When Do We Stop? Doctors Gone Wild

A colleague of mine has received a number of consultations from the oncology team, all with a similar story and consult request: “(insert number) aged female with history of metastatic (insert reproductive cancer here) found to have a thyroid nodule on recent surveillance CT scan/MRI. Please evaluate for further treatment.”

I have also received a number of these consultations and I, like my co-worker, respond initially in the same way: head hung then shaking from side-to-side. The initial reaction, I am afraid to say is this: “What do you expect from me in this case???”

Some of you will disagree with me on this one. No problem with that; we are here to share and discuss. My co-worker and I share similar views on this issue. The background situation of a metastatic cancer is the dominant feature here. This is what may have led to the discovery of the nodule in the first place—who knows, if the scan was not done, would they have found the nodule? All of the referrals we have received have in fact had small nodules all less than 1cm in size, and none of the patients noted the nodule on their own.

Thyroid cancer taken as an entity is less “aggressive” than many other types of cancer. The most common type, papillary thyroid cancer, carries an excellent prognosis for the majority of people, even in the more advanced stages, in terms of morbidity and even life expectancy. Follicular variants also have favorable prognoses. Medullary thyroid cancer is uncommon at about 5% of cancers and carries a worse prognosis given its tendency to spread prior to diagnosis. The most aggressive type, anaplastic cancer, is quite rare at less than 1% of thyroid cancers.

For most of the population, a thyroid nodule will be benign. For those in whom it is not benign, most will have papillary thyroid cancer or a follicular variant. And for these people, their prognosis will most likely be very good. Unfortunately, this is not often a similar case with metastatic cancers of non-thyroidal origin, as with our patients discussed here.

The life expectancy for the patients in question has been short, likely less than 2-4 years at best for many of them. Some were in the throes of chemo and radiation for their primary cancer when this new nodule was discovered. And so we had two questions at hand when facing this issue of the new thyroid nodule:

1) Even if this proved to be a new focus of metastatic disease, how would this change current management? Not likely in any way really, given the small size of the nodules.

2) If this was NOT metastatic disease, but instead turned out to be a new focus of thyroid cancer, how would we proceed? If the unlucky individual turned out to have anaplastic cancer the answer maybe different than if papillary—or would it?

Here the art of medicine comes into play while we scratch our heads pondering various scenarios. Even with the less than toxic (versus standard chemo) iodine ablation, the patient would still have to endure a surgery first, then the radioiodine, followed by a few months of fluctuating hormone levels. People without other health issues will often say those months are tough. Imagine pouring this hot mix on top of someone who is already undergoing much more aggressive treatments for their metastatic cancers.

So what happened in our situations? Two of my colleague’s patients are having surveillance ultrasounds set up. Their nodules are so small that even biopsy seems unwarranted. One of my patients with metastatic lung cancer, after discussing the options and likely scenarios, decided to have the biopsy done and thankfully it was benign. We never made it to the next fork in the road. But my next patient in this scenario just might, and I’ll continue to shake my head at the situation: the unknown goal of the consult, the unfortunate circumstances for my patients in this situation, and the inevitable courage they show when discussing the possibility of yet another malignancy.