SERVICES
RESEARCH, AND HOW EVIDENCE CAN
TRANSFORM PRACTICE.
I THINK SECONDLY, ALL OF US HAVE
TO BE OPEN TO CHANGE.
I THINK ALL OF US IN OUR MINDS
MAY HAVE A SENSE OF WHAT WE
BELIEVE IS THE RIGHT THING TO
DO, BUT WE NEED TO BE OPEN TO
NEW EVIDENCE AND THEN AMEND OUR
PRACTICE, AND IT'S SOMETHING
I'VE LEARNED THE HARD WAY, I
USED TO DO TOTAL THYROIDECTOMIES
FOR ALL OF MY THYROID CANCER
PATIENT, BUT I NOW USE IT
PROBABLY LESS THAN HALF THE
TIME.
AND AS YOU HEARD, I'M BLESSED TO
BE ABLE TO CO-CHAIR THE NEXT
GUIDELINES-WRITING COMMITTEE FOR
THYROID CANCER FROM THE AMERICAN
THYROID ASSOCIATION.
I ALSO HAVE A FEW MESSAGES FOR
THE LEARNERS AND JUNIOR FACULTY
IN THE AUDIENCE.
I'VE TALKED THIS WHOLE HOUR
ABOUT A SMALL GLAND THAT WEIGHS
30 OR 40 GRAMS, AND MANY WOULD
SAY, WHY DON'T YOU DO SOMETHING
MORE THAN THAT?
BUT I THINK IT'S IMPORTANT AS
YOU DEFINE YOUR CAREER AS AN
ACADEMIC PHYSICIAN OR SCIENTIST
TO BUILD UP AND NOT ACROSS.
TO BUILD A BODY OF RESEARCH
WHERE YOU BECOME THE WORLD
EXPERT IN A TOPIC, AND WITH THAT
FUND OF KNOWLEDGE AND SKILLSET,
YOU CAN CHALLENGE PREVAILING
THOUGHTS.
WELL, WHEN YOU'RE A LEARNER,
IT'S REALLY HARD TO KNOW WHAT
THE RIGHT QUESTIONS ARE.
AND THAT'S WHERE A MENTOR PLAYS
A ROLE.
DR. ADAM DID ALMOST ALL OF THE
HEAVY LIFTING, BUT WHAT WAS MY
ROLE AS HIS MENTOR?
TO HELP ASK THE QUESTION OR TO
FIGURE OUT HOW TO ASK THAT OLD
QUESTION IN A NEW WAY.
SO I WENT TO PRINCETON, AND ANY
TIME YOU TALK TO A PRINCETON
PERSON, THEY HAVE TO HAVE AN
ALBERT EINSTEIN QUOTE, BECAUSE
EINSTEIN SPENDS A LOT OF TIME AT
THE INSTITUTE FOR ADVANCED
STUDIES AT PRINCETON, AND THIS
IS MY FAVORITE EINSTEIN QUOTE,
SO TRUE.
"IF I HAD AN HOUR TO SOLVE A
PROBLEM AND MY LIFE DEPENDED ON
IT, I WOULD USE THE FIRST 55
MINUTES DETERMINING THE PROPER
QUESTIONS TO ASK."
AND I WOULD ARGUE THE BEST
SCIENCE DOESN'T ALWAYS COME FROM
NEW QUESTIONS, IT CAN COME FROM
OLD QUESTIONS THAT ARE REVISITED
IN NEW WAYS.
MAYBE A NEW TWIST, MAYBE A NEW
PRESENTATION.
MAYBE A NEW DATASET.
BUT REMEMBER, IF YOU'RE A
LEARNER OR A JUNIOR FACULTY
MEMBER, MENTORS ARE NOT
PANACEAS.
YOU ARE WHO YOU ARE.
THEY CAN SHAPE YOU, HELP AND
PROMOTE YOU, BUT ALL OF US MUST
TAKE OWNERSHIP FOR OUR OWN
SUCCESS OR FAILURE.
SO I WANTED TO CLOSE WITH
DR. ADAM, THAT GUY WHO IS THE
THIRD YEAR RESIDENT AT DUKE.
HERE WE ARE AT HIS GRADUATION
DINNER FROM DUKE WHEN HE
FINISHED THE GENERAL SURGERY
TRAINING PROGRAM.
