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Welcome to the Clinical
Center Grand Rounds,

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a weekly series of educational
lectures for physicians and

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health care professionals
broadcast from the Clinical

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Center at the National
Institutes of Health in

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Bethesda, MD.

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The NIH Clinical Center is the
world's largest hospital totally

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dedicated to investigational
research and leads the global

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effort in training today's
investigators and discovering

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tomorrow's cures.

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Learn more by visiting us online
at http://clinicalcenter.nih.gov

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OUR SPEAKER TODAY IS DR. JULIE

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ANN SOSA, THE LEON

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GOLDMAN CHAIR OF SURGERY,

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UNIVERSITY OF CALIFORNIA

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SAN FRANCISCO, WHERE SHE IS ALSO

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A PROFESSOR IN THE DEPARTMENT OF

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MEDICINE AND AFFILIATED FACULTY

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FOR THE PHILIP R. LEE INSTITUTE

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FOR HEALTH POLICY STUDIES.

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OVER HER CAREER, SHE HAS

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MENTORED MORE THAN 90 STUDENTS,

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RESIDENTS AND FELLOWS, FOR WHICH

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SHE WAS RECOGNIZED AS A FULL

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MEMBER TO THE AMERICAN COLLEGE

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OF SURGEONS, ACADEMY OF MASTER

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EDUCATORS, IN 2020, AND WITH THE

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DISTINGUISHED LECTURESHIP AWARD

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IN 2017.

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IN MY OPINION, THESE ACCOLADES

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MAKE HER UNIQUELY SUITED FOR OUR

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GREAT TEACHER GRAND ROUNDS

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SERIES.

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AFTER EARNING DEGREES FROM

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PRINCETON AND OXFORD UNIVERSITY,

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DR. SOSA EARNED HER

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MEDICAL DEGREE FROM JOHNS HIGH
JOHNS

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HOPKINS SCHOOL OF MEDICINE AND

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COMPLETED A RESIDENCY IN GENERAL

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SURGERY.

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HER TRAINING INCLUDED A

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FELLOWSHIP IN CLINICAL RESEARCH

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AS A ROBERT WOOD JOHNSON

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CLINICAL SCHOLAR, SPECIALIST

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TRAINING AT UNIVERSITY OF OXFORD

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HOSPITALS, AND A FELLOWSHIP AT

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JOHNS HOPKINS HOSPITAL IN

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BALTIMORE, MARYLAND.

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SHORTLY AFTER DR. SOSA CONTINUED

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AT THE YALE UNIVERSITY SCHOOL OF

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MEDICINE AS AN ASSISTANT

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PROFESSOR OF SURGERY BEFORE

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BEING PROMOTED TO DIRECTOR AND

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LATER MOVED TO DUKE UNIVERSITY

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SCHOOL OF MEDICINE AS A TENURED

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PROFESSOR OF SURGERY AND

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MEDICINE.

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SHE MOVED TO HER CURRENT

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POSITION AT UCSF IN 2018.

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DR. SOSA'S RESEARCH FOCUSES ON

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DEVELOPING TREATMENTS FOR

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ADVANCED THYROID CANCER AND

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UNDERSTANDING ENVIRONMENTAL

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FACTORS THAT CAN RAISE A

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PERSON'S RISK FOR THE DISEASE.

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HER CLINICAL INTEREST IS IN

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ENDOCRINE SURGERY WITH A FOCUS

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IN THYROID CANCER.

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SHE IS A NATIONAL INSTITUTES OF

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HEALTH AND FOOD AND DRUG

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ADMINISTRATION-FUNDED

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INVESTIGATOR, AND AN AUTHOR OF

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NEARLY 400 PEER REVIEWED

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PUBLICATIONS AND 80 BOOK

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CHAPTERS AND REVIEWS, ALL

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LARGELY FOCUSED ON OUTCOMES

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RESEARCH, HEALTHCARE DELIVERY,

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HYPERPARATHYROIDISM AND THYROID

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CANCER WITH A FOCUS ON CLINICAL

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TRIALS.

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SHE HAS AUTHORED OR EDITED SEVEN

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BOOKS.

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DR. SOSA HAS ALSO PUBLISHED

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EXTENSIVELY ON PREDICTORS OF

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OPTIMAL PATIENT OUTCOMES

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FOLLOWING A VARIETY OF

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CANCER-BASED PROCEDURES.

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SHE IS AN EDITOR OF GREENFIELD

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SURGERY SCIENTIFIC PRINCIPLES

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AND PRACTICE.

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DR. SOSA IS PRESIDENT-ELECT OF

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THE AMERICAN THYROID ASSOCIATION

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AND SERVES ON THE BOARD OF

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DIRECTORS AND EXECUTIVE COUNCIL

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OF THE ATA AND THE INTERNATIONAL

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THYROID ONCOLOGY GROUP, AS WELL

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AS THE PRACTICE GUIDELINES

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COMMITTEE FOR THE ATA, THE

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NATIONAL COMPREHENSIVE CANCER

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NETWORK, AND THE AMERICAN

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ASSOCIATION OF ENDOCRINE

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SURGEONS.

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DR. SOSA IS ALSO CHAIRING THE

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COMMITTEE RESPONSIBLE FOR

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WRITING THE NEXT ITERATION OF

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DIFFERENTIATED THYROID CANCER

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GUIDELINES FOR THE ATA.

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THE TITLE OF DR. SOSA'S

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PRESENTATION IS, SEEKING NEW

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SOLUTIONS FOR OLD CHALLENGES,

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ALWAYS WITH EVIDENCE AND

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COURAGE.

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PLEASE JOIN ME IN WELCOMING

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TODAY'S GREAT TEACHER SPEAKER,

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DR. JULIE ANN SOSA.

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>> ALL RIGHT.

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THANK YOU SO MUCH FOR THAT VERY

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WARM INTRODUCTION, 

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 AND ALSO THANK YOU

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TO THE NIH AND THE NIH CLINICAL

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CENTER FOR THIS INCREDIBLE HONOR

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AND PRIVILEGE TO SPEAK WITH YOU

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TODAY.

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UNFORTUNATELY FROM

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SAN FRANCISCO, ABOUT THYROID

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CANCER AND ABOUT SCIENCE AND

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INNOVATION MORE BROADLY, AND

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FINALLY ABOUT THE IMPORTANCE OF

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BRINGING COURAGE TO SCIENTIFIC

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INVESTIGATION, AS WELL AS

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BRINGING COURAGE INTO OUR

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PERSONAL AND PROFESSIONAL LIVES.

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AND I THINK WHEN IT COMES TO

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CHALLENGING HOW WE HAVE DONE

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THINGS AND HOW WE DO THINGS, WE

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OFTEN FOCUS ON THE BODY OF

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EVIDENCE WHEN WE IGNORE A LITTLE

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BIT THAT YOU NEED COURAGE TO BE

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ABLE TO DEPLOY THE EVIDENCE TO

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CHALLENGE THE STATUS QUO.

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SO HERE WE GO.

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THESE ARE MY DISCLOSURES.

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THEY PERTAIN TO MEDULLARY CANCER

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AND ARE IRRELEVANT TO THE

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DISCUSSION TODAY, WHICH WILL BE

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LARGELY FOCUSED ON

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DIFFERENTIATED THYROID CANCER.

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SO I'M A SURGEON, AND BEING A

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SURGEON AND A SURGEON SCIENTIST

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DEFINITELY IMPACTS THE LENS THAT

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I USE TO LOOK AT LIFE.

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AND I LOVE TO READ, AND I READ

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ALL KINDS OF THINGS, I READ

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POETRY, AND I ALSO READ THE

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CLASSICS.

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AND AS I THINK ABOUT THE CLASSIC

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PHILOSOPHERS, I SOMETIMES HAVE

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WONDERED, WHAT IF THEY'D BEEN A

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SURGEON, WHAT KIND OF SURGEON

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WOULD THOSE PHILOSOPHERS HAVE

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BEEN?

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NOT SURE THAT'S CROSSED ANYONE

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ELSE'S MIND, BUT IT'S CROSSED

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MINE.

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SO I THINK IF ARISTOTLE HAD BEEN

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A SURGEON, AND HE WASN'T, HE

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WOULD HAVE BEEN A CLINICAL

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SURGEON.

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AND WHY DO I SAY THAT?

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I SAY THAT BECAUSE ARISTOTLE

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SAID, QUOTE, WE ARE WHAT WE

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REPEATEDLY DO.

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EXCELLENCE, THEN, IS NOT AN ART,

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BUT A HABIT.

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AND THAT REALLY REFLECTS THE

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MANTRA THAT MANY SURGEONS USE,

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AND THAT IS PRACTICE MAKES

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PERFECT.

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WELL, IF THE PHILOSOPHER

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SOCRATES BEEN A SURGEON, I THINK

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HE WOULD HAVE BEEN AN ACADEMIC

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SURGEON.

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WHY DO I SAY THAT?

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HE SAID, QUOTE, I KNOW THAT I

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DON'T KNOW.

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AND ANOTHER SOCRATES QUOTE, TO

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KNOW IS TO KNOW THAT YOU KNOW

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NOTHING, THAT IS THE MEANING OF

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TRUE KNOWLEDGE.

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WELL, MANY PEOPLE SAY THERE IS

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AN INTERNAL CONTRADICTION

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BETWEEN BEING A CLINICAL SURGEON

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WHERE PRACTICE MAKES PERFECT AND

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BEING A SURGEON SCIENTIST, WHERE

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YOU DEFINE A ROUTINE AND YOU

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LOOK AND EMBRACE NOVEL TI.

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WELL, LET'S TALK A LITTLE BIT

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ABOUT THIS PHENOTYPE OF THE

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SURGEON SCIENTIST.

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STARTING WITH THE ARCH TYPE.

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I WOULD SAY THE ARCH TYPE OF THE

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SURGEON SCIENTIST, AS DEPICTED

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HERE, WAS A MAN.

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SCIENCE WAS PERFORMED

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EXCLUSIVELY IN A WET LABORATORY.

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AND ARE EXPECTATIONS OF SURGEON

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SCIENTISTS WERE TO BE THE TRIPLE

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THREAT TO BE AN EXCELLENT

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CLINICIAN, A SUE PURLTIVE

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RESEARCHER AND AN EFFECTIVE

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EDUCATOR.

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AN EXAMPLE OF SUCH AN ARCHETYPE

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IS WILLIAM STEWART HALSTEAD WHO

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WORKED, OF COURSE, AT JOHNS

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HOPKINS HOSPITAL.

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BUT I WOULD SAY THIS ARCHETYPE

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OF THE SURGEON SCIENTIST IS

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ANACHRONISTIC AND ARCANE.

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THE MODERN ACADEMIC SURGEON DOES

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NOT FIT ANY ONE PHENOTYPE.

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SURE, IT COULD BE A BASIC

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SCIENTIST BUT IT ALSO COULD BE A

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CLINICAL RESEARCHER, A HEALTH

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SERVICES RESEARCHER, EDUCATION

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RESEARCHER, GLOBAL HEALTH

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RESEARCHERS, FRANKLY, A MASTER

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TEACHER, A MASTER CLINICIAN, OR

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SOME COMBINATION OF THESE

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THINGS, OF COURSE DEPICTED HERE

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AS THE PROTOTYPE OF THE CHIMERA.

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WHICH REMINDS ME FROM A COUPLE

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OF YEARS BACK, THE PHENOMENON OF

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THE BLUE VERSUS THE BROWN DRESS,

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WHERE DIFFERENT PEOPLE LOOKED AT

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THE SAME IMAGE AND BASED ON

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THEIR RETINAL MAKEUP, SEE

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DRESSES OF DIFFERENT COLORS.

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SO I THINK THE MODERN SURGEON

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SCIENTIST IS SOMEONE WHO COULD

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BE ONE OF MANY PHENOTYPES, ALL

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OF WHICH SHOULD BE HIGHLY VALUED

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BY OUR ACADEMIC COMMUNITY.

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IN THE END, A BOUQUET OF 12

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WHITE FLOWERS MIGHT BE

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BEAUTIFUL, BUT A BOUQUET OF 12

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DIFFERENTLY COLORED FLOURS IS

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ARGUABLY EVEN MORE BEAUTIFUL.

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WHAT I THINK IS ESSENTIAL,

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THOUGH, THE FOUNDATION OF

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SCIENCE AND SURGICAL SCIENCE IS

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THAT WE MUST BRING CREATIVITY,

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DISCOVERY, AND INNOVATION TO

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EVERYTHING WE DO, AND IS THAT IN

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CONTRADICTION TO THE MANTRA OF

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SURGERY THAT PRACTICE MAKES

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PERFECT?

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I DON'T THINK SO.

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I THINK WE CAN BRING THESE TWO

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WORLDS TOGETHER AS LONG AS IN

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00:09:32,920 --> 00:09:35,040
THE END, THE INNOVATION AND THE

260
00:09:35,040 --> 00:09:36,560
DISCOVERY ULTIMATELY RETURNS TO

261
00:09:36,560 --> 00:09:40,920
THE BEDSIDE AND IMPACTS IN A

262
00:09:40,920 --> 00:09:42,880
POSITIVE WAY THE OUTCOME OF OUR

263
00:09:42,880 --> 00:09:43,240
PATIENTS.

264
00:09:43,240 --> 00:09:46,960
SO THERE MUST BE TRANSLATIONAL

265
00:09:46,960 --> 00:09:49,040
IMPACT TO WHAT WE DO, AND TO BE

266
00:09:49,040 --> 00:09:50,960
ABLE TO ACCOMPLISH THAT GREAT

267
00:09:50,960 --> 00:09:54,280
FEAT, I WOULD ARGUE WE NEED BOTH

268
00:09:54,280 --> 00:09:56,680
COURAGE AND EVIDENCE.

269
00:09:56,680 --> 00:09:58,200
SO WHAT I'D LIKE TO DO IS TO

270
00:09:58,200 --> 00:10:01,280
TELL A NARRATIVE AROUND THYROID

271
00:10:01,280 --> 00:10:01,720
CANCER.

272
00:10:01,720 --> 00:10:05,520
WE WILL BRING EVIDENCE AND

273
00:10:05,520 --> 00:10:07,440
COURAGE TO WHAT WE DO, AND SINCE

274
00:10:07,440 --> 00:10:09,080
THIS IS A GREAT TEACHERS GRAND

275
00:10:09,080 --> 00:10:10,440
ROUNDS, I'M GOING TO PUT IN THE

276
00:10:10,440 --> 00:10:12,880
EPICENTER OF OUR DISCUSSION A

277
00:10:12,880 --> 00:10:18,880
LEARNER. THE ULTIMATE MESSAGE I
WOULD

278
00:10:18,880 --> 00:10:21,280
LIKE TO CONVEY TODAY IS THAT AS

279
00:10:21,280 --> 00:10:24,000
A LEARNER, YOU CAN TRANSFORM

280
00:10:24,000 --> 00:10:28,440
PRACTICE IF GUIDED BY MENTORSHIP

281
00:10:28,440 --> 00:10:29,320
AND SPONSORSHIP.

282
00:10:29,320 --> 00:10:33,040
SO LET'S START WITH SOME FACTS.

283
00:10:33,040 --> 00:10:36,080
AND WE'LL START WITH

284
00:10:36,080 --> 00:10:36,840
EPIDEMIOLOGY BECAUSE SINCE THE

285
00:10:36,840 --> 00:10:40,520
BEGINNING OF THE PANDEMIC,

286
00:10:40,520 --> 00:10:42,400
EPIDEMIOLOGY NOW REIGNS QUEEN OR

287
00:10:42,400 --> 00:10:44,080
KING IN SCIENCE, AND THIS IS A

288
00:10:44,080 --> 00:10:45,560
FIGURE THAT SHOWS THE

289
00:10:45,560 --> 00:10:47,280
EPIDEMIOLOGY OF THYROID CANCER

290
00:10:47,280 --> 00:10:50,360
IN THE UNITED STATES.

291
00:10:50,360 --> 00:10:51,560
AND WHAT YOU SEE IS THAT THE

292
00:10:51,560 --> 00:10:52,960
INCIDENCE OF THE DISEASE HAS

293
00:10:52,960 --> 00:10:55,920
INCREASED BY MORE THAN THREE

294
00:10:55,920 --> 00:10:58,880
FOLD OVER THREE DECADES.

295
00:10:58,880 --> 00:11:00,880
AND THIS PHENOMENON HAS BEEN

296
00:11:00,880 --> 00:11:02,640
SEEN IN ALL DEMOGRAPHIC

297
00:11:02,640 --> 00:11:03,040
SUBTYPES.

298
00:11:03,040 --> 00:11:05,360
ALL GENDERS, RACIAL, ETHNIC

299
00:11:05,360 --> 00:11:07,000
SUBGROUPS AND IN THE YOUNG AND

300
00:11:07,000 --> 00:11:07,600
IN THE OLD.

301
00:11:07,600 --> 00:11:12,120
IN FACT, UNTIL 2020, I USED TO

302
00:11:12,120 --> 00:11:13,720
SAY THERE WAS A PANDEMIC OF

303
00:11:13,720 --> 00:11:14,880
THYROID CANCER IN THE WORLD,

304
00:11:14,880 --> 00:11:16,000
BECAUSE SUM LAR OBSERVATIONS

305
00:11:16,000 --> 00:11:17,680
HAVE BEEN MADE IN VIRTUALLY

306
00:11:17,680 --> 00:11:21,200
EVERY DEVELOPED AND DEVELOPING

307
00:11:21,200 --> 00:11:22,040
COUNTRY FOR WHICH THERE ARE

308
00:11:22,040 --> 00:11:22,480
DATA.

309
00:11:22,480 --> 00:11:23,920
I'VE NOW AMENDED THE USE OF THE

310
00:11:23,920 --> 00:11:25,640
WORD PANDEMIC, AND I SAY JUST

311
00:11:25,640 --> 00:11:26,560
EPIDEMIC.

312
00:11:26,560 --> 00:11:27,920
SO WHAT IS GOING ON?

313
00:11:27,920 --> 00:11:31,040
IT'S REALLY FASCINATING.

314
00:11:31,040 --> 00:11:33,480
SO MANY PEOPLE HAVE TURNED TO A

315
00:11:33,480 --> 00:11:38,360
SINGLE PIVOTAL STUDY TO TRY TO

316
00:11:38,360 --> 00:11:40,120
EXPLAIN THIS RISE IN INCIDENCE.

317
00:11:40,120 --> 00:11:42,880
THE STUDY WAS PUBLISHED IN JAMA

318
00:11:42,880 --> 00:11:44,720
IN R6 BY WELCH AND DAVIES.

319
00:11:44,720 --> 00:11:46,080
I'M JUST GOING TO QUICKLY WALK

320
00:11:46,080 --> 00:11:50,840
YOU THROUGH THREE PIVOTAL IMAGES

321
00:11:50,840 --> 00:11:51,680
FROM THAT PAPER.

322
00:11:51,680 --> 00:11:52,720
STARTING IN THE UPPER LEFT-HAND

323
00:11:52,720 --> 00:11:54,480
CORNER, WHERE YOU SEE INCIDENCE

324
00:11:54,480 --> 00:11:56,840
OF ALL HISTOLOGIC SUBTYPES

325
00:11:56,840 --> 00:12:00,120
RISING, BUT THE ENGINE FOR THE

326
00:12:00,120 --> 00:12:03,640
RISE LARGELY APPEARS TO BE ONE

327
00:12:03,640 --> 00:12:05,280
HISTOLOGIC SUBTYPE, PAPILLARY

328
00:12:05,280 --> 00:12:06,080
THYROID CANCER, WHICH NOW

329
00:12:06,080 --> 00:12:07,560
ACCOUNTS FOR MORE THAN 90% OF

330
00:12:07,560 --> 00:12:08,920
NEW CASES.

331
00:12:08,920 --> 00:12:11,880
THEN MOVING TO THE UPPER

332
00:12:11,880 --> 00:12:13,040
RIGHT-HAND CORNER, YOU SEE

333
00:12:13,040 --> 00:12:14,320
INCIDENT TUMORS BASED ON THE

334
00:12:14,320 --> 00:12:17,000
SIZE OF THE TUMOR, AND YOU SEE

335
00:12:17,000 --> 00:12:20,080
IT AS THE SMALLEST TUMORS, THOSE

336
00:12:20,080 --> 00:12:21,520
LESS THAN 1 CENTIMETER IN SIZE,

337
00:12:21,520 --> 00:12:24,400
WHICH WE CALL PAPILLARY THYROID

338
00:12:24,400 --> 00:12:27,000
MICRO CARCINOMAS, THAT, AGAIN,

339
00:12:27,000 --> 00:12:29,960
APPEAR TO BE THE ENGINE BEHIND

340
00:12:29,960 --> 00:12:31,360
THE INCREASE IN INCIDENCE.

341
00:12:31,360 --> 00:12:34,680
AND THEN FINALLY, THE MOST

342
00:12:34,680 --> 00:12:36,400
IMPORTANT FIGURE FROM THAT WELCH

343
00:12:36,400 --> 00:12:38,360
AND DAVIES STUDY, THE ONE IN THE

344
00:12:38,360 --> 00:12:39,480
BOTTOM CENTER, WHERE YOU SEE

345
00:12:39,480 --> 00:12:43,680
THIS RISE IN INCIDENCE AGAIN,

346
00:12:43,680 --> 00:12:46,880
SUPERIMPOSED ON LEVEL MORTALITY.

347
00:12:46,880 --> 00:12:48,880
LEADING THE AUTHORS TO CONCLUDE,

348
00:12:48,880 --> 00:12:52,280
QUOTE, WE BELIEVE INCREASED

349
00:12:52,280 --> 00:12:54,320
DIAGNOSTIC SCRUTINY IS THE MOST

350
00:12:54,320 --> 00:12:55,280
LIKELY EXPLANATION FOR THE

351
00:12:55,280 --> 00:12:56,600
APPARENT INCREASE IN INCIDENCE.

352
00:12:56,600 --> 00:13:00,000
THAT IS, IT IS ALL

353
00:13:00,000 --> 00:13:01,680
OVERDIAGNOSIS.

354
00:13:01,680 --> 00:13:04,360
WELL, ALL OF YOU KNOW THIS

355
00:13:04,360 --> 00:13:06,480
FIGURE, FIGURE OF THE ICEBERG,

356
00:13:06,480 --> 00:13:07,720
JUST A LITTLE BIT OF THE ICEBERG

357
00:13:07,720 --> 00:13:08,920
ABOVE THE SURFACE OF THE WATER.

358
00:13:08,920 --> 00:13:11,240
MOST OF IT BELOW THE WATER

359
00:13:11,240 --> 00:13:14,080
LEADING PEOPLE TO SAY THE WHOLE

360
00:13:14,080 --> 00:13:16,920
TRUTH IS OFTEN HIDDEN FROM VIEW.

361
00:13:16,920 --> 00:13:18,280
NOW I DON'T WANT TO GET

362
00:13:18,280 --> 00:13:20,240
POLITICAL TODAY, TODAY IS NOT

363
00:13:20,240 --> 00:13:21,680
THE DAY TO GET POLITICAL, BUT I

364
00:13:21,680 --> 00:13:26,200
WOULD TAKE THAT ICEBERG

365
00:13:26,200 --> 00:13:27,040
METAPHOR1 STEP FURTHER AND SAY,

366
00:13:27,040 --> 00:13:28,600
JUST AS THE ICEBERGS ARE MELTING

367
00:13:28,600 --> 00:13:32,320
WITH CLIMATE CHANGE, SO, TOO,

368
00:13:32,320 --> 00:13:33,480
MIGHT BE TRUTH, IN THE UNITED

369
00:13:33,480 --> 00:13:34,400
STATES AND THE WORLD.

370
00:13:34,400 --> 00:13:37,840
AND SO I HAVE TO SAY, I READ

371
00:13:37,840 --> 00:13:40,160
THAT WELCH AND DAVIES STUDY AT

372
00:13:40,160 --> 00:13:43,760
LEAST 70 OR 75 TIMES.

373
00:13:43,760 --> 00:13:47,480
AND WHAT REALLY BOTHERED ME WAS

374
00:13:47,480 --> 00:13:48,680
THAT LAST FIGURE, AND HERE IT IS

375
00:13:48,680 --> 00:13:51,760
AGAIN ON THE LEFT, SHOWING

376
00:13:51,760 --> 00:13:53,640
RISING INCIDENCE, NEW CASES,

377
00:13:53,640 --> 00:13:57,760
SUPERIMPOSED ON A FLAT MORTALITY

378
00:13:57,760 --> 00:13:58,080
TREND.

379
00:13:58,080 --> 00:13:58,480
DEATHS.

380
00:13:58,480 --> 00:14:01,680
AND WHAT BOTHERED ME IS THAT

381
00:14:01,680 --> 00:14:05,880
BOTH THESE LINES ARE PUT ON THE

382
00:14:05,880 --> 00:14:07,760
SAME ARITHMETIC Y SCALE.

383
00:14:07,760 --> 00:14:10,160
WHAT WE KNOW IS THAT NEW CASES

384
00:14:10,160 --> 00:14:11,560
IS A VERY LARGE NUMBER.

385
00:14:11,560 --> 00:14:14,520
NOWADAYS IN EXCESS OF ABOUT 49

386
00:14:14,520 --> 00:14:16,160
OR 50,000 NEW CASES OF THYROID

387
00:14:16,160 --> 00:14:18,400
CANCER IN THE UNITED STATES EACH

388
00:14:18,400 --> 00:14:19,360
YEAR.

389
00:14:19,360 --> 00:14:20,800
FORTUNATELY, THYROID CANCER IS

390
00:14:20,800 --> 00:14:22,960
AN INDOLENT DISEASE WITH

391
00:14:22,960 --> 00:14:25,240
SURVIVAL AT A DECADE OF AT LEAST

392
00:14:25,240 --> 00:14:27,240
95 TO 98%.

393
00:14:27,240 --> 00:14:32,880
SO THERE IS AN OVERALL SCARCITY

394
00:14:32,880 --> 00:14:34,080
OF DEATHS, AND DEATH IS A VERY

395
00:14:34,080 --> 00:14:34,440
SMALL NUMBER.

396
00:14:34,440 --> 00:14:35,960
SO WE'RE TAKING A VERY LARGE

397
00:14:35,960 --> 00:14:40,280
NUMBER AND A VERY SMALL NUMBER

398
00:14:40,280 --> 00:14:41,920
AND PUTTING THEM ON THE SAME

399
00:14:41,920 --> 00:14:42,320
ARITHMETIC SCALE.

400
00:14:42,320 --> 00:14:44,000
SO WHAT I WONDERED ABOUT IS, IS

401
00:14:44,000 --> 00:14:46,440
IT NOT POSSIBLE THAT WITH THIS

402
00:14:46,440 --> 00:14:49,560
ARITHMETIC SCALE, WE ARE

403
00:14:49,560 --> 00:14:52,080
CAMOUFLAGING REAL CHANGES IN

404
00:14:52,080 --> 00:14:54,800
MORTALITY THAT ARE BEING

405
00:14:54,800 --> 00:14:58,000
DISGUISED BY THE Y AXIS.

406
00:14:58,000 --> 00:14:59,800
SO I'M NOT A BIOSTATISTICIAN AND

407
00:14:59,800 --> 00:15:01,680
I'M CERTAINLY NOT AN

408
00:15:01,680 --> 00:15:02,320
EPIDEMIOLOGIST, BUT FORTUNATELY

409
00:15:02,320 --> 00:15:03,960
I HAVE REALLY GOOD FRIENDS WHO

410
00:15:03,960 --> 00:15:08,520
ARE, SO I CALLED UP MY FRIEND AT

411
00:15:08,520 --> 00:15:09,120
THE NATIONAL CANCER INSTITUTE

412
00:15:09,120 --> 00:15:11,200
AND I SAID, KARI, CAN YOU TAKE

413
00:15:11,200 --> 00:15:13,000
THESE NUMBER, NEW CASES AND

414
00:15:13,000 --> 00:15:15,960
DEATHS, AND PUT THEM ON A SEMI

415
00:15:15,960 --> 00:15:17,880
LOG SCALE, SEND IT BACK TO ME?

416
00:15:17,880 --> 00:15:20,760
WELL, IT TOOK HER ABOUT 30

417
00:15:20,760 --> 00:15:22,400
MINUTES TO DO, AND SHE SENT ME

418
00:15:22,400 --> 00:15:23,840
BACK THE FIGURE ON THE RIGHT.

419
00:15:23,840 --> 00:15:25,320
AND THIS SUBSEQUENTLY WAS

420
00:15:25,320 --> 00:15:27,960
PUBLISHED IN NATURE REVIEWS, AND

421
00:15:27,960 --> 00:15:32,080
IT MAKES A VERY SIMPLE BUT VERY

422
00:15:32,080 --> 00:15:33,000
IMPORTANT POINT.

423
00:15:33,000 --> 00:15:36,680
AGAIN, WE SEE INCIDENCE RISING

424
00:15:36,680 --> 00:15:39,400
WITH AN ANNUAL PERCENTAGE CHANGE

425
00:15:39,400 --> 00:15:40,080
OF 5.6%.

426
00:15:40,080 --> 00:15:42,840
BUT NOW, WE NO LONGER SEE

427
00:15:42,840 --> 00:15:45,880
MORTALITY FLAT.

428
00:15:45,880 --> 00:15:47,960
WE NOW SEE MORTALITY RISING,

429
00:15:47,960 --> 00:15:50,440
WITH AN ANNUAL PERCENTAGE CHANGE

430
00:15:50,440 --> 00:15:51,760
OF 0.8% PER YEAR, AND THIS

431
00:15:51,760 --> 00:15:54,840
SHOULD RAISE THE EYEBROWS IN THE

432
00:15:54,840 --> 00:15:56,640
AUDIENCE OF ONCOLOGISTS,

433
00:15:56,640 --> 00:15:57,400
SURGICAL ONCOLOGISTS.

434
00:15:57,400 --> 00:15:57,880
WHY?

435
00:15:57,880 --> 00:15:59,680
BECAUSE WE ARE WINNING THE WAR

436
00:15:59,680 --> 00:16:00,880
ON CANCER IN THE UNITED STATES

437
00:16:00,880 --> 00:16:01,480
AND THE WORLD.

438
00:16:01,480 --> 00:16:04,000
THERE ARE ONLY A FEW DIAGNOSES

439
00:16:04,000 --> 00:16:06,440
WHERE WE ARE NOT IMPROVING

440
00:16:06,440 --> 00:16:07,680
PATIENT SURVIVAL.

441
00:16:07,680 --> 00:16:09,760
ONE IS HEPATOCELLULAR CARCINOMA,

442
00:16:09,760 --> 00:16:11,720
AND NOW WE KNOW A SECOND IS

443
00:16:11,720 --> 00:16:12,680
ACTUALLY THYROID CANCER.

444
00:16:12,680 --> 00:16:16,000
AND WITH THAT SIMPLE BACK OF THE

445
00:16:16,000 --> 00:16:17,480
ENVELOPE CALCULATION COMING FROM

446
00:16:17,480 --> 00:16:20,480
A QUESTION ABOUT A Y AXIS, YOU,

447
00:16:20,480 --> 00:16:24,720
TOO, CAN PUBLISH AN ARTICLE OR

448
00:16:24,720 --> 00:16:25,920
STUDY IN THE JOURNAL JAMA.

449
00:16:25,920 --> 00:16:29,440
AND HERE IS DR. KETAHARA'S AND

450
00:16:29,440 --> 00:16:31,520
MY STUDY REVISING THE WORK OF

451
00:16:31,520 --> 00:16:34,440
WELCH AND DAVIES PUBLISHED IN

452
00:16:34,440 --> 00:16:35,920
2017.

453
00:16:35,920 --> 00:16:38,720
AND ESSENTIALLY WHAT WE DID IS

454
00:16:38,720 --> 00:16:41,160
TO REDO THE WELCH AND DAVIES

455
00:16:41,160 --> 00:16:45,520
STUDIES WITH TWO SIMPLE CHANGES.

456
00:16:45,520 --> 00:16:47,960
LIKE WELCH AND DAVIES, WE

457
00:16:47,960 --> 00:16:49,560
GARNERED OUR INCIDENCE DATA FROM

458
00:16:49,560 --> 00:16:53,840
THE SEER 9 DATABASE WITH MORE

459
00:16:53,840 --> 00:16:55,360
THAN 77,000 PATIENTS WITH

460
00:16:55,360 --> 00:16:56,440
THYROID CANCER.

461
00:16:56,440 --> 00:16:59,200
MANY OF YOU MAY HAVE USED THIS

462
00:16:59,200 --> 00:16:59,680
DATABASE.

463
00:16:59,680 --> 00:17:01,280
REPRESENTS ABOUT 10% OF THE U.S.

464
00:17:01,280 --> 00:17:02,920
POPULATION AND CONTAINS A LOT OF

465
00:17:02,920 --> 00:17:05,440
VERY VALUABLE DEMOGRAPHIC,

466
00:17:05,440 --> 00:17:06,880
PATHOLOGIC AND CLINICAL

467
00:17:06,880 --> 00:17:08,480
VARIABLES, ALL OF WHICH CAN

468
00:17:08,480 --> 00:17:14,480
CONTRIBUTE TO SURVIVAL.

469
00:17:14,480 --> 00:17:15,520
OUR THYROID CANCER MORTALITY

470
00:17:15,520 --> 00:17:18,280
LIKE WELCH AND DAVIES CAME FROM

471
00:17:18,280 --> 00:17:18,880
THE DEATH CERTIFICATE

472
00:17:18,880 --> 00:17:20,560
INFORMATION FROM THE NATIONAL

473
00:17:20,560 --> 00:17:21,160
CENTER FOR HEALTH STATISTICS.

474
00:17:21,160 --> 00:17:22,880
BUT THEN WE CHANGED THE FIRST

475
00:17:22,880 --> 00:17:24,400
THING FROM WELCH AND DAVIES, AND

476
00:17:24,400 --> 00:17:25,800
THAT IS INSTEAD OF USING

477
00:17:25,800 --> 00:17:27,400
MORTALITY, WE USED

478
00:17:27,400 --> 00:17:29,360
INCIDENCE-BASED MORTALITY.

479
00:17:29,360 --> 00:17:29,520
WHY?

480
00:17:29,520 --> 00:17:32,040
BECAUSE IBM IS PROBABLY THE

481
00:17:32,040 --> 00:17:33,400
SUPERIOR OUTCOME WHEN YOU ARE

482
00:17:33,400 --> 00:17:35,920
LOOKING AT AN INDOLENT DISEASE

483
00:17:35,920 --> 00:17:38,480
LIKE THYROID CANCER, WHERE THERE

484
00:17:38,480 --> 00:17:41,320
IS A PAUCITY OF OUTCOME EVENTS,

485
00:17:41,320 --> 00:17:43,080
SPECIFICALLY MORTALITY.

486
00:17:43,080 --> 00:17:45,000
LIKE WELCH AND DAVIES, WE

487
00:17:45,000 --> 00:17:47,600
CALCULATED AGE-ADJUSTED RATES

488
00:17:47,600 --> 00:17:51,360
AND ANNUAL PERCENTAGE CHANGES

489
00:17:51,360 --> 00:17:53,880
FROM JOINPOINT REGRESSION

490
00:17:53,880 --> 00:17:54,440
ANALYSES.

491
00:17:54,440 --> 00:17:56,640
THEN WE CHANGED THE SECOND THING

492
00:17:56,640 --> 00:17:58,720
FROM WELCH AND DAVIES STUDY, AND

493
00:17:58,720 --> 00:18:00,520
THAT IS WE CHANGED THE Y AXIS

494
00:18:00,520 --> 00:18:03,160
FROM THE DATA WE PRESENT FROM AN

495
00:18:03,160 --> 00:18:04,160
ARITHMETIC SCALE TO A SEMI LOG

496
00:18:04,160 --> 00:18:04,440
SCALE.

497
00:18:04,440 --> 00:18:07,680
AND LET'S LOOK AT WHAT WE FOUND.

498
00:18:07,680 --> 00:18:08,600
STARTING WITH INCIDENCE.

499
00:18:08,600 --> 00:18:09,600
AND I'M GOING TO, FOR THE

500
00:18:09,600 --> 00:18:11,880
PURPOSES OF TIME, JUST FOCUS ON

501
00:18:11,880 --> 00:18:12,480
PAPILLARY THYROID CANCER.

502
00:18:12,480 --> 00:18:16,080
IT MAKES IT A MORE HOMOGENEOUS

503
00:18:16,080 --> 00:18:16,880
PRESENTATION, AND AGAIN, THIS IS

504
00:18:16,880 --> 00:18:19,080
MORE THAN 90% OF INCIDENCE

505
00:18:19,080 --> 00:18:19,360
CASES.

506
00:18:19,360 --> 00:18:21,920
FIRST WE LOOK AT INCIDENCE BASED

507
00:18:21,920 --> 00:18:24,040
ON STAGE OF DISEASE.

508
00:18:24,040 --> 00:18:25,840
AND YOU SEE LOCALIZED DISEASE,

509
00:18:25,840 --> 00:18:27,920
THAT IS, DISEASE CONFINED TO THE

510
00:18:27,920 --> 00:18:31,720
THYROID RISING AT 4.6% PER YEAR

511
00:18:31,720 --> 00:18:32,360
ANNUAL PERCENTAGE CHANGE.

512
00:18:32,360 --> 00:18:34,440
BUT THEN WE SEE SOMETHING

513
00:18:34,440 --> 00:18:36,880
SURPRISING, AND THAT IS THE

514
00:18:36,880 --> 00:18:38,520
INCIDENCE OF REGIONAL, MEANING

515
00:18:38,520 --> 00:18:39,880
METASTATIC TO CERVICAL LYMPH

516
00:18:39,880 --> 00:18:42,600
NODES, AND DISTANT DISEASE, ALSO

517
00:18:42,600 --> 00:18:45,560
INCREASING.

518
00:18:45,560 --> 00:18:46,560
THIS SHOULD NOT BE HAPPENING IF

519
00:18:46,560 --> 00:18:48,320
ALL WE'RE TALKING ABOUT IS

520
00:18:48,320 --> 00:18:50,440
SUBCLINICAL DISEASE, AND THIS IS

521
00:18:50,440 --> 00:18:53,280
ALL OVERDIAGNOSIS.

522
00:18:53,280 --> 00:18:55,280
NOW WE LOOK AT INCIDENCE BASED

523
00:18:55,280 --> 00:18:56,800
ON THE SIZE OF THE TUMORS, AND

524
00:18:56,800 --> 00:18:58,480
AS WELCH AND DAVIES SHOWED,

525
00:18:58,480 --> 00:19:00,280
THESE PAPILLARY THYROID

526
00:19:00,280 --> 00:19:01,160
CARCINOMAS LESS THAN

527
00:19:01,160 --> 00:19:02,640
1 CENTIMETER IN SIZE RISING

528
00:19:02,640 --> 00:19:04,840
RAPIDLY AT A RATE OF 9.3% PER

529
00:19:04,840 --> 00:19:07,280
YEAR, BUT WE ALSO SEE TUMORS OF

530
00:19:07,280 --> 00:19:10,360
ALL SIZES INCREASING IN

531
00:19:10,360 --> 00:19:12,280
INCIDENCE, INCLUDING TUMORS OVER

532
00:19:12,280 --> 00:19:15,920
4 CENTIMETERS IN SIZE AT A RATE

533
00:19:15,920 --> 00:19:16,600
OF 6.1% PER YEAR.

534
00:19:16,600 --> 00:19:18,680
THESE ARE ABOUT THE SIZE OF A

535
00:19:18,680 --> 00:19:19,520
GOLF BALL.

536
00:19:19,520 --> 00:19:20,640
NO ONE WOULD CLAIM THAT THESE

537
00:19:20,640 --> 00:19:24,440
LARGE TUMORS ARE OVERDIAGNOSED.