I BET YOU KNOW WHERE HE IS NOW.
THAT'S RIGHT, HERE HE IS,
BECOMING A NEW FACULTY MEMBER
AND ASSISTANT PROFESSOR AT UCSF.
AND I JUST WANT TO FINISH BY
SAYING, I EXPECT DR. ADAM TO BE
THE FUTURE OF SURGICAL SCIENCE,
GUIDED BY MENTORS, BUT REALLY
THE VOICE THAT WILL HELP US
IDENTIFY THE BEST PATH FORWARD.
PLEASE BE OPEN MINDED IN
EVERYTHING YOU DO.
SERENDIPITY IS AN INCREDIBLY
POWERFUL FORCE.
AND TO EVERYTHING, INCLUDING
PREVAILING THOUGHTS HELD BY ALL
OF THE THOUGHT LEADERS IN A
FIELD, HAVE THE COURAGE TO USE
NEW EVIDENCE TO CHALLENGE
CONVENTION.
THAT TAKES COURAGE AND SCIENCE.
ALL OF US ARE LEADERS, YES, I'M
A CHAIR OF SURGERY, BUT I WOULD
ARGUE THE MORE POWERFUL FORM OF
LEADERSHIP IS THOUGHT
LEADERSHIP.
AND ALL OF US ARE THOUGHT
LEADERS IN OUR OWN WAYS.
AND THIS WAS A RECENT TWITTER
EXCHANGE IN THE ACADEMIC SURGERY
COMMUNITY, TALKING ABOUT THE
PACE AND CADENCE OF CHANGE AND
THE IMPORTANCE OF LEADERS
LEADING FORWARD THAT CHANGE.
AND THIS IS HOW AMERICAN SURGERY
IS CHANGED, CHANGING THE
ASSOCIATION FOR ACADEMIC SURGE
REAL, ONE OF THE LARGEST
ORGANIZATIONS IN OUR DISCIPLINE.
LOOK AT OUR CURRENT LEADERS.
SO SPECTACULAR, AND YET SO
DIVERSE.
AND FINALLY, FINISHING WITH
ANOTHER TWITTER EXCHANGE, THIS
IS DR. AHMAD WHO ASKED ON
TWITTER, WHAT'S THE MOST
POWERFUL ADVANCEMENT IN SURGERY
THAT HAS OCCURRED OVER THE LAST
30 YEARS?
AND PEOPLE TALKED ABOUT ROBOTICS
AND LAP LAPAROSCOPY, AND I SAID,
"THE DIVERSIFICATION OF SURGERY,
HANDS DOWN."
AND I HOPE THAT ALL OF YOU TODAY
WILL TAKE AWAY SOME LESSONS
AROUND DOING SCIENCE AND HEALTH
SERVICES RESEARCH, ABOUT
STUDYING THYROID CANCER, BUT
ALSO ABOUT CHANGING OUR ACADEMIC
COMMUNITY, LEADING TO GREATER
DIVERSIFICATION, WHICH ALSO I
BELIEVE WILL LEAD TO GREATER
CREATIVITY AND INNOVATION.
TO THE NIH, THANK YOU SO MUCH
FOR THE PRIVILEGE OF GIVING
THESE GRAND ROUNDS.
>> THANK YOU SO MUCH, DR. SOSA.
THAT WAS INCREDIBLY
THOUGHT-PROVOKING.
NOT ONLY AS SOMEONE WHO STUDIED
THE THYROID PRETTY EXTENSIVELY
DURING THE LATTER PART OF MY
SURGICAL TRAINING.
WE'RE WAITING TO SEE IF WE GET
SOME FEEDBACK FROM SOME OF OUR
VIEWER, BUT I HAD A COUPLE OF
QUESTIONS AND I THINK THE FIRST
ONE REALLY SPOKE TO THE CONTENT,
YOUR WORK WITH OUTCOMES RESEARCH.
AND I KNOW THAT ONE OF THE
THINGS THAT WE DISCUSSED WITH
DIVERSITY AND INCLUSION AND
PARTICULARLY EQUITY IS THAT WE
HAVE GREAT HEALTHCARE DESERTS IN
THIS COUNTRY, AND SO HOW DO YOU
SEE THE INTERSECTION OF WANTING
TO PROMOTE OUTCOMES RESEARCH AND
WANTING EVERY PATIENT TO HAVE
THEIR THYROIDECTOMY DONE BY
SOMEONE WHO DOES ONE EVERY OTHER
WEEK VERSUS THESE GREAT SWATHS
THAT THE PUBLIC HEALTH CRISIS
THAT WE HAVE WHERE THERE ARE
MANY COMMUNITIES WHERE THERE'S
NOT A SURGEON AROUND FOR 50
SQUARE MILES?
>> YEAH, THAT'S A REALLY GOOD
QUESTION, AND YOU'VE HIGHLIGHTED
ONE OF MY MANY SHORTCOMINGS AND
LIMITATIONS, AND THAT IS, I'M A
PRETTY GOOD SURGEON AND A PRETTY
GOOD SCIENTIST BUT NOT A GREAT
PROBLEM-SOLVER, MEANING POLICY
MAKER, RIGHT?
I THINK THE POINT YOU'RE MAKING,
WHICH IS THE POINT I HAD TO MAKE
TO BLUE CROSS/BLUE SHIELD AND
ANTHEM IS, YES, IN A PERFECT
WORLD, EVERY AMERICAN WHO NEEDS
THEIR THYROID OUT WOULD HAVE
ACCESS TO A HIGH VOLUME THYROID
SURGEON.
THE FACT OF THE MATTER IS, THERE
ARE NOT ENOUGH HIGH VOLUME
SURGEONS, AND WHAT YOU HIGHLIGHT
IS, THEY'RE NOT EQUITABLY
DISTRIBUTED.
AND I'M PART OF THE PROBLEM.
AS CHAIR OF UCSF SURGERY, I KEEP
HIRING MORE AND MORE ENDOCRINE
SURGEONS.
WE NOW HAVE SIX FULL TIME
ENDOCRINE SURGEONS IN ONE
BUILDING.
WHEN WHOLE PARTS OF THE UNITED
STATES AND WHOLE STATES, THE
WESTERN UNITED STATES AND THE
SOUTHERN UNITED STATES, WHOLE
STATES HAVE ZERO HIGH VOLUME
SURGEONS.
SO THE REALITY IS, WE CAN'T DO
THAT.
SO WHERE DOES THE ANSWER LIE?
I THINK SOME OF IT IS REDOING
THE HEALTHCARE MARKETPLACE AND
HOW WE DELIVER CARE.
THIS IS A COMPLICATED DEBATE
ABOUT PRIVATE VERSUS PUBLIC,
SHOULD WE HAVE A NATIONAL HEALTH
SYSTEM.
SECONDLY, I THINK WE NEED TO
INCENTIVIZE PEOPLE TO, A, TRAIN
IN SPECIALTIES, BUT B, SERVE
THEIR COMMUNITIES.
SOMETIMES THAT MEANS URBAN
DESERTS.
SOMETIMES THAT MEANS RURAL
DESERTS.
SO WE NEED TO INCENTIVIZE AND
VALUE THAT SERVICE.
SO THAT HAS IMPLICATIONS FOR
POLICY MAKERS, AS WELL AS
EDUCATORS.
AND THEN I THINK WE HAVE TO FIND
WAYS TO SUPPORT PATIENTS
TRAVELING.
THERE ARE SOME OPERATIONS WHERE
PATIENTS CAN'T TRAVEL BECAUSE
THE DISEASE OR THE SURGERY IS SO
MORBID OR MORTAL, BUT THYROID
CANCER AND THYROID SURGERY ARE
NOT THOSE.
AND SO PATIENTS CAN TRAVEL, BUT
THEY CAN'T, OF COURSE, BECAUSE
THEY CAN'T AFFORD TO DO THAT.
SO IT'S A COMPLICATED SOLUTION.
WE DON'T HAVE A SOLUTION, BUT
THE REALITY CANNOT YET BE THAT
EVERY AMERICAN CAN HAVE SURGERY
BY A HIGH VOLUME SURGEON.
>> I THINK ONE OTHER THING THAT
STRUCK ME PARTICULARLY TOWARD
THE END OF YOUR TALK, I'M SORT
OF MOVING FROM EARLY CAREER TO
MID CAREER TRANSITION, AND
LEARNING HOW TO BE A BETTER
MENTOR, AND I THINK THE
IMPORTANCE OF -- FOR ALL OF US,
WHETHER WE'RE ASKING A QUESTION
AT THE BENCH OR AS WE'RE DIGGING
THROUGH CHARTS, IS TO HAVE A
CRISP QUESTION.