538
00:19:24,440 --> 00:19:25,880
AND THEN SWITCHING TO

539
00:19:25,880 --> 00:19:27,080
INCIDENCE-BASED MORTALITY, WHERE

540
00:19:27,080 --> 00:19:29,280
WELCH AND DAVIES HAD SEEN LEVEL

541
00:19:29,280 --> 00:19:32,360
MORTALITY RATES OVER TIME, WE

542
00:19:32,360 --> 00:19:34,280
NOW HAVE SEEN RISING MORTALITY

543
00:19:34,280 --> 00:19:38,400
TRENDS OVER TIME FOR ALL STAGES

544
00:19:38,400 --> 00:19:41,160
OF THYROID CANCER, AND FOR

545
00:19:41,160 --> 00:19:43,680
TUMORS OF ALL SIZES, INCLUDING

546
00:19:43,680 --> 00:19:45,480
TUMORS LESS THAN 2 CENTIMETERS

547
00:19:45,480 --> 00:19:47,880
IN SIZE.

548
00:19:47,880 --> 00:19:51,200
AT A RATE OF 6.8% PER YEAR.

549
00:19:51,200 --> 00:19:52,280
POTENTIALLY LENDING CREDENCE

550
00:19:52,280 --> 00:19:53,880
THAT THERE IS A FUNDAMENTAL

551
00:19:53,880 --> 00:19:56,320
CHANGE IN THE BIOLOGIC PROFILE

552
00:19:56,320 --> 00:19:58,520
OF THE DISEASE, PERHAPS RELATED

553
00:19:58,520 --> 00:20:00,680
TO THE MOLECULAR UNDERPINNINGS

554
00:20:00,680 --> 00:20:04,320
OF IT.

555
00:20:04,320 --> 00:20:05,920
SO WHAT WERE OUR CONCLUSIONS?

556
00:20:05,920 --> 00:20:10,360
LIKE WELCH AND DAVIES, WE AGREE,

557
00:20:10,360 --> 00:20:13,960
AVERAGE INCREASE OF 3.6% OVER A

558
00:20:13,960 --> 00:20:15,240
THREE-DECADE PERIOD AFFECTING

559
00:20:15,240 --> 00:20:17,000
ALL SUBGROUPS ESPECIALLY FOR

560
00:20:17,000 --> 00:20:19,920
PAPILLARY THYROID CARCINOMA.

561
00:20:19,920 --> 00:20:21,360
BUT IN ADDITION TO WELCH AND

562
00:20:21,360 --> 00:20:22,720
DAVIES WHO THOUGHT MORTALITY WAS

563
00:20:22,720 --> 00:20:25,800
FLAT, WE FOUND INCIDENCE BASED

564
00:20:25,800 --> 00:20:27,080
MORTALITY RISE BY MORE THAN 15%

565
00:20:27,080 --> 00:20:29,880
OVER THIS PERIOD, IMPACTING ALL

566
00:20:29,880 --> 00:20:32,200
DEMOGRAPHIC SUBGROUPS, AND AGAIN

567
00:20:32,200 --> 00:20:35,320
ESPECIALLY TRUE FOR PAPILLARY

568
00:20:35,320 --> 00:20:36,000
THYROID CARCINOMA.

569
00:20:36,000 --> 00:20:37,520
SO YES, I DO AGREE WITH WELCH

570
00:20:37,520 --> 00:20:41,960
AND DAVIES THAT OVERDIAGNOSIS IS

571
00:20:41,960 --> 00:20:44,040
A LARGE PART OF THE EXPLANATION

572
00:20:44,040 --> 00:20:46,880
OF THE EPIDEMIOLOGIC PHENOMENON

573
00:20:46,880 --> 00:20:48,720
THAT WE SAW BUT IT IS NOT THE

574
00:20:48,720 --> 00:20:49,240
ONLY EXPLANATION.

575
00:20:49,240 --> 00:20:51,040
AND I WOULD ARGUE THAT WE ARE

576
00:20:51,040 --> 00:20:53,120
DOING OURSELVES AND MORE

577
00:20:53,120 --> 00:20:54,760
IMPORTANTLY OUR PATIENTS A

578
00:20:54,760 --> 00:20:58,040
DISSERVICE IF WE DISTRACT

579
00:20:58,040 --> 00:20:59,600
ATTENTION FROM A DISEASE WHERE

580
00:20:59,600 --> 00:21:03,320
WE ARE POTENTIALLY LOSING, NOT

581
00:21:03,320 --> 00:21:06,680
GAINING GROUND.

582
00:21:06,680 --> 00:21:08,120
THAT'S ALL WELL AND GOOD, BUT

583
00:21:08,120 --> 00:21:09,840
WHAT DO YOU THINK IS GOING ON,

584
00:21:09,840 --> 00:21:11,680
AND I THINK THERE ARE

585
00:21:11,680 --> 00:21:13,480
POTENTIALLY OTHER EXPLANATIONS

586
00:21:13,480 --> 00:21:15,280
FOR WHAT IS GOING ON.

587
00:21:15,280 --> 00:21:18,080
ONE OF THE IMPORTANT ONES IS

588
00:21:18,080 --> 00:21:19,080
OVERWEIGHT AND OBESITY.

589
00:21:19,080 --> 00:21:20,760
I THINK ALL OF YOU WILL BE

590
00:21:20,760 --> 00:21:22,760
FAMILIAR WITH THE FIGURE ON THE

591
00:21:22,760 --> 00:21:25,840
RIGHT, SHOWING INCREASING

592
00:21:25,840 --> 00:21:29,640
PREVALENCE OF OVERWEIGHT AND

593
00:21:29,640 --> 00:21:32,480
OBESITY AMONG ADULT AMERICANS.

594
00:21:32,480 --> 00:21:33,680
BUT WHAT MANY OF YOU MAY NOT

595
00:21:33,680 --> 00:21:35,240
KNOW IS THAT OVERWEIGHT AND

596
00:21:35,240 --> 00:21:38,000
OBESITY BOTH APPEAR TO BE

597
00:21:38,000 --> 00:21:40,720
ASSOCIATED WITH THIS RISE IN

598
00:21:40,720 --> 00:21:44,320
INCIDENCE OF THYROID CANCER IN

599
00:21:44,320 --> 00:21:46,520
RED, SHOWING THE THYROID CANCER

600
00:21:46,520 --> 00:21:50,880
INCIDENCE THAT WE BELIEVE IS

601
00:21:50,880 --> 00:21:53,400
ATTRIBUTABLE TO OVERWEIGHT AND

602
00:21:53,400 --> 00:21:55,800
OBESITY, BUT WHAT IS REALLY

603
00:21:55,800 --> 00:21:58,080
STRIKING IS THE FIGURE ON THE

604
00:21:58,080 --> 00:22:00,560
RIGHT, WHERE WE BELIEVE

605
00:22:00,560 --> 00:22:04,360
OVERWEIGHT AND OBESITY NOW

606
00:22:04,360 --> 00:22:05,960
POTENTIALLY EXPLAIN MORE THAN

607
00:22:05,960 --> 00:22:08,880
HALF OF INCIDENT CASES OF THE

608
00:22:08,880 --> 00:22:10,480
MOST ADVANCED DISEASE.

609
00:22:10,480 --> 00:22:13,480
THAT IS TUMORS OVER

610
00:22:13,480 --> 00:22:14,160
4 CENTIMETERS IN SIZE.

611
00:22:14,160 --> 00:22:16,840
AND THIS IS A STUDY I PUBLISHED

612
00:22:16,840 --> 00:22:19,160
TOGETHER WITH DR. KETAHARA IN

613
00:22:19,160 --> 00:22:20,880
THE JOURNAL OF THE NATIONAL

614
00:22:20,880 --> 00:22:22,360
CANCER INSTITUTE.

615
00:22:22,360 --> 00:22:24,960
WELL, FORTUNATELY THAT PART OF

616
00:22:24,960 --> 00:22:26,080
THE DISEASE THAT WE UNDERSTAND

617
00:22:26,080 --> 00:22:31,440
BETTER, THAT THAT IS RELATED TO

618
00:22:31,440 --> 00:22:32,440
OVERDIAGNOSIS, WE HAVE GOTTEN

619
00:22:32,440 --> 00:22:33,400
BETTER CONTROL.

620
00:22:33,400 --> 00:22:34,240
HOW?

621
00:22:34,240 --> 00:22:35,480
WITH CLINICAL PRACTICE

622
00:22:35,480 --> 00:22:37,120
GUIDELINES, DISCOURAGING

623
00:22:37,120 --> 00:22:38,880
SURVEILLANCE AND SCREENING OF

624
00:22:38,880 --> 00:22:40,560
THYROID NODULES.

625
00:22:40,560 --> 00:22:43,200
THE U.S. PREVENTIVE SERVICES

626
00:22:43,200 --> 00:22:44,360
TASK FORCE HAS RECOMMENDED

627
00:22:44,360 --> 00:22:45,000
AGAINST SUCH.

628
00:22:45,000 --> 00:22:47,520
AND WE'VE ALSO CHANGED THE

629
00:22:47,520 --> 00:22:50,400
NOMENCLATURE OF THYROID CANCER,

630
00:22:50,400 --> 00:22:52,000
SUCH THAT YOU CAN SEE JUST OVER

631
00:22:52,000 --> 00:22:54,240
THE LAST COUPLE OF YEARS, WE

632
00:22:54,240 --> 00:22:58,400
HAVE BEGUN TO START TO,

633
00:22:58,400 --> 00:22:59,960
QUOTE-UNQUOTE, FLATTEN THE

634
00:22:59,960 --> 00:23:00,480
CURVE.

635
00:23:00,480 --> 00:23:05,440
WELL, WHERE ARE WE TODAY, THEN,

636
00:23:05,440 --> 00:23:06,640
AS COMPARED TO 20 OR 30 YEARS

637
00:23:06,640 --> 00:23:08,440
AGO WITH REGARD TO THE

638
00:23:08,440 --> 00:23:09,720
MANAGEMENT OF THYROID CANCER?

639
00:23:09,720 --> 00:23:12,040
AND I'M A LITTLE FACETIOUS HERE,

640
00:23:12,040 --> 00:23:13,800
BUT IT'S LIKE THE PROCESS OF

641
00:23:13,800 --> 00:23:14,320
EVOLUTION.

642
00:23:14,320 --> 00:23:17,080
WHAT WE ARE DOG  DOING AND WHAT
WE

643
00:23:17,080 --> 00:23:19,560
ARE THINKING TODAY IN SOME WAYS

644
00:23:19,560 --> 00:23:21,960
VERY MUCH RESEMBLES WHERE WE

645
00:23:21,960 --> 00:23:23,920
WERE A LONG TIME AGO.

646
00:23:23,920 --> 00:23:25,600
THESE ARE THE GUIDELINES THAT

647
00:23:25,600 --> 00:23:27,760
DRIVE THE MANAGEMENT OF THYROID

648
00:23:27,760 --> 00:23:29,480
CANCER IN THE UNITED STATES AND

649
00:23:29,480 --> 00:23:30,480
PROBABLY THE WORLD.

650
00:23:30,480 --> 00:23:33,680
THEY WERE LAST PUBLISHED IN 2015

651
00:23:33,680 --> 00:23:34,720
BY THE ATA.

652
00:23:34,720 --> 00:23:36,160
WHENEVER I TALK ABOUT

653
00:23:36,160 --> 00:23:38,320
GUIDELINES, THEY ALWAYS SAY

654
00:23:38,320 --> 00:23:39,480
FIRST UNDERSTAND WHO WROTE THE

655
00:23:39,480 --> 00:23:40,040
GUIDELINES.

656
00:23:40,040 --> 00:23:40,200
WHY?

657
00:23:40,200 --> 00:23:43,080
BECAUSE ALL OF US BRING IMPLICIT

658
00:23:43,080 --> 00:23:44,800
BIASES TO WHAT WE DO AND HOW WE

659
00:23:44,800 --> 00:23:45,080
THINK.

660
00:23:45,080 --> 00:23:47,080
SO THESE WERE THE FOUR AUTHORS

661
00:23:47,080 --> 00:23:48,640
OF THOSE GUIDELINES PERTAINING

662
00:23:48,640 --> 00:23:50,160
TO SURGERY.

663
00:23:50,160 --> 00:23:52,880
THE ETA IN MANY WAYS IS VERY

664
00:23:52,880 --> 00:23:55,240
EQUITABLE AND FAIR AND THAT IS

665
00:23:55,240 --> 00:23:55,600
WONDERFUL.

666
00:23:55,600 --> 00:23:58,440
TWO OF US WERE

667
00:23:58,440 --> 00:23:59,280
OTOLARYNGOLOGISTS, ON THE LEFT.

668
00:23:59,280 --> 00:24:01,680
TWO OF US WERE ENDOCRINE

669
00:24:01,680 --> 00:24:02,880
SURGEONS ON THE RIGHT, TWO OF US

670
00:24:02,880 --> 00:24:04,760
ON TOP HAD BEEN ON PRIOR

671
00:24:04,760 --> 00:24:07,800
GUIDELINES, TWO OF US WERE

672
00:24:07,800 --> 00:24:08,040
NEWBIES.

673
00:24:08,040 --> 00:24:10,400
I WOULD SAY WE ARE STILL

674
00:24:10,400 --> 00:24:12,040
STRUGGLING WITH GENDER EQUITY IN

675
00:24:12,040 --> 00:24:14,520
THE THYROIDOLOGY COMMUNITY.

676
00:24:14,520 --> 00:24:16,120
WELL, THE CURRENT GUIDELINES IN

677
00:24:16,120 --> 00:24:19,280
MANY WAYS ARE NOT SO NOVEL IN

678
00:24:19,280 --> 00:24:21,480
THAT THEY REFLECT PRINCIPLES AND

679
00:24:21,480 --> 00:24:23,080
TENETS THAT SHOULD BE THE

680
00:24:23,080 --> 00:24:24,680
UNDERPINNING OF ALL

681
00:24:24,680 --> 00:24:25,440
CANCER-RELATED GUIDELINES.

682
00:24:25,440 --> 00:24:27,280
WE WANT TO IMPROVE SURVIVAL, WE

683
00:24:27,280 --> 00:24:31,440
WANT TO REDUCE THE RISK OF

684
00:24:31,440 --> 00:24:33,720
RECURRENCE AND METASTATIC

685
00:24:33,720 --> 00:24:40,080
SPREAD, LONG TERM SURVEILLANCE.

686
00:24:40,080 --> 00:24:42,000
SO WHAT IS REALLY UNIQUE ABOUT

687
00:24:42,000 --> 00:24:43,080
CURRENT GUIDELINES AND THESE

688
00:24:43,080 --> 00:24:44,360
GUIDELINES IS THAT FOR THE FIRST

689
00:24:44,360 --> 00:24:47,800
TIME, WE REALLY STRIVE TO

690
00:24:47,800 --> 00:24:48,560
MINIMIZE TREATMENT-RELATED

691
00:24:48,560 --> 00:24:50,040
MORBIDITY, AND IS THAT SUCH A

692
00:24:50,040 --> 00:24:50,440
NOVEL CONCEPT?

693
00:24:50,440 --> 00:24:51,280
I DON'T THINK SO.

694
00:24:51,280 --> 00:24:52,800
IT'S WHAT WE DO EACH AND EVERY

695
00:24:52,800 --> 00:24:55,080
DAY IN OUR CLINICS, AS

696
00:24:55,080 --> 00:24:55,640
CLINICIANS.

697
00:24:55,640 --> 00:24:58,120
WE WANT TO ON ONE HAND AVOID THE

698
00:24:58,120 --> 00:24:59,680
OVERTREATMENT OF INDOLENT

699
00:24:59,680 --> 00:25:01,480
DISEASE, BUT AT THE SAME TIME,

700
00:25:01,480 --> 00:25:03,760
AVOIDING UNDERTREATMENT OF

701
00:25:03,760 --> 00:25:05,080
CLINICALLY SIGNIFICANT CANCERS,

702
00:25:05,080 --> 00:25:06,240
AND HOW DO WE DO IT?

703
00:25:06,240 --> 00:25:07,960
WELL, WE HAVE TO WEIGH THE RISKS

704
00:25:07,960 --> 00:25:10,480
OF MISDIAGNOSIS.

705
00:25:10,480 --> 00:25:11,680
INCREASINGLY THE PATIENT IS AT

706
00:25:11,680 --> 00:25:13,160
THE EPICENTER OF DECISION HAD

707
00:25:13,160 --> 00:25:14,040
BEEN MAKING.

708
00:25:14,040 --> 00:25:15,800
OF COURSE THERE ARE THE

709
00:25:15,800 --> 00:25:17,520
OMNIPRESENT MEDICAL-LEGAL

710
00:25:17,520 --> 00:25:18,120
CONSIDERATIONS AND WE ALWAYS

711
00:25:18,120 --> 00:25:20,760
HAVE TO CONSIDER COST.

712
00:25:20,760 --> 00:25:22,400
WELL, LET'S WORK OUR WAY THROUGH

713
00:25:22,400 --> 00:25:27,480
THE GUIDELINES AND EVIDENCE AND

714
00:25:27,480 --> 00:25:28,080
MAYBE CHALLENGE SOME OF THE

715
00:25:28,080 --> 00:25:29,600
EVIDENCE THAT HAS BEEN CITED

716
00:25:29,600 --> 00:25:30,400
UNTIL RECENTLY.

717
00:25:30,400 --> 00:25:32,160
AND WE'RE GOING TO GO FROM SMALL

718
00:25:32,160 --> 00:25:36,360
TO LARGE, INSIDE TO OUTSIDE THE

719
00:25:36,360 --> 00:25:36,840
THYROID.

720
00:25:36,840 --> 00:25:38,480
STARTING WITH THOSE TINY TUMORS,

721
00:25:38,480 --> 00:25:39,560
I'VE TALKED ABOUT THEM NOW A

722
00:25:39,560 --> 00:25:41,360
COUPLE OF TIMES, THESE PAPILLARY

723
00:25:41,360 --> 00:25:43,800
THYROID MICRO CARCINOMAS LESS

724
00:25:43,800 --> 00:25:45,120
THAN 1 CENTIMETER, RISING THE

725
00:25:45,120 --> 00:25:46,800
FASTEST IN INCIDENCE.

726
00:25:46,800 --> 00:25:50,880
AND IN 2014, THERE WAS A REALLY

727
00:25:50,880 --> 00:25:53,080
PROVOCATIVE COMMENTARY PUBLISHED

728
00:25:53,080 --> 00:25:54,720
BY TWO THYROIDOLOGISTS IN THE

729
00:25:54,720 --> 00:25:56,480
JOURNAL THYROID, ASKING WHETHER

730
00:25:56,480 --> 00:25:58,440
THE IDENTIFICATION AND

731
00:25:58,440 --> 00:26:00,200
ERADICATION OF ALL OF THESE TINY

732
00:26:00,200 --> 00:26:02,400
TUMORS IS REALLY A WORTHWHILE

733
00:26:02,400 --> 00:26:04,200
GOAL, OR IF, RATHER, WE MAY NOT

734
00:26:04,200 --> 00:26:06,760
WANT TO REMOVE THEM SURGICALLY

735
00:26:06,760 --> 00:26:09,240
BUT RATHER LEAVE THEM IN AND

736
00:26:09,240 --> 00:26:10,120
ACTIVELY SURVEIL THEM.

737
00:26:10,120 --> 00:26:11,520
AND WHENEVER I GO BACK AND READ

738
00:26:11,520 --> 00:26:12,720
THIS COMMENTARY, I ALWAYS SAY,

739
00:26:12,720 --> 00:26:14,480
IF WE'RE GOING TO NOT REMOVE BUT

740
00:26:14,480 --> 00:26:16,480
ACTIVELY SURVEIL, WE'D BETTER DO

741
00:26:16,480 --> 00:26:19,520
IT MORE FASTIDIOUSLY THAN THE

742
00:26:19,520 --> 00:26:20,800
EDITORS OF THE JOURNAL THYROID,

743
00:26:20,800 --> 00:26:25,800
WHO MISSPELLED MICROPAPILLARY

744
00:26:25,800 --> 00:26:26,440
THYROID CANCER.

745
00:26:26,440 --> 00:26:28,880
SO A CAUTIONARY NOTE AROUND

746
00:26:28,880 --> 00:26:30,360
ACTIVE SURVEILLANCE.

747
00:26:30,360 --> 00:26:32,760
WELL, ARE THERE ANY DATA TO

748
00:26:32,760 --> 00:26:34,600
SUGGEST WE CAN ACTIVELY SURVEIL

749
00:26:34,600 --> 00:26:36,480
THESE TINY TUMORS?

750
00:26:36,480 --> 00:26:39,960
WE'RE BUILDING SOME BODY OF

751
00:26:39,960 --> 00:26:40,840
EVIDENCE HERE IN THE UNITED

752
00:26:40,840 --> 00:26:41,920
STATES, BUT REALLY THE LARGEST

753
00:26:41,920 --> 00:26:44,400
BODY OF WORK HAS COME FROM JAPAN

754
00:26:44,400 --> 00:26:46,440
IN THE ETO RESEARCH GROUP.

755
00:26:46,440 --> 00:26:49,960
THEY'VE PUBLISHED CYRIL 
SERIALLY ON A

756
00:26:49,960 --> 00:26:51,880
COHORT OF PATIENTS THAT NOW WELL

757
00:26:51,880 --> 00:26:52,400
EXCEEDS 1200 PATIENTS.

758
00:26:52,400 --> 00:26:55,840
THIS IS MY FAVORITE STUDY FROM

759
00:26:55,840 --> 00:27:02,360
THAT SERIES FROM 2014 LOOKING AT

760
00:27:02,360 --> 00:27:03,200
1235 PATIENTS FOLLOWED FOR A

761
00:27:03,200 --> 00:27:05,800
MEAN OF 75 MONTHS DIVIDED INTO

762
00:27:05,800 --> 00:27:07,120
THREE AGE GROUPS, AND BASICALLY

763
00:27:07,120 --> 00:27:10,280
ALL OF THESE PATIENTS HAD

764
00:27:10,280 --> 00:27:12,120
PAPILLARY THYROID MICRO

765
00:27:12,120 --> 00:27:13,840
CARCINOMAS AND THE TUMORS WERE

766
00:27:13,840 --> 00:27:15,320
NOT REMOVED BUT FOLLOWED,

767
00:27:15,320 --> 00:27:17,080
LOOKING FOR NODAL METASTASIS OR

768
00:27:17,080 --> 00:27:18,040
PROGRESSION OF CLINICAL DISEASE

769
00:27:18,040 --> 00:27:20,840
TO A TUMOR SIZE 1.2 CENTIMETERS

770
00:27:20,840 --> 00:27:21,120
OR GREATER.

771
00:27:21,120 --> 00:27:23,960
AND WHAT THE AUTHORS FIND IS

772
00:27:23,960 --> 00:27:26,400
REALLY EXTRAORDINARY.

773
00:27:26,400 --> 00:27:29,080
AT A DECADE, 10 YEARS, JUST 8%

774
00:27:29,080 --> 00:27:30,200
OF THESE PATIENTS EXPERIENCED

775
00:27:30,200 --> 00:27:31,920
ANY ENLARGEMENT OF THEIR TUMORS,

776
00:27:31,920 --> 00:27:35,680
AND LESS THAN 4% OF THESE

777
00:27:35,680 --> 00:27:36,600
PATIENTS DEVELOPED NODAL

778
00:27:36,600 --> 00:27:38,080
METASTASES.

779
00:27:38,080 --> 00:27:39,600
WHEN THE PATIENTS WERE DIVIDED

780
00:27:39,600 --> 00:27:43,120
UP INTO AGE GROUPS, WHAT YOU SEE

781
00:27:43,120 --> 00:27:44,400
IS THAT THE PROPORTION OF

782
00:27:44,400 --> 00:27:45,960
PATIENTS WHO HAD THE MOST

783
00:27:45,960 --> 00:27:52,080
PROGRESSION OF DISEASE WERE THE

784
00:27:52,080 --> 00:27:53,440
YOUNGEST PATIENTS SHOWN IN THE

785
00:27:53,440 --> 00:27:55,280
DOTTED LINE ON THE LEFT AND IN

786
00:27:55,280 --> 00:27:56,880
THE RIGHT, AND IT WAS LOWEST

787
00:27:56,880 --> 00:27:58,840
PROGRESSION FOR THE OLDEST

788
00:27:58,840 --> 00:28:00,760
PATIENTS SHOWN IN THE SOLID

789
00:28:00,760 --> 00:28:03,000
LINE, INDEED ON MULTIVARIATE

790
00:28:03,000 --> 00:28:04,080
REGRESSION ANALYSIS, YOUNG AGE

791
00:28:04,080 --> 00:28:06,680
WAS AN INDEPENDENT PREDICTOR OF

792
00:28:06,680 --> 00:28:06,960
PROGRESSION.

793
00:28:06,960 --> 00:28:08,920
LEADING THE AUTHORS TO CONCLUDE

794
00:28:08,920 --> 00:28:12,080
THAT OLDER PATIENTS ARE PROBABLY

795
00:28:12,080 --> 00:28:15,960
THE BEST PATIENTS TO ACTIVELY

796
00:28:15,960 --> 00:28:17,240
SURVEIL OR OBSERVE RATHER THAN

797
00:28:17,240 --> 00:28:17,640
OPERATE ON.

798
00:28:17,640 --> 00:28:19,400
BUT EVEN IN YOUNG PATIENTS,

799
00:28:19,400 --> 00:28:21,360
WHERE THERE IS THE MOST

800
00:28:21,360 --> 00:28:27,160
PROGRESSIVE DISEASE, THERE

801
00:28:27,160 --> 00:28:28,600
APPEARS TO BE PLENTY OF TIME TO

802
00:28:28,600 --> 00:28:30,760
FOLLOW PATIENTS AND THEN RESCUE

803
00:28:30,760 --> 00:28:32,400
PATIENTS WITH DELAYED SURGERY

804
00:28:32,400 --> 00:28:34,120
AND WITHOUT AN IMPACT ON

805
00:28:34,120 --> 00:28:35,400
SURVIVAL.

806
00:28:35,400 --> 00:28:37,760
SO A LOT OF PEOPLE SAID, WELL,

807
00:28:37,760 --> 00:28:39,080
LET'S EMBRACE ACTIVE

808
00:28:39,080 --> 00:28:40,240
SURVEILLANCE IN THE UNITED

809
00:28:40,240 --> 00:28:40,480
STATES.

810
00:28:40,480 --> 00:28:42,480
LET'S JUST START DOING IF IT

811
00:28:42,480 --> 00:28:44,000
WORKS IN JAPAN.

812
00:28:44,000 --> 00:28:45,520
AND I'M SOMEONE WHO ALWAYS TAKES

813
00:28:45,520 --> 00:28:48,760
A CAUTIONARY -- BEFORE WE DO

814
00:28:48,760 --> 00:28:49,680
SOMETHING NEW, LET'S SEE WHAT

815
00:28:49,680 --> 00:28:50,800
WE'RE DOING RIGHT NOW.

816
00:28:50,800 --> 00:28:53,360
SO THIS IS THE STUDY FROM OUR

817
00:28:53,360 --> 00:28:55,200
RESEARCH GROUP COMPARING

818
00:28:55,200 --> 00:28:56,320
SURVIVAL AT A POPULATION LEVEL

819
00:28:56,320 --> 00:28:58,480
FOR PATIENTS WITH PAPILLARY

820
00:28:58,480 --> 00:29:00,120
THYROID MICRO CARCINOMAS TO THE

821
00:29:00,120 --> 00:29:01,440
GENERAL U.S. POPULATION.

822
00:29:01,440 --> 00:29:03,680
AND WHAT YOU SEE IS THAT IF

823
00:29:03,680 --> 00:29:05,960
ANYTHING, PATIENTS WITH

824
00:29:05,960 --> 00:29:07,080
PAPILLARY THYROID MICRO

825
00:29:07,080 --> 00:29:08,160
CARCINOMAS, THEY LIVE LONGER

826
00:29:08,160 --> 00:29:09,440
THAN THE AVERAGE AMERICAN.

827
00:29:09,440 --> 00:29:10,960
WELL, A LOT OF PEOPLE SAY, HOW

828
00:29:10,960 --> 00:29:11,360
IS THAT POSSIBLE?

829
00:29:11,360 --> 00:29:13,080
HOW CAN YOU HAVE THYROID CANCER

830
00:29:13,080 --> 00:29:14,480
AND LIVE LONGER THAN SOMEONE

831
00:29:14,480 --> 00:29:16,040
WITH NO CANCER?

832
00:29:16,040 --> 00:29:18,200
AND OF COURSE IF YOU HAVE A TWO

833
00:29:18,200 --> 00:29:20,080
OR THREE OR FOUR-MILLIMETER

834
00:29:20,080 --> 00:29:22,480
CANCER DISCOVERED AND TREATED IN

835
00:29:22,480 --> 00:29:23,560
YOUR THYROID, YOU ALMOST

836
00:29:23,560 --> 00:29:24,600
CERTAINLY HAVE BETTER HEALTHCARE

837
00:29:24,600 --> 00:29:26,360
AND BETTER ACCESS TO HEALTHCARE

838
00:29:26,360 --> 00:29:28,880
THAN THE AVERAGE AMERICAN, WHICH

839
00:29:28,880 --> 00:29:32,680
MAY WELL CONVEY A SURVIVAL

840
00:29:32,680 --> 00:29:33,480
ADVANTAGE.

841
00:29:33,480 --> 00:29:34,440
WELL, RIGHT NOW IN THE UNITED

842
00:29:34,440 --> 00:29:35,960
STATES, PEOPLE WITH THESE TINY

843
00:29:35,960 --> 00:29:37,720
TUMORS ARE BEING OVERTREATED FOR

844
00:29:37,720 --> 00:29:39,360
THEIR DISEASE.

845
00:29:39,360 --> 00:29:41,080
NEARLY THREE QUARTERS OF THEM

846
00:29:41,080 --> 00:29:44,280
ARE UNDERGOING TOTAL THYROID 

847
00:29:44,280 --> 00:29:45,160
THYROIDECTOMY, WHEN THE

848
00:29:45,160 --> 00:29:46,800
RECOMMENDATIONS CURRENTLY ARE

849
00:29:46,800 --> 00:29:48,600
FOR THYROID LOBECTOMY.

850
00:29:48,600 --> 00:29:50,600
A LOT OF PEOPLE SAY WAIT A

851
00:29:50,600 --> 00:29:52,120
MINUTE, JULIE ANN, YOU'RE

852
00:29:52,120 --> 00:29:52,800
MISREPRESENTING THIS.

853
00:29:52,800 --> 00:29:53,840
THESE ARE ACTUALLY PEOPLE WHO

854
00:29:53,840 --> 00:29:55,880
ARE HAVING TOTAL THYROIDECTOMIES

855
00:29:55,880 --> 00:29:58,880
BECAUSE THEY HAVE MULTINODULE

856
00:29:58,880 --> 00:29:59,480
GOITER, GRAVES' DISEASE, OTHER

857
00:29:59,480 --> 00:30:01,200
REASONS TO HAVE THEIR WHOLE

858
00:30:01,200 --> 00:30:02,840
THYROID TAKEN OUT, AND ONLY ON

859
00:30:02,840 --> 00:30:04,360
THE SURGICAL HISTOPATHOLOGY IS

860
00:30:04,360 --> 00:30:06,320
THE TINY CANCER IDENTIFIED.

861
00:30:06,320 --> 00:30:07,960
SO IT WAS NOT THE REASON FOR THE

862
00:30:07,960 --> 00:30:09,080
SURGERY.

863
00:30:09,080 --> 00:30:11,920
BUT I WOULD SAY, UH-UH.

864
00:30:11,920 --> 00:30:13,240
WHY DO I SAY THAT?

865
00:30:13,240 --> 00:30:14,480
BECAUSE THESE PATIENTS NOT ONLY

866
00:30:14,480 --> 00:30:16,200
HAD THEIR WHOLE THYROID REMOVED

867
00:30:16,200 --> 00:30:20,000
FOR A TINY, TINY CANCER, BUT A

868
00:30:20,000 --> 00:30:23,160
THIRD OF THEM GO ON TO ALSO

869
00:30:23,160 --> 00:30:24,880
UNDERGO ADJUVANT RADIOACTIVE

870
00:30:24,880 --> 00:30:26,280
IODINE.

871
00:30:26,280 --> 00:30:28,480
SO WHAT DO THE GUIDELINES

872
00:30:28,480 --> 00:30:29,920
CURRENTLY RECOMMEND IN THE

873
00:30:29,920 --> 00:30:33,240
UNITED STATES?

874
00:30:33,240 --> 00:30:35,120
THYROID LOBECTOMY IS THE

875
00:30:35,120 --> 00:30:36,880
OVERWHELMING RECOMMENDATION, BUT

876
00:30:36,880 --> 00:30:39,520
THE GUIDELINES FOR THE FIRST

877
00:30:39,520 --> 00:30:41,800
TIME INTRODUCE THE WORD "IF.

878
00:30:41,800 --> 00:30:44,480
"IF SURGERY IS CHOSEN.

879
00:30:44,480 --> 00:30:47,400
MEANING THE DOOR WAS OPENED A

880
00:30:47,400 --> 00:30:51,320
CRACK TO PERMIT THE APPLICATION

881
00:30:51,320 --> 00:30:53,640
OF ACTIVE SURVEILLANCE IN VERY

882
00:30:53,640 --> 00:30:54,280
SPECIFIC CIRCUMSTANCES.

883
00:30:54,280 --> 00:30:58,000
WELL, LET'S SWITCH GEAR AND GO

884
00:30:58,000 --> 00:31:01,600
ONE SIZE UP AND TALK ABOUT THE

885
00:31:01,600 --> 00:31:03,480
BREAD AND BUTTER OF THYROID

886
00:31:03,480 --> 00:31:04,840
CANCER PRESENTATION, WHICH IS A

887
00:31:04,840 --> 00:31:07,520
LOW RISK DIFFERENTIATED THYROID

888
00:31:07,520 --> 00:31:07,760
CANCER.

889
00:31:07,760 --> 00:31:09,080
1 TO 4 CENTIMETERS IN SIZE,

890
00:31:09,080 --> 00:31:11,000
CONFINED TO THE THYROID, THAT

891
00:31:11,000 --> 00:31:12,800
HAS NOT SPREAD OUTSIDE THE

892
00:31:12,800 --> 00:31:15,280
THYROID OR METASTASIZED TO LYMPH

893
00:31:15,280 --> 00:31:15,480
NODES.

894
00:31:15,480 --> 00:31:19,360
THIS IS THE AGE-OLD DEBATE,

895
00:31:19,360 --> 00:31:22,280
TOTAL THIGH ROADECTOMY VERSUS

896
00:31:22,280 --> 00:31:23,280
LOBECTOMY, THE REMOVAL OF HALF.

897
00:31:23,280 --> 00:31:25,480
THOSE WHO ARGUE FOR TOTAL

898
00:31:25,480 --> 00:31:27,000
THYROIDECTOMY SAY THERE'S OFTEN

899
00:31:27,000 --> 00:31:28,080
BILATERAL AND MULTIFOCAL

900
00:31:28,080 --> 00:31:28,560
DISEASE.

901
00:31:28,560 --> 00:31:30,600
WE MAY WANT TO GIVE RADIOACTIVE

902
00:31:30,600 --> 00:31:31,680
IODINE AFTER SURGERY AND FOR

903
00:31:31,680 --> 00:31:33,320
THAT, YOU WANT YOUR WHOLE

904
00:31:33,320 --> 00:31:34,440
THYROID REMOVED.

905
00:31:34,440 --> 00:31:36,080
AND ZEROING OUT THE THYROID

906
00:31:36,080 --> 00:31:38,280
GLOBULIN LEVEL OF TUMOR MARKER

907
00:31:38,280 --> 00:31:39,960
IS DONE WITH TOTAL

908
00:31:39,960 --> 00:31:41,600
THYROIDECTOMY, MAKING BIOMARKERS

909
00:31:41,600 --> 00:31:45,600
A USEFUL ADJUNCT.

910
00:31:45,600 --> 00:31:47,800
THOSE WHO COUNTER AND ARGUE FOR

911
00:31:47,800 --> 00:31:49,880
LOBECTOMY SAYS WHO WANTS

912
00:31:49,880 --> 00:31:51,280
SUPPLEMENTATION LET ALONE

913
00:31:51,280 --> 00:31:52,720
THYROID HORMONE REPLACEMENT?

914
00:31:52,720 --> 00:31:54,280
IT'S AN INDOLENT DISEASE WITH AN

915
00:31:54,280 --> 00:31:56,880
EXCELLENT PROGNOSIS, AND BIGGER

916
00:31:56,880 --> 00:31:58,240
SURGERY IMPLIES MORE

917
00:31:58,240 --> 00:32:00,680
COMPLICATIONS.

918
00:32:00,680 --> 00:32:05,120
WELL, UNTIL VERY RECENTLY, WE

919
00:32:05,120 --> 00:32:06,400
PERFORMED TOTAL THYROIDECTOMY

920
00:32:06,400 --> 00:32:07,360
FOR ALL OF THESE PATIENTS.

921
00:32:07,360 --> 00:32:09,800
WHY DID THE AMERICAN THYROID

922
00:32:09,800 --> 00:32:12,520
ASSOCIATION RECOMMEND THAT?

923
00:32:12,520 --> 00:32:14,120
AGAIN, IT'S AMAZING HOW LITTLE

924
00:32:14,120 --> 00:32:16,160
EVIDENCE THERE IS FOR MANY OF

925
00:32:16,160 --> 00:32:18,400
THE THINGS THAT WE THINK ARE

926
00:32:18,400 --> 00:32:19,680
STANDARD PRACTICE.

927
00:32:19,680 --> 00:32:22,440
IT WAS A SINGLE STUDY PUBLISHED

928
00:32:22,440 --> 00:32:26,040
BY BILIMORIA ET AL. IN 2007

929
00:32:26,040 --> 00:32:27,600
LOOKING AT MORE THAN 52,000

930
00:32:27,600 --> 00:32:29,080
PATIENTS FROM THE NATIONAL

931
00:32:29,080 --> 00:32:29,480
CANCER DATABASE.

932
00:32:29,480 --> 00:32:31,280
AND I'M JUST GOING TO CUT TO THE

933
00:32:31,280 --> 00:32:31,720
CHASE.

934
00:32:31,720 --> 00:32:34,840
HERE'S THE PIVOTAL FIGURE FROM

935
00:32:34,840 --> 00:32:36,240
THAT ARTICLE COMPARING PATIENTS

936
00:32:36,240 --> 00:32:39,080
WHO UNDERGO LOBECTOMY TO TOTAL

937
00:32:39,080 --> 00:32:39,440
THYROIDECTOMY.

938
00:32:39,440 --> 00:32:41,200
AND WHAT YOU SEE IS IF YOU

939
00:32:41,200 --> 00:32:45,280
UNDERGO A LOBECTOMY, YOU ARE 31%

940
00:32:45,280 --> 00:32:47,880
MORE LIKELY TO DIE THAN IF YOU

941
00:32:47,880 --> 00:32:50,520
HAD UNDERGONE TOTAL

942
00:32:50,520 --> 00:32:52,880
THYROIDECTOMY FOR YOUR LOW RISK

943
00:32:52,880 --> 00:32:54,400
DIFFERENTIATED THYROID CANCER.

944
00:32:54,400 --> 00:32:56,480
PRETTY COMPELLING, AND THE

945
00:32:56,480 --> 00:32:58,240
REASON WHY THE ATA MADE THE

946
00:32:58,240 --> 00:33:01,640
RECOMMENDATION IT DID.