AND THAT HAS BEEN DEMONSTRATED
OVER AND OVER TO ME BY MY MENTOR
AND I THINK WHAT I WILL TAKE
AWAY FROM THIS IS LEARNING TO
HELP MY MENTEES FORM THOSE
QUESTIONS SO THEY KNOW EXACTLY
WHAT THEY'RE LOOKING FOR AND THE
RIGHT ANKLE OF ANGLE OF APPROACH.
BUT ABSOLUTELY THRILLING BODY OF
WORK.
WHEN I TRAINED, I LEARNED THOSE
2009 GUIDELINES AND THEN HAD TO
RETRAIN MYSELF ON THE 2015
GUIDELINES, EVEN IF I JUST
APPROACH ENDOCRINE SURGERY NOW
IN A MORE TUMOR BOARD THOUGHT
KIND OF WAY RATHER THAN
PRACTICALLY PERFORMING THEM.
>> AND DR. GOFF, THERE'S MORE
CHANGES COMING, SO BUCKLE UP AND
GET READY FOR THE NEXT ITERATION
OF THE GUIDELINES.
I CAN'T REALLY SAY YET WHAT
THEY'RE GOING TO SHOW, BUT I
WILL SAY THERE ARE MORE CHANGES
COMING, AND I THINK THE
IMPORTANT THING, AS YOU SAID, IS
I LEARNED IT THIS WAY, BUT MAYBE
I DIDN'T LEARN IT QUITE RIGHT,
AND I HAVE TO BE OPEN TO DOING
THINGS IN A DIFFERENT WAY.
>> I THINK THE MESSAGE THAT
LEARNING IS LIFE-LONG,
PARTICULARLY IN MEDICINE,
PARTICULARLY AS WE FIT THIS ERA
WHERE OUR TOOLS ARE GETTING
BETTER, OUR KNOWLEDGE IS GETTING
BETTER AND WE ALL HAVE TO JUST
KEEP RETRAINING ON THE THINGS
THAT WE THINK WE KNOW HOW TO DO,
BECAUSE PRACTICE DOESN'T ALWAYS
MAKE PERFECT, IT MAKES
PERMANENT.
SO YOU HAVE TO BE CAREFUL.
>> THAT'S RIGHT.
I LOVE THAT.
>> YEAH.
YOU KNOW, WE'VE GOTTEN A COUPLE
OF PEOPLE TELLING US THAT IT WAS
A FANTASTIC TALK BUT NOBODY'S
REALLY GIVEN ME ANY SORT OF
SUBSTANTIVE QUESTION, AND WE'VE
HIT THE END OF THE HOUR.
SO I DIDN'T KNOW IF YOU HAD ANY
PARTING WISDOM YOU WANTED TO
LEAVE US WITH, BUT I JUST WANTED
TO THANK YOU ON BEHALF OF THE
GREAT TEACHERS COMMITTEE AND THE
WHOLE CLINICAL CENTER, IT WAS A
WONDERFUL TALK.
>> OH, WELL, THANK YOU.
THANK YOU AGAIN SO MUCH.
AS I SAID, IT'S AN HONOR AND A
PRIVILEGE, AND I DON'T KNOW -- I
AM A VERY -- YOU COULD PROBABLY
TELL, I'M AN EXTROVERT, BUT I
THINK IN LIFE, LIFE IS SHORT,
AND YOU HAVE TO PURSUE WHAT
BRINGS YOU JOY.
AND OTHER PEOPLE CANNOT TELL YOU
WHAT BRINGS YOU JOY.
YOU HAVE TO DISCOVER THAT ABOUT
YOURSELF.
AND IN CASE YOU CAN'T TELL WHAT
BRINGS ME THE GREATEST JOY IS
SCIENCE THAT I CAN SHARE WITH
THE NEXT GENERATION, BECAUSE I
THINK IT'S NOT THE PUBLICATION,
IT'S THE IMPACT ON LEARNERS AND
LEGACY THAT WILL ULTIMATELY
DRIVE HOW WE ARE REMEMBERED.
SO THANK YOU.
>> THANK YOU VERY MUCH.