947
00:33:01,640 --> 00:33:04,560
BUT THEN AFTER THAT BILIMORIA

948
00:33:04,560 --> 00:33:08,080
STUDY WAS PUBLISHED, YOU , A FEW

949
00:33:08,080 --> 00:33:09,320
PEOPLE SCRATCHED THEIR HEADS AND

950
00:33:09,320 --> 00:33:10,600
SAID WELL, THERE ARE SOME

951
00:33:10,600 --> 00:33:11,640
VARIABLES THAT SEEM TO HAVE BEEN

952
00:33:11,640 --> 00:33:12,800
MISSING FROM THAT NATIONAL

953
00:33:12,800 --> 00:33:15,680
CANCER DATABASE, AND THEN IN

954
00:33:15,680 --> 00:33:17,680
2010, MENDELSOHN LOOKED AT MORE

955
00:33:17,680 --> 00:33:18,480
THAN 22,000 PATIENTS IN A

956
00:33:18,480 --> 00:33:20,440
DIFFERENT DATASET, BUT WAS

957
00:33:20,440 --> 00:33:23,360
UNABLE TO DEMONSTRATE A SURVIVAL

958
00:33:23,360 --> 00:33:24,880
ADVANTAGE WITH TOTAL

959
00:33:24,880 --> 00:33:26,440
THYROIDECTOMY.

960
00:33:26,440 --> 00:33:31,120
SO SOMETIMES THE BEST SCIENCE

961
00:33:31,120 --> 00:33:32,480
DOES NOT COME FROM ASKING A NEW

962
00:33:32,480 --> 00:33:33,680
QUESTION, RATHER, IT COMES FROM

963
00:33:33,680 --> 00:33:36,440
ASKING AN OLD QUESTION BUT IN A

964
00:33:36,440 --> 00:33:38,080
NEW WAY.

965
00:33:38,080 --> 00:33:40,600
SORT OF LIKE DR. KETAHARA AND I

966
00:33:40,600 --> 00:33:42,880
DID AROUND THE EPIDEMIOLOGY OF

967
00:33:42,880 --> 00:33:47,840
THIS EPIDEMIC OF THYROID CANCER.

968
00:33:47,840 --> 00:33:49,360
SO THIS IS A STUDY AGAIN

969
00:33:49,360 --> 00:33:51,000
PUBLISHED BY OUR RESEARCH GROUP

970
00:33:51,000 --> 00:33:52,960
BUT THIS TIME LED BY A LEARNER.

971
00:33:52,960 --> 00:34:00,680
THIS IS DR. MOHAMED ADAM WHEN HE

972
00:34:00,680 --> 00:34:02,840
WAS A THIRD YEAR RESIDENT AT

973
00:34:02,840 --> 00:34:03,280
DUKE UNIVERSITY.

974
00:34:03,280 --> 00:34:04,960
WHAT WE DID IN THIS STUDY WAS

975
00:34:04,960 --> 00:34:09,680
ESSENTIALLY REDO THE BILIMORIA

976
00:34:09,680 --> 00:34:11,400
STUDY BUT WITH AN EMBELLISHED

977
00:34:11,400 --> 00:34:11,720
DATASET.

978
00:34:11,720 --> 00:34:16,680
SO LIKE BILIMORIA, WE USED THE

979
00:34:16,680 --> 00:34:17,240
NATIONAL CANCER DATABASE

980
00:34:17,240 --> 00:34:19,280
COMPARING SURVIVAL FROM TOTAL

981
00:34:19,280 --> 00:34:21,120
THYROIDECTOMY TO THYROID

982
00:34:21,120 --> 00:34:23,720
LOBECTOMY, BUT THIS TIME,

983
00:34:23,720 --> 00:34:26,200
ENRICHING THE DATASET FOR MANY

984
00:34:26,200 --> 00:34:31,560
VARIABLES THAT WERE MISSING FOR

985
00:34:31,560 --> 00:34:34,160
BILIMORIA BUT BY  WHICH COULD
WELL

986
00:34:34,160 --> 00:34:37,480
IMPACT SUR VIE. WE HAD MORE THAN

987
00:34:37,480 --> 00:34:38,480
61,000 PATIENTS, LOBECTOMY ON

988
00:34:38,480 --> 00:34:40,320
THE LEFT, TOTAL THYROIDECTOMY ON

989
00:34:40,320 --> 00:34:41,200
THE RIGHT.

990
00:34:41,200 --> 00:34:44,080
HERE YOU'LL SEE DEMOGRAPHIC

991
00:34:44,080 --> 00:34:44,680
VARIABLES.

992
00:34:44,680 --> 00:34:46,360
P VALUES THAT ARE STATISTICALLY

993
00:34:46,360 --> 00:34:47,320
SIGNIFICANT BUT I WOULD ARGUE

994
00:34:47,320 --> 00:34:50,360
NOT CLINICALLY SIGNIFICANT, BUT

995
00:34:50,360 --> 00:34:51,240
THESE DEFINITELY ARE.

996
00:34:51,240 --> 00:34:54,520
AND ALL OF THESE VARIABLES HAD

997
00:34:54,520 --> 00:34:57,240
BEEN MISSING FOR BILIMORIA,

998
00:34:57,240 --> 00:34:58,280
PRESENT FOR US AND DEFINITELY

999
00:34:58,280 --> 00:34:59,000
RELEVANT TO SURVIVAL.

1000
00:34:59,000 --> 00:35:02,560
NOT REALLY -- IT'S SURPRISING,

1001
00:35:02,560 --> 00:35:05,240
MORE MULTIFOCAL DISEASE, MORE

1002
00:35:05,240 --> 00:35:11,880
EXTRA THIGH  THYROIDAL
EXTENSION, AND

1003
00:35:11,880 --> 00:35:14,120
MORE POSITIVE SURGICAL MARGINS

1004
00:35:14,120 --> 00:35:15,600
IN THE TOTAL THYROIDECTOMY

1005
00:35:15,600 --> 00:35:15,800
GROUP.

1006
00:35:15,800 --> 00:35:17,960
BUT WHEN WE TOOK THIS ENRICHED

1007
00:35:17,960 --> 00:35:19,640
DATASET AND REPLICATED THE

1008
00:35:19,640 --> 00:35:22,240
ANALYSES OF BILIMORIA, THE

1009
00:35:22,240 --> 00:35:24,120
SURVIVAL ADVANTAGE OF TOTAL

1010
00:35:24,120 --> 00:35:26,400
THYROIDECTOMY DISAPPEARED.

1011
00:35:26,400 --> 00:35:30,880
AND SURVIVAL IS COMPARABLE FOR

1012
00:35:30,880 --> 00:35:37,680
TOTAL THYROIDECTOMY AND

1013
00:35:37,680 --> 00:35:38,080
LOBECTOMY.

1014
00:35:38,080 --> 00:35:40,920
SO HERE ARE GUIDELINES FROM THE

1015
00:35:40,920 --> 00:35:42,040
ATA RECOMMENDING TOTAL

1016
00:35:42,040 --> 00:35:43,080
THYROIDECTOMY FOR THE

1017
00:35:43,080 --> 00:35:43,680
OVERWHELMING MAJORITY OF

1018
00:35:43,680 --> 00:35:46,080
PATIENTS WITH LOW RISK DISEASE,

1019
00:35:46,080 --> 00:35:50,320
AND HERE ARE THE 2015 GUIDELINES

1020
00:35:50,320 --> 00:35:53,920
WHERE TOTAL THYROIDECTOMY OR

1021
00:35:53,920 --> 00:35:56,480
THYROID LOBECTOMY ARE EQUIVALENT

1022
00:35:56,480 --> 00:35:59,120
WITH REGARD TO SURVIVAL, AND,

1023
00:35:59,120 --> 00:36:00,880
THEREFORE, BOTH ARE TREATMENT

1024
00:36:00,880 --> 00:36:04,000
OPTIONS FOR PATIENTS.

1025
00:36:04,000 --> 00:36:05,920
IN THE END, SHOULD I MAKE THIS

1026
00:36:05,920 --> 00:36:06,600
DECISION OR RECOMMENDATION?

1027
00:36:06,600 --> 00:36:09,760
I DON'T THINK SO.

1028
00:36:09,760 --> 00:36:12,480
I THINK ALL OF US, IF WE'RE GOOD

1029
00:36:12,480 --> 00:36:13,400
CLINICIANS, WISE CLINICIANS, WE

1030
00:36:13,400 --> 00:36:15,000
PRESENT THE RISK AND BENEFITS OF

1031
00:36:15,000 --> 00:36:16,440
BOTH TREATMENT ALTERNATIVES TO

1032
00:36:16,440 --> 00:36:19,480
OUR PATIENTS, AND WE ALLOW THE

1033
00:36:19,480 --> 00:36:22,040
PATIENTS TO EXERCISE THEIR

1034
00:36:22,040 --> 00:36:23,760
PREFERENCES BASED ON THEIR

1035
00:36:23,760 --> 00:36:24,880
VALUES.

1036
00:36:24,880 --> 00:36:28,680
BUT AGAIN, GUIDELINES

1037
00:36:28,680 --> 00:36:30,400
TRANSFORMED BY A LEARNER DOING

1038
00:36:30,400 --> 00:36:33,400
IMPACTFUL RESEARCH BASED ON AN

1039
00:36:33,400 --> 00:36:35,520
OLD QUESTION ANSWERED IN A NEW

1040
00:36:35,520 --> 00:36:36,040
WAY.

1041
00:36:36,040 --> 00:36:37,360
WELL, LET'S NOW CHANGE GEARS

1042
00:36:37,360 --> 00:36:38,720
AGAIN AND WE'RE GOING TO HOP

1043
00:36:38,720 --> 00:36:40,880
OUTSIDE THE THYROID, AND WE'RE

1044
00:36:40,880 --> 00:36:41,960
GOING TO TALK ABOUT THE LYMPH

1045
00:36:41,960 --> 00:36:43,920
NODES AROUND THE THYROID THAT

1046
00:36:43,920 --> 00:36:47,000
MIGHT CONTAIN METASTATIC

1047
00:36:47,000 --> 00:36:47,680
DISEASE.

1048
00:36:47,680 --> 00:36:48,640
JUST A QUICK PRIMER.

1049
00:36:48,640 --> 00:36:53,440
THIS IS THE STATE YOUR  STATE
YOUR STAGES 
SYSTEM FOR

1050
00:36:53,440 --> 00:36:54,120
DIFFERENTIATED THYROID CANCER.

1051
00:36:54,120 --> 00:36:55,200
IT'S QUIRKY AND WEIRD.

1052
00:36:55,200 --> 00:37:01,120
THIS IS THE AJCC STAGING SIM

1053
00:37:01,120 --> 00:37:01,440
CYST TEM.

1054
00:37:01,440 --> 00:37:02,880
WHAT YOU NEED TO KNOW IS A

1055
00:37:02,880 --> 00:37:03,280
SIMPLE THING.

1056
00:37:03,280 --> 00:37:06,000
IF YOU ARE YOUNG, THIS IS THE

1057
00:37:06,000 --> 00:37:07,160
SEVENTH EDITION, WE'RE NOW ON

1058
00:37:07,160 --> 00:37:07,680
THE EIGHTH EDITION.

1059
00:37:07,680 --> 00:37:09,600
BUT IF YOU'RE YOUNG, THEN UNDER

1060
00:37:09,600 --> 00:37:11,600
45 YEARS, NOW WITH THE EIGHTH

1061
00:37:11,600 --> 00:37:14,480
EDITION, UNDER 55 YEARS, YOU CAN

1062
00:37:14,480 --> 00:37:22,000
ONLY BE STAGE ONE  I OR STAGE
II,

1063
00:37:22,000 --> 00:37:23,920
BASED ON WHETHER YOU HAVE EXTRA

1064
00:37:23,920 --> 00:37:24,840
CERVICAL METASTASES.

1065
00:37:24,840 --> 00:37:26,960
SO DISTANT METASTATIC DISEASE.

1066
00:37:26,960 --> 00:37:29,880
IF YOU'RE OVER 45 IN THE SEVENTH

1067
00:37:29,880 --> 00:37:31,880
EDITION, IN THE EIGHTH EDITION,

1068
00:37:31,880 --> 00:37:34,880
OVER 55, YOU CAN BE STAGE I, II,

1069
00:37:34,880 --> 00:37:36,120
III OR IV.

1070
00:37:36,120 --> 00:37:37,600
SO WHAT'S THE BIG DIFFERENCE?

1071
00:37:37,600 --> 00:37:40,880
IF YOU ARE YOUNG AND YOU HAVE

1072
00:37:40,880 --> 00:37:44,240
METASTATIC DISEASE IN THE NECK,

1073
00:37:44,240 --> 00:37:45,320
WE DO NOT TREAT YOU DIFFERENTLY

1074
00:37:45,320 --> 00:37:47,280
FROM NOT HAVING METASTATIC

1075
00:37:47,280 --> 00:37:49,680
DISEASE, BUT IF YOU ARE OLDER,

1076
00:37:49,680 --> 00:37:52,280
WE UPSTAGE YOU FOR THE NODAL

1077
00:37:52,280 --> 00:37:53,480
METASTASES.

1078
00:37:53,480 --> 00:37:55,480
SO I'LL JUST TELL YOU, THIS IS

1079
00:37:55,480 --> 00:37:56,360
SUPER QUIRKY.

1080
00:37:56,360 --> 00:38:02,440
THERE IS NO OTHER CANCER STAGING

1081
00:38:02,440 --> 00:38:05,120
SYSTEM THAT DEPLOYS AGE IN THIS

1082
00:38:05,120 --> 00:38:05,280
WAY.

1083
00:38:05,280 --> 00:38:06,880
SO I SCRATCHED MY HEAD AND SAID,

1084
00:38:06,880 --> 00:38:08,800
WHY DO WE DO SOMETHING

1085
00:38:08,800 --> 00:38:11,960
DIFFERENTLY FOR THYROID CANCER

1086
00:38:11,960 --> 00:38:18,080
THAN EVERY OTHER SOLID TUMOR

1087
00:38:18,080 --> 00:38:18,720
UNKNOWN TO MAN?

1088
00:38:18,720 --> 00:38:21,800
SO I TERNED TO MY MENTEE LEARNER

1089
00:38:21,800 --> 00:38:27,560
AND ACADEMIC SURGEON

1090
00:38:27,560 --> 00:38:29,440
EXTRAORDINARIE KNOW HAMED ADAM,

1091
00:38:29,440 --> 00:38:33,320
AGAIN A THIRD YEAR WHEN HE DOES

1092
00:38:33,320 --> 00:38:35,240
THIS STUDY WITH AN IMPACT FACTOR

1093
00:38:35,240 --> 00:38:36,320
OF NEARLY 30.

1094
00:38:36,320 --> 00:38:37,680
AND WHAT WE ASKED IS A SIMPLE

1095
00:38:37,680 --> 00:38:38,240
QUESTION.

1096
00:38:38,240 --> 00:38:40,440
DO LYMPH NODE METASTASES IN

1097
00:38:40,440 --> 00:38:42,240
YOUNG PEOPLE REALLY MEAN

1098
00:38:42,240 --> 00:38:42,680
NOTHING?

1099
00:38:42,680 --> 00:38:45,480
OR DO THEY, IN FACT, IN

1100
00:38:45,480 --> 00:38:47,120
CONTRADICTION TO STAGING

1101
00:38:47,120 --> 00:38:49,080
SYSTEMS, IMPACT SURVIVAL, AND IF

1102
00:38:49,080 --> 00:38:52,480
THEY DO, DOES THE VOLUME OF

1103
00:38:52,480 --> 00:38:54,680
METASTATIC DISEASE HAVE

1104
00:38:54,680 --> 00:38:55,080
RELEVANCE?

1105
00:38:55,080 --> 00:38:56,600
SO TO ANSWER THAT QUESTION,

1106
00:38:56,600 --> 00:38:58,080
DR. ADAM AND OUR RESEARCH GROUP

1107
00:38:58,080 --> 00:39:01,000
LOOKED AT TWO LARGE POPULATION

1108
00:39:01,000 --> 00:39:02,880
LEVEL DATABASES, THE NATIONAL

1109
00:39:02,880 --> 00:39:05,880
CANCER DATABASE AND SEER.

1110
00:39:05,880 --> 00:39:07,480
I'VE SHOWN YOU BOTH OF THESE

1111
00:39:07,480 --> 00:39:08,200
STUDIES BEFORE.

1112
00:39:08,200 --> 00:39:10,120
THEY CONTAIN A LOT OF

1113
00:39:10,120 --> 00:39:11,520
DEMOGRAPHIC, CLINICAL AND

1114
00:39:11,520 --> 00:39:13,000
PATHOLOGIC VARIABLES, ALL OF

1115
00:39:13,000 --> 00:39:15,640
WHICH CAN PREDICT SURVIVAL, AND

1116
00:39:15,640 --> 00:39:20,480
AGAIN WHEN PREDICTED SURVIVAL IS

1117
00:39:20,480 --> 00:39:21,480
OUT COME BECAUSE THAT IS WHAT

1118
00:39:21,480 --> 00:39:24,120
STAGING SYSTEMS ARE TO COULD,

1119
00:39:24,120 --> 00:39:26,000
NOT PREDICT RECURRENT OR

1120
00:39:26,000 --> 00:39:26,680
PERSISTENT DISEASE.

1121
00:39:26,680 --> 00:39:28,280
VERY SIMPLE STUDY DESIGN.

1122
00:39:28,280 --> 00:39:29,520
OUR FOCUS WAS ON YOUNG PATIENTS,

1123
00:39:29,520 --> 00:39:32,120
SO WE USED THE SEVENTH EDITION,

1124
00:39:32,120 --> 00:39:34,440
LESS THAN 45 YEARS OF AGE, AND

1125
00:39:34,440 --> 00:39:36,000
WE DIVIDED THESE PATIENT INTO

1126
00:39:36,000 --> 00:39:38,800
TWO GROUPS.

1127
00:39:38,800 --> 00:39:41,400
THOSE WHO HAD CERVICAL LYMPH

1128
00:39:41,400 --> 00:39:42,680
NODE METASTASES AND THOSE WHO

1129
00:39:42,680 --> 00:39:45,000
DID NOT HAVE CERVICAL LYMPH NODE

1130
00:39:45,000 --> 00:39:45,320
METASTASES.

1131
00:39:45,320 --> 00:39:48,840
WE DID UNADJUSTED AND ADJUSTED

1132
00:39:48,840 --> 00:39:50,360
SURVIVAL ANALYSIS, AND THEN WE

1133
00:39:50,360 --> 00:39:51,880
DID SOMETHING COOL, AND THIS IS

1134
00:39:51,880 --> 00:39:55,360
WHY YOU ALWAYS WANT TO HAVE

1135
00:39:55,360 --> 00:39:56,400
BIOSTATISTICIANS AS MEMBERS OF

1136
00:39:56,400 --> 00:39:58,240
YOUR RESEARCH TEAM, AND THAT IS,

1137
00:39:58,240 --> 00:40:03,040
WE DEPLOYED RESTRICTIVE CUBIC

1138
00:40:03,040 --> 00:40:03,400
SPLINES.

1139
00:40:03,400 --> 00:40:05,320
NOW IF YOU'RE NOT ALREADY ASLEEP

1140
00:40:05,320 --> 00:40:06,680
FROM MY PRESENTATION, AND I HOPE

1141
00:40:06,680 --> 00:40:08,080
YOU'RE NOT, PLEASE WAKE UP FOR

1142
00:40:08,080 --> 00:40:09,640
THIS, BECAUSE THIS IS A REALLY

1143
00:40:09,640 --> 00:40:12,120
COOL TOOL TO HAVE IN YOUR

1144
00:40:12,120 --> 00:40:13,440
TOOLKIT IF YOU DO HEALTH

1145
00:40:13,440 --> 00:40:15,520
SERVICES RESEARCH.

1146
00:40:15,520 --> 00:40:16,680
SO WHETHER YOU KNOW IT OR NOT,

1147
00:40:16,680 --> 00:40:18,920
WHEN YOU DO MULTIVARIABLE

1148
00:40:18,920 --> 00:40:21,640
REGRESSION ANALYSIS, THERE IS AN

1149
00:40:21,640 --> 00:40:25,360
ASSUMPTION OF A LINEAR

1150
00:40:25,360 --> 00:40:26,640
ASSOCIATION BETWEEN YOUR

1151
00:40:26,640 --> 00:40:27,680
DEPENDENT AND YOUR INDEPENDENT

1152
00:40:27,680 --> 00:40:27,960
VARIABLES.

1153
00:40:27,960 --> 00:40:28,920
SO WHAT DOES THAT MEAN?

1154
00:40:28,920 --> 00:40:30,920
SO I'M KIND OF SIMPLE SO LET'S

1155
00:40:30,920 --> 00:40:31,760
KEEP IT SIMPLE.

1156
00:40:31,760 --> 00:40:32,960
SO YOU'RE DRIVING SUPER FAST ON

1157
00:40:32,960 --> 00:40:34,640
THE HIGHWAY AND YOU HEAR A SIREN

1158
00:40:34,640 --> 00:40:36,280
BEHIND YOU BECAUSE YOU ARE GOING

1159
00:40:36,280 --> 00:40:36,680
TOO FAST.

1160
00:40:36,680 --> 00:40:37,960
THE POLICE ARE THERE SO YOU SLAM

1161
00:40:37,960 --> 00:40:40,120
ON THE BRAKES.

1162
00:40:40,120 --> 00:40:41,800
WHAT WE KNOW IS THAT THE FASTER

1163
00:40:41,800 --> 00:40:45,200
YOU WERE TRAVELING, THE LONGER

1164
00:40:45,200 --> 00:40:45,920
IT TAKES TO STOP.

1165
00:40:45,920 --> 00:40:49,240
SO THAT'S A LINEAR ASSOCIATION.

1166
00:40:49,240 --> 00:40:51,080
WELL, I'M FROM CANADA, I'M FROM

1167
00:40:51,080 --> 00:40:52,720
MONTREAL, AND IN MONTREAL, WE

1168
00:40:52,720 --> 00:40:55,240
TALK ABOUT TWO THINGS:  COLD AND

1169
00:40:55,240 --> 00:40:56,480
COLDER.

1170
00:40:56,480 --> 00:40:59,720
AND SO THESE ARE THE SEASONAL

1171
00:40:59,720 --> 00:41:01,960
TEMPERATURES IN MONTREAL OVER

1172
00:41:01,960 --> 00:41:03,280
THE COURSE OF A YEAR.

1173
00:41:03,280 --> 00:41:04,920
NOT SURPRISINGLY, IN THE WINTER,

1174
00:41:04,920 --> 00:41:07,040
IT IS COLD, AND IN THE SUMMER,

1175
00:41:07,040 --> 00:41:09,120
IT IS LESS COLD.

1176
00:41:09,120 --> 00:41:14,120
BUT YOU CANNOT FIT THE SEASONAL

1177
00:41:14,120 --> 00:41:15,080
VARIATION IN TEMPERATURE TO A

1178
00:41:15,080 --> 00:41:15,440
STRAIGHT LINE.

1179
00:41:15,440 --> 00:41:18,600
SO THERE IS A NON-LINEAR

1180
00:41:18,600 --> 00:41:20,080
ASSOCIATION HERE, AND A

1181
00:41:20,080 --> 00:41:21,640
REGRESSION ANALYSIS WOULD BE

1182
00:41:21,640 --> 00:41:22,200
POORLY SERVED.

1183
00:41:22,200 --> 00:41:25,120
SO WHAT DO RESTRICTIVE CUBIC

1184
00:41:25,120 --> 00:41:26,240
SPLINES DO?

1185
00:41:26,240 --> 00:41:28,040
THEY RELAX THE LINEARITY

1186
00:41:28,040 --> 00:41:29,280
ASSUMPTION THAT IS OTHERWISE

1187
00:41:29,280 --> 00:41:31,840
MADE IN MULTIVARIABLE REGRESSION

1188
00:41:31,840 --> 00:41:32,160
ANALYSIS.

1189
00:41:32,160 --> 00:41:33,480
AND I'LL SHOW YOU HOW WE

1190
00:41:33,480 --> 00:41:34,040
DEPLOYED IT.

1191
00:41:34,040 --> 00:41:36,120
BUT LET'S START WITH OUR

1192
00:41:36,120 --> 00:41:37,040
SURVIVAL ANALYSIS, AND PLEASE

1193
00:41:37,040 --> 00:41:40,240
SEE HERE, WE ARE PREDICTING

1194
00:41:40,240 --> 00:41:41,080
DEATH, NOT SURVIVAL.

1195
00:41:41,080 --> 00:41:42,680
AND WE ARE COMPARING YOUNG

1196
00:41:42,680 --> 00:41:45,120
PATIENTS WHO DO NOT HAVE

1197
00:41:45,120 --> 00:41:46,400
CERVICAL LYMPH NODE METASTASES

1198
00:41:46,400 --> 00:41:49,040
SHOWN IN THE SOLID LINE TO THOSE

1199
00:41:49,040 --> 00:41:51,440
WHO DO HAVE CERVICAL LYMPH NODE

1200
00:41:51,440 --> 00:41:52,960
METASTASES SHOWN IN THE DOTTED

1201
00:41:52,960 --> 00:41:53,240
LINE.

1202
00:41:53,240 --> 00:41:56,040
AND WHAT YOU SEE IS THAT IF YOU

1203
00:41:56,040 --> 00:41:58,080
ARE YOUNG AND YOU HAVE CERVICAL

1204
00:41:58,080 --> 00:42:00,520
LYMPH NODE METASTASES, YOU ARE

1205
00:42:00,520 --> 00:42:03,560
MORE LIKELY TO SUCCUMB TO YOUR

1206
00:42:03,560 --> 00:42:05,680
DISEASE THAN IF YOU DON'T.

1207
00:42:05,680 --> 00:42:08,560
THIS FLIES IN THE FACE OF

1208
00:42:08,560 --> 00:42:11,880
CURRENT STAGING SYSTEMS,

1209
00:42:11,880 --> 00:42:13,480
STATISTICALLY AND CLINICALLY

1210
00:42:13,480 --> 00:42:13,960
SIGNIFICANT.

1211
00:42:13,960 --> 00:42:16,480
WE THEN CHANGED FROM THE NCDB TO

1212
00:42:16,480 --> 00:42:19,080
SEER, AND WE COME TO EXACTLY THE

1213
00:42:19,080 --> 00:42:22,680
SAME CONCLUSION, PERHAPS EVEN A

1214
00:42:22,680 --> 00:42:23,600
BIGGER DIFFERENCE IN SURVIVAL

1215
00:42:23,600 --> 00:42:25,440
BETWEEN THOSE WITH AND THOSE

1216
00:42:25,440 --> 00:42:28,600
WITHOUT CERVICAL LYMPH NODE

1217
00:42:28,600 --> 00:42:29,080
METASTASES.

1218
00:42:29,080 --> 00:42:31,800
AND THE VOLUME OF CERVICAL LYMPH

1219
00:42:31,800 --> 00:42:32,880
NODE METASTASES MATTERS.

1220
00:42:32,880 --> 00:42:35,080
WHAT WE FOUND USING RESTRICTIVE

1221
00:42:35,080 --> 00:42:38,680
CUBIC SPLINES IS THAT EVERY

1222
00:42:38,680 --> 00:42:39,840
INCREMENTAL METASTATIC LYMPH

1223
00:42:39,840 --> 00:42:43,400
NODE UP TO THE NUMBER 6 CONFERS

1224
00:42:43,400 --> 00:42:45,600
A DECREMENT IN SURVIVAL.

1225
00:42:45,600 --> 00:42:49,080
AND AFTER 6, THERE IS NO

1226
00:42:49,080 --> 00:42:49,400
ASSOCIATION.

1227
00:42:49,400 --> 00:42:51,240
SO WHAT DID WE CONCLUDE FROM

1228
00:42:51,240 --> 00:42:56,560
THIS IMPORTANT STUDY ?L 
CERVICAL

1229
00:42:56,560 --> 00:42:58,280
LYMPH NODE METASTASES DO APPEAR

1230
00:42:58,280 --> 00:43:00,000
TO BE ASSOCIATED WITH

1231
00:43:00,000 --> 00:43:02,400
COMPROMISED SURVIVAL AMONG YOUNG

1232
00:43:02,400 --> 00:43:02,680
PATIENTS.

1233
00:43:02,680 --> 00:43:04,000
UNFORTUNATELY IN THE SEVENTH AND

1234
00:43:04,000 --> 00:43:05,480
THE EIGHTH EDITION, YOUNG

1235
00:43:05,480 --> 00:43:07,480
PATIENTS WITH NODAL METASTASES

1236
00:43:07,480 --> 00:43:10,240
ARE BEING UNDERSTAGED.

1237
00:43:10,240 --> 00:43:12,880
AND IF YOU ARE UNDERSTAGED FOR

1238
00:43:12,880 --> 00:43:15,840
YOUR DISEASE, YOU ARE ALMOST

1239
00:43:15,840 --> 00:43:17,160
CERTAINLY ALSO BEING

1240
00:43:17,160 --> 00:43:18,920
UNDERTREATED FOR YOUR DISEASE.

1241
00:43:18,920 --> 00:43:22,320
NOW, I'M NOT STRONG AND POWERFUL

1242
00:43:22,320 --> 00:43:25,160
LIKE THE AJCC/UICC, BUT I CAN

1243
00:43:25,160 --> 00:43:28,120
CHANGE WHAT I DO IN MY PRACTICE.

1244
00:43:28,120 --> 00:43:29,480
AND THE IMPLICATIONS OF THESE

1245
00:43:29,480 --> 00:43:32,960
RESEARCH FINDINGS FOR OUR

1246
00:43:32,960 --> 00:43:34,600
CLINICAL GROUP IS THAT WE MORE

1247
00:43:34,600 --> 00:43:37,400
RIGOROUSLY PREOPERATIVELY SCREEN

1248
00:43:37,400 --> 00:43:39,320
YOUNG PATIENTS LOOKING FOR LYMPH

1249
00:43:39,320 --> 00:43:40,480
NODE METASTASES, AND IF WE FIND

1250
00:43:40,480 --> 00:43:44,080
THEM, WE PERFORM SIMULTANEOUS

1251
00:43:44,080 --> 00:43:51,680
LIMB FAD NECT 

1252
00:43:51,680 --> 00:43:52,080
LYMPHADENECTOMY.

1253
00:43:52,080 --> 00:43:53,280
THE FINAL STUDY I WANT TO

1254
00:43:53,280 --> 00:43:54,240
PRESENT ABOUT CHANGING WHAT WE

1255
00:43:54,240 --> 00:43:55,880
DO IS NOT A CASE OF WHERE LESS

1256
00:43:55,880 --> 00:43:57,080
IS MORE, BUT RATHER WHERE MORE

1257
00:43:57,080 --> 00:43:59,560
IS MORE, AND WE'RE GOING TO GO

1258
00:43:59,560 --> 00:44:01,280
FULL CIRCLE BACK TO ERRS STO

1259
00:44:01,280 --> 00:44:04,320
TELL AND  ARISTOTLE

1260
00:44:04,320 --> 00:44:06,080
AND THE CLINICAL SURGEON AND

1261
00:44:06,080 --> 00:44:07,360
MORE IS BETTER.

1262
00:44:07,360 --> 00:44:08,600
AND THIS IS THE ASSOCIATION

1263
00:44:08,600 --> 00:44:10,240
BETWEEN SURGEON EXPERIENCE AND

1264
00:44:10,240 --> 00:44:13,920
PATIENT OUTCOMES, PRACTICE MAKES

1265
00:44:13,920 --> 00:44:17,920
PERFECT, AND A FINAL EXAMPLE OF

1266
00:44:17,920 --> 00:44:20,720
HOW DR. ADAM, AS A LEARNER, HAS

1267
00:44:20,720 --> 00:44:23,120
TRANSFORMED HOW WELL THINK IN

1268
00:44:23,120 --> 00:44:28,040
OUR THYROIDOLOGY COMMUNITY.

1269
00:44:28,040 --> 00:44:29,320
SO AS MANY OF YOU KNOW, THERE IS

1270
00:44:29,320 --> 00:44:30,480
A LARGE BODY OF EVIDENCE IN

1271
00:44:30,480 --> 00:44:31,680
SURGERY AND IN OTHER FIELDS THAT

1272
00:44:31,680 --> 00:44:33,960
DEMONSTRATES THE MORE YOU DO OF

1273
00:44:33,960 --> 00:44:35,040
SOMETHING, ON AVERAGE, THE

1274
00:44:35,040 --> 00:44:37,680
BETTER YOU ARE AT DOING IT.

1275
00:44:37,680 --> 00:44:39,280
AND THIS HAS BEEN SHOWN FOR A

1276
00:44:39,280 --> 00:44:41,400
NUMBER OF DIFFERENT SURGICAL

1277
00:44:41,400 --> 00:44:43,520
PROCEDURES AND DIAGNOSIS,

1278
00:44:43,520 --> 00:44:44,680
INCLUDING THYROIDECTOMY.

1279
00:44:44,680 --> 00:44:47,120
BUT WHEN YOU LOOK AT THE

1280
00:44:47,120 --> 00:44:48,640
LITERATURE, IT'S VERY

1281
00:44:48,640 --> 00:44:50,160
INTERESTING.

1282
00:44:50,160 --> 00:44:53,360
YOU FIND THAT DIFFERENT AUTHORS

1283
00:44:53,360 --> 00:44:55,680
HAVE DEFINED VOLUME THRESHOLDS

1284
00:44:55,680 --> 00:44:58,160
DIFFERENTLY, BUT NO ONE HAS

1285
00:44:58,160 --> 00:45:01,480
TREATED SURGEON VOLUME AS THE

1286
00:45:01,480 --> 00:45:03,080
CONTINUOUS VARIABLE THAT IT IS.

1287
00:45:03,080 --> 00:45:05,600
I DO FIVE CASES A YEAR, SHE DOES

1288
00:45:05,600 --> 00:45:07,880
10 CASES A YEAR, HE DOES 15

1289
00:45:07,880 --> 00:45:10,000
CASES A YEAR.

1290
00:45:10,000 --> 00:45:13,360
IT'S A CONTINUOUS, NOT A

1291
00:45:13,360 --> 00:45:14,080
CATEGORICAL VARIABLE.

1292
00:45:14,080 --> 00:45:16,680
SO WHAT WE DID IN OUR RESEARCH

1293
00:45:16,680 --> 00:45:20,080
GROUP IS FOR THE FIRST TIME,

1294
00:45:20,080 --> 00:45:23,680
LOOK AT SURGEON VOLUME AS A

1295
00:45:23,680 --> 00:45:24,920
CONTINUOUS VARIABLE, TRYING TO

1296
00:45:24,920 --> 00:45:27,640
UNDERSTAND A THRESHOLD.

1297
00:45:27,640 --> 00:45:30,080
IS THERE A THRESHOLD EFFECT AS

1298
00:45:30,080 --> 00:45:32,520
THERE WAS WITH THE NUMBER OF

1299
00:45:32,520 --> 00:45:34,000
LYMPH NODES AND THE RISK OF

1300
00:45:34,000 --> 00:45:35,920
SURVIVAL THAT IS ASSOCIATED WITH

1301
00:45:35,920 --> 00:45:39,080
IMPROVEMENT IN PATIENT OUTCOMES.

1302
00:45:39,080 --> 00:45:41,160
SO HERE IS ANNUAL SURGEON VOLUME

1303
00:45:41,160 --> 00:45:44,880
OF TOTAL THYROIDECTOMY AT THE

1304
00:45:44,880 --> 00:45:46,280
POPULATION LEVEL.

1305
00:45:46,280 --> 00:45:50,240
IT RANGES FROM 1 TO 157 TOTAL

1306
00:45:50,240 --> 00:45:51,440
THYROIDECTOMIES A YEAR FOR

1307
00:45:51,440 --> 00:45:52,680
THYROID SURGEONS.

1308
00:45:52,680 --> 00:45:56,360
WE THEN TOOK OUR RESTRICTIVE

1309
00:45:56,360 --> 00:45:57,920
CUBIC SPLINES, LOOKING TO SEE IF

1310
00:45:57,920 --> 00:45:59,200
THERE IS A THRESHOLD.

1311
00:45:59,200 --> 00:46:02,680
AND WHAT WE FOUND IS SOMETHING

1312
00:46:02,680 --> 00:46:05,920
VERY INTERESTING AND NO VILLE,

1313
00:46:05,920 --> 00:46:08,360
AND THAT IS, EACH INCREMENTAL

1314
00:46:08,360 --> 00:46:12,120
THYROID OPERATION THAT A SURGEON

1315
00:46:12,120 --> 00:46:15,480
DOES UP TO THE NUMBER 25, ON

1316
00:46:15,480 --> 00:46:21,040
AVERAGE, APPEARS TO CONFER AN

1317
00:46:21,040 --> 00:46:22,080
OUTCOMES ADVANTAGE TO THEIR

1318
00:46:22,080 --> 00:46:24,680
PATIENT, BUT AFTER 25

1319
00:46:24,680 --> 00:46:27,600
THYROIDECTOMIES A YEAR, THERE IS

1320
00:46:27,600 --> 00:46:29,240
NO ASSOCIATION BETWEEN SURGEON

1321
00:46:29,240 --> 00:46:31,000
VOLUME AND PATIENT OUTCOMES.

1322
00:46:31,000 --> 00:46:32,480
AND IT'S INTERESTING, IF YOU GO

1323
00:46:32,480 --> 00:46:34,080
BACK AND LOOK AT THE LITERATURE,

1324
00:46:34,080 --> 00:46:36,520
WHERE PEOPLE HAVE USED DIFFERENT

1325
00:46:36,520 --> 00:46:40,920
CUT POINTS AS CATEGORICAL CUT

1326
00:46:40,920 --> 00:46:42,240
POINT VARIABLE DEFINITIONS,

1327
00:46:42,240 --> 00:46:43,680
NOBODY HAD USED THE NUMBER 25,

1328
00:46:43,680 --> 00:46:45,000
WHICH IS EVIDENCE-DRIVEN.

1329
00:46:45,000 --> 00:46:48,800
SO NOW FOR THE FIRST TIME, WE

1330
00:46:48,800 --> 00:46:50,240
HAVE THE DEFINITION OF WHAT A

1331
00:46:50,240 --> 00:46:51,520
HIGH VOLUME THYROID SURGEON IS,

1332
00:46:51,520 --> 00:46:53,360
WE THEN REDEFINE LOW AND HIGH

1333
00:46:53,360 --> 00:46:55,600
VOLUME BASED ON THAT CUT POINT,

1334
00:46:55,600 --> 00:46:58,520
AND WHAT YOU SEE IS SOMETHING

1335
00:46:58,520 --> 00:46:58,960
DRAMATIC.

1336
00:46:58,960 --> 00:47:00,680
IF YOU HAVE SURGERY BY A LOW

1337
00:47:00,680 --> 00:47:02,960
VOLUME SURGEON, YOU'RE 55% MORE

1338
00:47:02,960 --> 00:47:06,720
LIKELY TO HAVE A COMPLICATION,

1339
00:47:06,720 --> 00:47:07,880
AND SIGNIFICANTLY LONGER LENGTH

1340
00:47:07,880 --> 00:47:09,680
OF STAY AS A RESULT, AND HIGHER

1341
00:47:09,680 --> 00:47:10,640
COSTS.

1342
00:47:10,640 --> 00:47:14,040
NOW, I UNDERSTAND ASSOCIATION IS

1343
00:47:14,040 --> 00:47:15,320
NOT CAUSATION.

1344
00:47:15,320 --> 00:47:17,800
BUT HERE IS THE DOSE-RESPONSE

1345
00:47:17,800 --> 00:47:20,000
CURVE FOR VOLUME AND OUTCOMES.

1346
00:47:20,000 --> 00:47:22,040
YOU SEE HOW BEAUTIFULLY THE TWO

1347
00:47:22,040 --> 00:47:24,680
ARE ALIGNED.

1348
00:47:24,680 --> 00:47:26,240
PERHAPS THE MOST SHOCKING DATA

1349
00:47:26,240 --> 00:47:29,760
THAT I AM SHOWING YOU TODAY AND

1350
00:47:29,760 --> 00:47:31,200
DISCOURAGING IS THAT MORE THAN

1351
00:47:31,200 --> 00:47:33,760
HALF OF SURGEONS DOING THYROID

1352
00:47:33,760 --> 00:47:36,680
OPERATIONS IN THE UNITED STATES

1353
00:47:36,680 --> 00:47:39,640
TODAY DO JUST ONE PER YEAR.

1354
00:47:39,640 --> 00:47:40,720
WHAT'S IMENT PUBLICATION OF

1355
00:47:40,720 --> 00:47:42,280
THAT?

1356
00:47:42,280 --> 00:47:44,000
THE IMPLICATION IS THAT THE

1357
00:47:44,000 --> 00:47:47,520
MAJORITY OF PATIENTS IN THE

1358
00:47:47,520 --> 00:47:49,360
UNITED STATES UNDERGOING THYROID

1359
00:47:49,360 --> 00:47:52,200
SURGERY ARE UNDERGOING SUCH

1360
00:47:52,200 --> 00:47:53,720
SURGERY BY LOW VOLUME SURGEONS

1361
00:47:53,720 --> 00:47:55,640
AND, THEREFORE, ARE BEING

1362
00:47:55,640 --> 00:48:00,680
EXPOSED TO ADDITIONAL RISK.

1363
00:48:00,680 --> 00:48:01,400
IS THIS IMPORTANT?

1364
00:48:01,400 --> 00:48:02,120
IT SURE IS.

1365
00:48:02,120 --> 00:48:03,280
IT'S IMPORTANT BECAUSE THYROID

1366
00:48:03,280 --> 00:48:06,040
SURGERY IS ONE OF THE 10 MOST

1367
00:48:06,040 --> 00:48:08,240
COMMONLY PERFORMED OPERATIONS IN

1368
00:48:08,240 --> 00:48:10,000
THE UNITED STATES.

1369
00:48:10,000 --> 00:48:12,720
AND WHEN DR. ADAM PUBLISHED HIS

1370
00:48:12,720 --> 00:48:15,680
STUDY IN THE ANNALS OF SURGERY,

1371
00:48:15,680 --> 00:48:16,720
YOU THINK, WHO SAW THAT?

1372
00:48:16,720 --> 00:48:18,320
I'LL TELL YOU WHO SAW IT.

1373
00:48:18,320 --> 00:48:19,360
"THE NEW YORK TIMES" SAW IT,

1374
00:48:19,360 --> 00:48:21,760
HERE IS THEIR ARTICLE ON THE

1375
00:48:21,760 --> 00:48:24,280
LEFT, AND HERE IS "THE

1376
00:48:24,280 --> 00:48:26,560
WASHINGTON POST'S" COVERAGE OF

1377
00:48:26,560 --> 00:48:28,360
THIS SCIENCE.

1378
00:48:28,360 --> 00:48:29,280
INCREDIBLY IMPACTFUL.

1379
00:48:29,280 --> 00:48:31,680
AND PERHAPS AS A RESULT OF THE

1380
00:48:31,680 --> 00:48:33,880
MEDIA COVERAGE, BLUE CROSS AND

1381
00:48:33,880 --> 00:48:36,240
BLUE SHIELD CALLED ME ABOUT A

1382
00:48:36,240 --> 00:48:38,080
MONTH AFTER PUBLICATION TO SAY,

1383
00:48:38,080 --> 00:48:42,240
SHOULD WE BE CHANGING HOW WE

1384
00:48:42,240 --> 00:48:43,760
REFER PATIENTS FOR THYROID

1385
00:48:43,760 --> 00:48:45,280
SURGERY AND PERHAPS JUST AS

1386
00:48:45,280 --> 00:48:47,880
IMPORTANTLY, HOW WE REIMBURSE

1387
00:48:47,880 --> 00:48:49,280
THYROID SURGERY.

1388
00:48:49,280 --> 00:48:52,240
SO WHERE WOULD I LIKE TO LEAVE

1389
00:48:52,240 --> 00:48:52,680
YOU?

1390
00:48:52,680 --> 00:48:56,200
I THINK THE FIRST IS TO

1391
00:48:56,200 --> 00:48:56,880
UNDERLINE THE IMPORTANCE OF

1392
00:48:56,880 --> 00:48:57,440
EVIDENCE.

1393
00:48:57,440 --> 00:48:59,040
EVIDENCE FROM HEALTH SERVICES

1394
00:48:59,040 --> 00:49:02,680
RESEARCH, AND HOW EVIDENCE CAN

1395
00:49:02,680 --> 00:49:03,440
TRANSFORM PRACTICE.

1396
00:49:03,440 --> 00:49:05,600
I THINK SECONDLY, ALL OF US HAVE

1397
00:49:05,600 --> 00:49:07,080
TO BE OPEN TO CHANGE.

1398
00:49:07,080 --> 00:49:09,280
I THINK ALL OF US IN OUR MINDS

1399
00:49:09,280 --> 00:49:10,600
MAY HAVE A SENSE OF WHAT WE

1400
00:49:10,600 --> 00:49:12,280
BELIEVE IS THE RIGHT THING TO

1401
00:49:12,280 --> 00:49:16,360
DO, BUT WE NEED TO BE OPEN TO

1402
00:49:16,360 --> 00:49:17,760
NEW EVIDENCE AND THEN AMEND OUR

1403
00:49:17,760 --> 00:49:18,480
PRACTICE, AND IT'S SOMETHING

1404
00:49:18,480 --> 00:49:20,120
I'VE LEARNED THE HARD WAY, I

1405
00:49:20,120 --> 00:49:22,200
USED TO DO TOTAL THYROIDECTOMIES

1406
00:49:22,200 --> 00:49:23,680
FOR ALL OF MY THYROID CANCER

1407
00:49:23,680 --> 00:49:25,200
PATIENT, BUT I NOW USE IT

1408
00:49:25,200 --> 00:49:28,240
PROBABLY LESS THAN HALF THE

1409
00:49:28,240 --> 00:49:28,680
TIME.

1410
00:49:28,680 --> 00:49:30,440
AND AS YOU HEARD, I'M BLESSED TO

1411
00:49:30,440 --> 00:49:34,280
BE ABLE TO CO-CHAIR THE NEXT

1412
00:49:34,280 --> 00:49:35,880
GUIDELINES-WRITING COMMITTEE FOR

1413
00:49:35,880 --> 00:49:37,680
THYROID CANCER FROM THE AMERICAN

1414
00:49:37,680 --> 00:49:39,480
THYROID ASSOCIATION.

1415
00:49:39,480 --> 00:49:42,160
I ALSO HAVE A FEW MESSAGES FOR

1416
00:49:42,160 --> 00:49:45,080
THE LEARNERS AND JUNIOR FACULTY

1417
00:49:45,080 --> 00:49:46,520
IN THE AUDIENCE.

1418
00:49:46,520 --> 00:49:47,800
I'VE TALKED THIS WHOLE HOUR

1419
00:49:47,800 --> 00:49:50,400
ABOUT A SMALL GLAND THAT WEIGHS

1420
00:49:50,400 --> 00:49:52,720
30 OR 40 GRAMS, AND MANY WOULD

1421
00:49:52,720 --> 00:49:54,640
SAY, WHY DON'T YOU DO SOMETHING

1422
00:49:54,640 --> 00:49:55,880
MORE THAN THAT?

1423
00:49:55,880 --> 00:49:59,160
BUT I THINK IT'S IMPORTANT AS

1424
00:49:59,160 --> 00:50:01,360
YOU DEFINE YOUR CAREER AS AN

1425
00:50:01,360 --> 00:50:02,680
ACADEMIC PHYSICIAN OR SCIENTIST

1426
00:50:02,680 --> 00:50:06,280
TO BUILD UP AND NOT ACROSS.

1427
00:50:06,280 --> 00:50:08,680
TO BUILD A BODY OF RESEARCH

1428
00:50:08,680 --> 00:50:11,120
WHERE YOU BECOME THE WORLD

1429
00:50:11,120 --> 00:50:13,680
EXPERT IN A TOPIC, AND WITH THAT

1430
00:50:13,680 --> 00:50:15,560
FUND OF KNOWLEDGE AND SKILLSET,

1431
00:50:15,560 --> 00:50:18,160
YOU CAN CHALLENGE PREVAILING

1432
00:50:18,160 --> 00:50:19,080
THOUGHTS.

1433
00:50:19,080 --> 00:50:20,320
WELL, WHEN YOU'RE A LEARNER,

1434
00:50:20,320 --> 00:50:22,120
IT'S REALLY HARD TO KNOW WHAT

1435
00:50:22,120 --> 00:50:24,360
THE RIGHT QUESTIONS ARE.

1436
00:50:24,360 --> 00:50:25,520
AND THAT'S WHERE A MENTOR PLAYS

1437
00:50:25,520 --> 00:50:30,080
A ROLE.

1438
00:50:30,080 --> 00:50:31,680
DR. ADAM DID ALMOST ALL OF THE

1439
00:50:31,680 --> 00:50:32,280
HEAVY LIFTING, BUT WHAT WAS MY

1440
00:50:32,280 --> 00:50:34,080
ROLE AS HIS MENTOR?

1441
00:50:34,080 --> 00:50:36,840
TO HELP ASK THE QUESTION OR TO

1442
00:50:36,840 --> 00:50:39,600
FIGURE OUT HOW TO ASK THAT OLD

1443
00:50:39,600 --> 00:50:40,760
QUESTION IN A NEW WAY.

1444
00:50:40,760 --> 00:50:42,840
SO I WENT TO PRINCETON, AND ANY

1445
00:50:42,840 --> 00:50:44,160
TIME YOU TALK TO A PRINCETON

1446
00:50:44,160 --> 00:50:46,680
PERSON, THEY HAVE TO HAVE AN

1447
00:50:46,680 --> 00:50:48,440
ALBERT EINSTEIN QUOTE, BECAUSE

1448
00:50:48,440 --> 00:50:49,880
EINSTEIN SPENDS A LOT OF TIME AT

1449
00:50:49,880 --> 00:50:51,040
THE INSTITUTE FOR ADVANCED

1450
00:50:51,040 --> 00:50:52,120
STUDIES AT PRINCETON, AND THIS

1451
00:50:52,120 --> 00:50:53,880
IS MY FAVORITE EINSTEIN QUOTE,

1452
00:50:53,880 --> 00:50:54,760
SO TRUE.

1453
00:50:54,760 --> 00:50:56,080
"IF I HAD AN HOUR TO SOLVE A

1454
00:50:56,080 --> 00:50:57,760
PROBLEM AND MY LIFE DEPENDED ON

1455
00:50:57,760 --> 00:50:59,920
IT, I WOULD USE THE FIRST 55

1456
00:50:59,920 --> 00:51:01,520
MINUTES DETERMINING THE PROPER

1457
00:51:01,520 --> 00:51:03,200
QUESTIONS TO ASK."

1458
00:51:03,200 --> 00:51:05,320
AND I WOULD ARGUE THE BEST

1459
00:51:05,320 --> 00:51:09,640
SCIENCE DOESN'T ALWAYS COME FROM

1460
00:51:09,640 --> 00:51:11,000
NEW QUESTIONS, IT CAN COME FROM

1461
00:51:11,000 --> 00:51:13,040
OLD QUESTIONS THAT ARE REVISITED

1462
00:51:13,040 --> 00:51:14,560
IN NEW WAYS.

1463
00:51:14,560 --> 00:51:17,680
MAYBE A NEW TWIST, MAYBE A NEW

1464
00:51:17,680 --> 00:51:18,120
PRESENTATION.

1465
00:51:18,120 --> 00:51:21,640
MAYBE A NEW DATASET.

1466
00:51:21,640 --> 00:51:23,480
BUT REMEMBER, IF YOU'RE A

1467
00:51:23,480 --> 00:51:25,880
LEARNER OR A JUNIOR FACULTY

1468
00:51:25,880 --> 00:51:27,320
MEMBER, MENTORS ARE NOT

1469
00:51:27,320 --> 00:51:27,960
PANACEAS.

1470
00:51:27,960 --> 00:51:28,720
YOU ARE WHO YOU ARE.

1471
00:51:28,720 --> 00:51:30,360
THEY CAN SHAPE YOU, HELP AND

1472
00:51:30,360 --> 00:51:32,600
PROMOTE YOU, BUT ALL OF US MUST

1473
00:51:32,600 --> 00:51:36,120
TAKE OWNERSHIP FOR OUR OWN

1474
00:51:36,120 --> 00:51:36,560
SUCCESS OR FAILURE.

1475
00:51:36,560 --> 00:51:40,280
SO I WANTED TO CLOSE WITH

1476
00:51:40,280 --> 00:51:41,560
DR. ADAM, THAT GUY WHO IS THE

1477
00:51:41,560 --> 00:51:43,120
THIRD YEAR RESIDENT AT DUKE.

1478
00:51:43,120 --> 00:51:45,080
HERE WE ARE AT HIS GRADUATION

1479
00:51:45,080 --> 00:51:46,600
DINNER FROM DUKE WHEN HE

1480
00:51:46,600 --> 00:51:49,160
FINISHED THE GENERAL SURGERY

1481
00:51:49,160 --> 00:51:50,200
TRAINING PROGRAM.

1482
00:51:50,200 --> 00:51:51,720
I BET YOU KNOW WHERE HE IS NOW.

1483
00:51:51,720 --> 00:51:54,480
THAT'S RIGHT, HERE HE IS,

1484
00:51:54,480 --> 00:51:57,480
BECOMING A NEW FACULTY MEMBER

1485
00:51:57,480 --> 00:52:00,800
AND ASSISTANT PROFESSOR AT UCSF.

1486
00:52:00,800 --> 00:52:02,800
AND I JUST WANT TO FINISH BY

1487
00:52:02,800 --> 00:52:05,520
SAYING, I EXPECT DR. ADAM TO BE

1488
00:52:05,520 --> 00:52:08,920
THE FUTURE OF SURGICAL SCIENCE,

1489
00:52:08,920 --> 00:52:11,080
GUIDED BY MENTORS, BUT REALLY

1490
00:52:11,080 --> 00:52:13,920
THE VOICE THAT WILL HELP US

1491
00:52:13,920 --> 00:52:15,880
IDENTIFY THE BEST PATH FORWARD.

1492
00:52:15,880 --> 00:52:17,800
PLEASE BE OPEN MINDED IN

1493
00:52:17,800 --> 00:52:21,080
EVERYTHING YOU DO.

1494
00:52:21,080 --> 00:52:22,440
SERENDIPITY IS AN INCREDIBLY

1495
00:52:22,440 --> 00:52:25,640
POWERFUL FORCE.

1496
00:52:25,640 --> 00:52:29,560
AND TO EVERYTHING, INCLUDING

1497
00:52:29,560 --> 00:52:30,280
PREVAILING THOUGHTS HELD BY ALL

1498
00:52:30,280 --> 00:52:32,480
OF THE THOUGHT LEADERS IN A

1499
00:52:32,480 --> 00:52:39,240
FIELD, HAVE THE COURAGE TO USE

1500
00:52:39,240 --> 00:52:40,240
NEW EVIDENCE TO CHALLENGE

1501
00:52:40,240 --> 00:52:40,880
CONVENTION.

1502
00:52:40,880 --> 00:52:42,840
THAT TAKES COURAGE AND SCIENCE.

1503
00:52:42,840 --> 00:52:44,960
ALL OF US ARE LEADERS, YES, I'M

1504
00:52:44,960 --> 00:52:47,520
A CHAIR OF SURGERY, BUT I WOULD

1505
00:52:47,520 --> 00:52:50,840
ARGUE THE MORE POWERFUL FORM OF

1506
00:52:50,840 --> 00:52:51,760
LEADERSHIP IS THOUGHT

1507
00:52:51,760 --> 00:52:52,600
LEADERSHIP.

1508
00:52:52,600 --> 00:52:55,080
AND ALL OF US ARE THOUGHT

1509
00:52:55,080 --> 00:52:57,160
LEADERS IN OUR OWN WAYS.

1510
00:52:57,160 --> 00:52:59,360
AND THIS WAS A RECENT TWITTER

1511
00:52:59,360 --> 00:53:02,400
EXCHANGE IN THE ACADEMIC SURGERY

1512
00:53:02,400 --> 00:53:04,120
COMMUNITY, TALKING ABOUT THE

1513
00:53:04,120 --> 00:53:05,960
PACE AND CADENCE OF CHANGE AND

1514
00:53:05,960 --> 00:53:08,320
THE IMPORTANCE OF LEADERS

1515
00:53:08,320 --> 00:53:09,840
LEADING FORWARD THAT CHANGE.

1516
00:53:09,840 --> 00:53:12,400
AND THIS IS HOW AMERICAN SURGERY

1517
00:53:12,400 --> 00:53:14,280
IS CHANGED, CHANGING THE

1518
00:53:14,280 --> 00:53:15,960
ASSOCIATION FOR ACADEMIC SURGE

1519
00:53:15,960 --> 00:53:17,560
REAL, ONE OF THE LARGEST

1520
00:53:17,560 --> 00:53:19,240
ORGANIZATIONS IN OUR DISCIPLINE.

1521
00:53:19,240 --> 00:53:21,720
LOOK AT OUR CURRENT LEADERS.

1522
00:53:21,720 --> 00:53:24,480
SO SPECTACULAR, AND YET SO

1523
00:53:24,480 --> 00:53:25,880
DIVERSE.

1524
00:53:25,880 --> 00:53:27,720
AND FINALLY, FINISHING WITH

1525
00:53:27,720 --> 00:53:30,400
ANOTHER TWITTER EXCHANGE, THIS

1526
00:53:30,400 --> 00:53:33,120
IS DR. AHMAD WHO ASKED ON

1527
00:53:33,120 --> 00:53:34,960
TWITTER, WHAT'S THE MOST

1528
00:53:34,960 --> 00:53:36,320
POWERFUL ADVANCEMENT IN SURGERY

1529
00:53:36,320 --> 00:53:37,680
THAT HAS OCCURRED OVER THE LAST

1530
00:53:37,680 --> 00:53:38,240
30 YEARS?

1531
00:53:38,240 --> 00:53:41,200
AND PEOPLE TALKED ABOUT ROBOTICS

1532
00:53:41,200 --> 00:53:44,320
AND LAP  LAPAROSCOPY, AND I
SAID,

1533
00:53:44,320 --> 00:53:46,000
"THE DIVERSIFICATION OF SURGERY,

1534
00:53:46,000 --> 00:53:47,200
HANDS DOWN."

1535
00:53:47,200 --> 00:53:50,160
AND I HOPE THAT ALL OF YOU TODAY

1536
00:53:50,160 --> 00:53:51,840
WILL TAKE AWAY SOME LESSONS

1537
00:53:51,840 --> 00:53:53,640
AROUND DOING SCIENCE AND HEALTH

1538
00:53:53,640 --> 00:53:56,400
SERVICES RESEARCH, ABOUT

1539
00:53:56,400 --> 00:53:58,280
STUDYING THYROID CANCER, BUT

1540
00:53:58,280 --> 00:54:01,640
ALSO ABOUT CHANGING OUR ACADEMIC

1541
00:54:01,640 --> 00:54:04,280
COMMUNITY, LEADING TO GREATER

1542
00:54:04,280 --> 00:54:06,000
DIVERSIFICATION, WHICH ALSO I

1543
00:54:06,000 --> 00:54:08,480
BELIEVE WILL LEAD TO GREATER

1544
00:54:08,480 --> 00:54:10,440
CREATIVITY AND INNOVATION.

1545
00:54:10,440 --> 00:54:12,800
TO THE NIH, THANK YOU SO MUCH

1546
00:54:12,800 --> 00:54:14,640
FOR THE PRIVILEGE OF GIVING

1547
00:54:14,640 --> 00:54:19,880
THESE GRAND ROUNDS.

1548
00:54:19,880 --> 00:54:21,400
>> THANK YOU SO MUCH, DR. SOSA.

1549
00:54:21,400 --> 00:54:23,280
THAT WAS INCREDIBLY

1550
00:54:23,280 --> 00:54:23,800
THOUGHT-PROVOKING.

1551
00:54:23,800 --> 00:54:25,880
NOT ONLY AS SOMEONE WHO STUDIED

1552
00:54:25,880 --> 00:54:27,600
THE THYROID PRETTY EXTENSIVELY

1553
00:54:27,600 --> 00:54:29,080
DURING THE LATTER PART OF MY

1554
00:54:29,080 --> 00:54:31,240
SURGICAL TRAINING.

1555
00:54:31,240 --> 00:54:32,480
WE'RE WAITING TO SEE IF WE GET

1556
00:54:32,480 --> 00:54:33,880
SOME FEEDBACK FROM SOME OF OUR

1557
00:54:33,880 --> 00:54:35,440
VIEWER, BUT I HAD A COUPLE OF

1558
00:54:35,440 --> 00:54:39,600
QUESTIONS AND I THINK THE FIRST

1559
00:54:39,600 --> 00:54:41,080
ONE REALLY SPOKE TO THE CONTENT,

1560
00:54:41,080 --> 00:54:44,160
YOUR WORK WITH OUTCOMES
RESEARCH.

1561
00:54:44,160 --> 00:54:45,280
AND I KNOW THAT ONE OF THE

1562
00:54:45,280 --> 00:54:46,480
THINGS THAT WE DISCUSSED WITH

1563
00:54:46,480 --> 00:54:48,280
DIVERSITY AND INCLUSION AND

1564
00:54:48,280 --> 00:54:49,480
PARTICULARLY EQUITY IS THAT WE

1565
00:54:49,480 --> 00:54:52,480
HAVE GREAT HEALTHCARE DESERTS IN

1566
00:54:52,480 --> 00:54:55,360
THIS COUNTRY, AND SO HOW DO YOU

1567
00:54:55,360 --> 00:54:58,080
SEE THE INTERSECTION OF WANTING

1568
00:54:58,080 --> 00:54:59,960
TO PROMOTE OUTCOMES RESEARCH AND

1569
00:54:59,960 --> 00:55:01,080
WANTING EVERY PATIENT TO HAVE

1570
00:55:01,080 --> 00:55:02,360
THEIR THYROIDECTOMY DONE BY

1571
00:55:02,360 --> 00:55:04,640
SOMEONE WHO DOES ONE EVERY OTHER

1572
00:55:04,640 --> 00:55:08,720
WEEK VERSUS THESE GREAT SWATHS

1573
00:55:08,720 --> 00:55:09,320
THAT THE PUBLIC HEALTH CRISIS

1574
00:55:09,320 --> 00:55:11,000
THAT WE HAVE WHERE THERE ARE

1575
00:55:11,000 --> 00:55:12,000
MANY COMMUNITIES WHERE THERE'S

1576
00:55:12,000 --> 00:55:13,760
NOT A SURGEON AROUND FOR 50

1577
00:55:13,760 --> 00:55:14,680
SQUARE MILES?

1578
00:55:14,680 --> 00:55:19,000
>> YEAH, THAT'S A REALLY GOOD

1579
00:55:19,000 --> 00:55:20,160
QUESTION, AND YOU'VE HIGHLIGHTED

1580
00:55:20,160 --> 00:55:22,760
ONE OF MY MANY SHORTCOMINGS AND

1581
00:55:22,760 --> 00:55:25,600
LIMITATIONS, AND THAT IS, I'M A

1582
00:55:25,600 --> 00:55:26,760
PRETTY GOOD SURGEON AND A PRETTY

1583
00:55:26,760 --> 00:55:31,480
GOOD SCIENTIST BUT NOT A GREAT

1584
00:55:31,480 --> 00:55:32,520
PROBLEM-SOLVER, MEANING POLICY

1585
00:55:32,520 --> 00:55:33,000
MAKER, RIGHT?

1586
00:55:33,000 --> 00:55:34,280
I THINK THE POINT YOU'RE MAKING,

1587
00:55:34,280 --> 00:55:38,280
WHICH IS THE POINT I HAD TO MAKE

1588
00:55:38,280 --> 00:55:40,040
TO BLUE CROSS/BLUE SHIELD AND

1589
00:55:40,040 --> 00:55:44,520
ANTHEM IS, YES, IN A PERFECT

1590
00:55:44,520 --> 00:55:45,920
WORLD, EVERY AMERICAN WHO NEEDS

1591
00:55:45,920 --> 00:55:47,440
THEIR THYROID OUT WOULD HAVE

1592
00:55:47,440 --> 00:55:50,280
ACCESS TO A HIGH VOLUME THYROID

1593
00:55:50,280 --> 00:55:50,680
SURGEON.

1594
00:55:50,680 --> 00:55:54,040
THE FACT OF THE MATTER IS, THERE

1595
00:55:54,040 --> 00:55:56,080
ARE NOT ENOUGH HIGH VOLUME

1596
00:55:56,080 --> 00:55:57,280
SURGEONS, AND WHAT YOU HIGHLIGHT

1597
00:55:57,280 --> 00:55:59,160
IS, THEY'RE NOT EQUITABLY

1598
00:55:59,160 --> 00:55:59,560
DISTRIBUTED.

1599
00:55:59,560 --> 00:56:01,520
AND I'M PART OF THE PROBLEM.

1600
00:56:01,520 --> 00:56:04,680
AS CHAIR OF UCSF SURGERY, I KEEP

1601
00:56:04,680 --> 00:56:06,880
HIRING MORE AND MORE ENDOCRINE

1602
00:56:06,880 --> 00:56:07,320
SURGEONS.

1603
00:56:07,320 --> 00:56:09,000
WE NOW HAVE SIX FULL TIME

1604
00:56:09,000 --> 00:56:10,040
ENDOCRINE SURGEONS IN ONE

1605
00:56:10,040 --> 00:56:11,600
BUILDING.

1606
00:56:11,600 --> 00:56:13,480
WHEN WHOLE PARTS OF THE UNITED

1607
00:56:13,480 --> 00:56:16,440
STATES AND WHOLE STATES, THE

1608
00:56:16,440 --> 00:56:19,240
WESTERN UNITED STATES AND THE

1609
00:56:19,240 --> 00:56:19,840
SOUTHERN UNITED STATES, WHOLE

1610
00:56:19,840 --> 00:56:22,840
STATES HAVE ZERO HIGH VOLUME

1611
00:56:22,840 --> 00:56:23,640
SURGEONS.

1612
00:56:23,640 --> 00:56:27,760
SO THE REALITY IS, WE CAN'T DO

1613
00:56:27,760 --> 00:56:27,960
THAT.

1614
00:56:27,960 --> 00:56:29,520
SO WHERE DOES THE ANSWER LIE?

1615
00:56:29,520 --> 00:56:33,280
I THINK SOME OF IT IS REDOING

1616
00:56:33,280 --> 00:56:35,520
THE HEALTHCARE MARKETPLACE AND

1617
00:56:35,520 --> 00:56:40,160
HOW WE DELIVER CARE.

1618
00:56:40,160 --> 00:56:41,280
THIS IS A COMPLICATED DEBATE

1619
00:56:41,280 --> 00:56:42,360
ABOUT PRIVATE VERSUS PUBLIC,

1620
00:56:42,360 --> 00:56:43,520
SHOULD WE HAVE A NATIONAL HEALTH

1621
00:56:43,520 --> 00:56:47,280
SYSTEM.

1622
00:56:47,280 --> 00:56:49,040
SECONDLY, I THINK WE NEED TO

1623
00:56:49,040 --> 00:56:51,880
INCENTIVIZE PEOPLE TO, A, TRAIN

1624
00:56:51,880 --> 00:56:55,800
IN SPECIALTIES, BUT B, SERVE

1625
00:56:55,800 --> 00:56:56,600
THEIR COMMUNITIES.

1626
00:56:56,600 --> 00:56:58,440
SOMETIMES THAT MEANS URBAN

1627
00:56:58,440 --> 00:56:59,080
DESERTS.

1628
00:56:59,080 --> 00:57:01,040
SOMETIMES THAT MEANS RURAL

1629
00:57:01,040 --> 00:57:01,520
DESERTS.

1630
00:57:01,520 --> 00:57:04,560
SO WE NEED TO INCENTIVIZE AND

1631
00:57:04,560 --> 00:57:06,080
VALUE THAT SERVICE.

1632
00:57:06,080 --> 00:57:07,720
SO THAT HAS IMPLICATIONS FOR

1633
00:57:07,720 --> 00:57:10,400
POLICY MAKERS, AS WELL AS

1634
00:57:10,400 --> 00:57:10,760
EDUCATORS.

1635
00:57:10,760 --> 00:57:13,160
AND THEN I THINK WE HAVE TO FIND

1636
00:57:13,160 --> 00:57:15,600
WAYS TO SUPPORT PATIENTS

1637
00:57:15,600 --> 00:57:16,240
TRAVELING.

1638
00:57:16,240 --> 00:57:18,400
THERE ARE SOME OPERATIONS WHERE

1639
00:57:18,400 --> 00:57:19,960
PATIENTS CAN'T TRAVEL BECAUSE

1640
00:57:19,960 --> 00:57:21,800
THE DISEASE OR THE SURGERY IS SO

1641
00:57:21,800 --> 00:57:25,040
MORBID OR MORTAL, BUT THYROID

1642
00:57:25,040 --> 00:57:26,360
CANCER AND THYROID SURGERY ARE

1643
00:57:26,360 --> 00:57:27,560
NOT THOSE.

1644
00:57:27,560 --> 00:57:29,480
AND SO PATIENTS CAN TRAVEL, BUT

1645
00:57:29,480 --> 00:57:31,480
THEY CAN'T, OF COURSE, BECAUSE

1646
00:57:31,480 --> 00:57:33,080
THEY CAN'T AFFORD TO DO THAT.

1647
00:57:33,080 --> 00:57:35,120
SO IT'S A COMPLICATED SOLUTION.

1648
00:57:35,120 --> 00:57:38,400
WE DON'T HAVE A SOLUTION, BUT

1649
00:57:38,400 --> 00:57:41,560
THE REALITY CANNOT YET BE THAT

1650
00:57:41,560 --> 00:57:42,480
EVERY AMERICAN CAN HAVE SURGERY

1651
00:57:42,480 --> 00:57:45,160
BY A HIGH VOLUME SURGEON.

1652
00:57:45,160 --> 00:57:50,160
>> I THINK ONE OTHER THING THAT

1653
00:57:50,160 --> 00:57:51,080
STRUCK ME PARTICULARLY TOWARD

1654
00:57:51,080 --> 00:57:52,680
THE END OF YOUR TALK, I'M SORT

1655
00:57:52,680 --> 00:57:54,440
OF MOVING FROM EARLY CAREER TO

1656
00:57:54,440 --> 00:57:55,480
MID CAREER TRANSITION, AND

1657
00:57:55,480 --> 00:57:57,040
LEARNING HOW TO BE A BETTER

1658
00:57:57,040 --> 00:58:00,320
MENTOR, AND I THINK THE

1659
00:58:00,320 --> 00:58:01,640
IMPORTANCE OF -- FOR ALL OF US,

1660
00:58:01,640 --> 00:58:02,840
WHETHER WE'RE ASKING A QUESTION

1661
00:58:02,840 --> 00:58:04,360
AT THE BENCH OR AS WE'RE DIGGING

1662
00:58:04,360 --> 00:58:07,120
THROUGH CHARTS, IS TO HAVE A

1663
00:58:07,120 --> 00:58:08,000
CRISP QUESTION.

1664
00:58:08,000 --> 00:58:09,320
AND THAT HAS BEEN DEMONSTRATED

1665
00:58:09,320 --> 00:58:13,680
OVER AND OVER TO ME BY MY MENTOR

1666
00:58:13,680 --> 00:58:15,880
AND I THINK WHAT I WILL TAKE

1667
00:58:15,880 --> 00:58:17,880
AWAY FROM THIS IS LEARNING TO

1668
00:58:17,880 --> 00:58:19,440
HELP MY MENTEES FORM THOSE

1669
00:58:19,440 --> 00:58:20,280
QUESTIONS SO THEY KNOW EXACTLY

1670
00:58:20,280 --> 00:58:22,320
WHAT THEY'RE LOOKING FOR AND THE

1671
00:58:22,320 --> 00:58:26,560
RIGHT ANKLE OF  ANGLE OF
APPROACH.

1672
00:58:26,560 --> 00:58:27,960
BUT ABSOLUTELY THRILLING BODY OF

1673
00:58:27,960 --> 00:58:28,920
WORK.

1674
00:58:28,920 --> 00:58:31,280
WHEN I TRAINED, I LEARNED THOSE

1675
00:58:31,280 --> 00:58:32,440
2009 GUIDELINES AND THEN HAD TO

1676
00:58:32,440 --> 00:58:34,000
RETRAIN MYSELF ON THE 2015

1677
00:58:34,000 --> 00:58:36,240
GUIDELINES, EVEN IF I JUST

1678
00:58:36,240 --> 00:58:38,080
APPROACH ENDOCRINE SURGERY NOW

1679
00:58:38,080 --> 00:58:40,040
IN A MORE TUMOR BOARD THOUGHT

1680
00:58:40,040 --> 00:58:41,880
KIND OF WAY RATHER THAN

1681
00:58:41,880 --> 00:58:43,120
PRACTICALLY PERFORMING THEM.

1682
00:58:43,120 --> 00:58:46,280
>> AND DR. GOFF, THERE'S MORE

1683
00:58:46,280 --> 00:58:48,800
CHANGES COMING, SO BUCKLE UP AND

1684
00:58:48,800 --> 00:58:50,280
GET READY FOR THE NEXT ITERATION

1685
00:58:50,280 --> 00:58:52,280
OF THE GUIDELINES.

1686
00:58:52,280 --> 00:58:53,640
I CAN'T REALLY SAY YET WHAT

1687
00:58:53,640 --> 00:58:55,400
THEY'RE GOING TO SHOW, BUT I

1688
00:58:55,400 --> 00:58:58,240
WILL SAY THERE ARE MORE CHANGES

1689
00:58:58,240 --> 00:58:59,880
COMING, AND I THINK THE

1690
00:58:59,880 --> 00:59:02,360
IMPORTANT THING, AS YOU SAID, IS

1691
00:59:02,360 --> 00:59:04,680
I LEARNED IT THIS WAY, BUT MAYBE

1692
00:59:04,680 --> 00:59:06,880
I DIDN'T LEARN IT QUITE RIGHT,

1693
00:59:06,880 --> 00:59:09,720
AND I HAVE TO BE OPEN TO DOING

1694
00:59:09,720 --> 00:59:13,960
THINGS IN A DIFFERENT WAY.

1695
00:59:13,960 --> 00:59:17,040
>> I THINK THE MESSAGE THAT

1696
00:59:17,040 --> 00:59:18,680
LEARNING IS LIFE-LONG,

1697
00:59:18,680 --> 00:59:20,080
PARTICULARLY IN MEDICINE,

1698
00:59:20,080 --> 00:59:22,880
PARTICULARLY AS WE FIT THIS ERA

1699
00:59:22,880 --> 00:59:24,160
WHERE OUR TOOLS ARE GETTING

1700
00:59:24,160 --> 00:59:27,280
BETTER, OUR KNOWLEDGE IS GETTING

1701
00:59:27,280 --> 00:59:28,880
BETTER AND WE ALL HAVE TO JUST

1702
00:59:28,880 --> 00:59:30,000
KEEP RETRAINING ON THE THINGS

1703
00:59:30,000 --> 00:59:31,960
THAT WE THINK WE KNOW HOW TO DO,

1704
00:59:31,960 --> 00:59:33,320
BECAUSE PRACTICE DOESN'T ALWAYS

1705
00:59:33,320 --> 00:59:34,480
MAKE PERFECT, IT MAKES

1706
00:59:34,480 --> 00:59:34,720
PERMANENT.

1707
00:59:34,720 --> 00:59:36,240
SO YOU HAVE TO BE CAREFUL.

1708
00:59:36,240 --> 00:59:37,640
>> THAT'S RIGHT.

1709
00:59:37,640 --> 00:59:38,000
I LOVE THAT.

1710
00:59:38,000 --> 00:59:39,960
>> YEAH.

1711
00:59:39,960 --> 00:59:41,280
YOU KNOW, WE'VE GOTTEN A COUPLE

1712
00:59:41,280 --> 00:59:43,280
OF PEOPLE TELLING US THAT IT WAS

1713
00:59:43,280 --> 00:59:44,560
A FANTASTIC TALK BUT NOBODY'S

1714
00:59:44,560 --> 00:59:45,280
REALLY GIVEN ME ANY SORT OF

1715
00:59:45,280 --> 00:59:46,200
SUBSTANTIVE QUESTION, AND WE'VE

1716
00:59:46,200 --> 00:59:48,280
HIT THE END OF THE HOUR.

1717
00:59:48,280 --> 00:59:50,680
SO I DIDN'T KNOW IF YOU HAD ANY

1718
00:59:50,680 --> 00:59:51,680
PARTING WISDOM YOU WANTED TO

1719
00:59:51,680 --> 00:59:54,320
LEAVE US WITH, BUT I JUST WANTED

1720
00:59:54,320 --> 00:59:56,040
TO THANK YOU ON BEHALF OF THE

1721
00:59:56,040 --> 00:59:58,680
GREAT TEACHERS COMMITTEE AND THE

1722
00:59:58,680 --> 01:00:00,080
WHOLE CLINICAL CENTER, IT WAS A

1723
01:00:00,080 --> 01:00:00,480
WONDERFUL TALK.

1724
01:00:00,480 --> 01:00:02,640
>> OH, WELL, THANK YOU.

1725
01:00:02,640 --> 01:00:03,880
THANK YOU AGAIN SO MUCH.

1726
01:00:03,880 --> 01:00:06,640
AS I SAID, IT'S AN HONOR AND A

1727
01:00:06,640 --> 01:00:09,120
PRIVILEGE, AND I DON'T KNOW -- I

1728
01:00:09,120 --> 01:00:10,480
AM A VERY -- YOU COULD PROBABLY

1729
01:00:10,480 --> 01:00:12,400
TELL, I'M AN EXTROVERT, BUT I

1730
01:00:12,400 --> 01:00:14,320
THINK IN LIFE, LIFE IS SHORT,

1731
01:00:14,320 --> 01:00:16,360
AND YOU HAVE TO PURSUE WHAT

1732
01:00:16,360 --> 01:00:19,120
BRINGS YOU JOY.

1733
01:00:19,120 --> 01:00:21,640
AND OTHER PEOPLE CANNOT TELL YOU

1734
01:00:21,640 --> 01:00:23,320
WHAT BRINGS YOU JOY.

1735
01:00:23,320 --> 01:00:27,000
YOU HAVE TO DISCOVER THAT ABOUT

1736
01:00:27,000 --> 01:00:27,400
YOURSELF.

1737
01:00:27,400 --> 01:00:29,560
AND IN CASE YOU CAN'T TELL WHAT

1738
01:00:29,560 --> 01:00:33,120
BRINGS ME THE GREATEST JOY IS

1739
01:00:33,120 --> 01:00:35,480
SCIENCE THAT I CAN SHARE WITH

1740
01:00:35,480 --> 01:00:38,680
THE NEXT GENERATION, BECAUSE I

1741
01:00:38,680 --> 01:00:40,120
THINK IT'S NOT THE PUBLICATION,

1742
01:00:40,120 --> 01:00:44,560
IT'S THE IMPACT ON LEARNERS AND

1743
01:00:44,560 --> 01:00:47,280
LEGACY THAT WILL ULTIMATELY

1744
01:00:47,280 --> 01:00:49,000
DRIVE HOW WE ARE REMEMBERED.

1745
01:00:49,000 --> 01:00:50,400
SO THANK YOU.

1746
01:00:50,400 --> 00:00:00,000
>> THANK YOU VERY MUCH.