February 19, 2025 • 24 mins
Discover the extraordinary journey of Dr. Ruth Decker, a leading thyroid and parathyroid surgeon whose unique blend of medical and legal expertise is transforming patient care. Explore how her roots in Sheboygan, education at Northwestern University and the University of Wisconsin, and a law degree from Washington University have shaped her innovative approach to surgery. Dr. Decker shares her secrets to demystifying complex procedures using a simple whiteboard, ensuring patients leave her office not just informed, but empowered to make the best decisions for their health.
Our conversation navigates the cutting-edge advancements in thyroid cancer treatment and diagnosis. Marvel at the power of ultrasound technology and the TI-RADS scoring system in revolutionizing cancer detection and management. Dr. Decker sheds light on the nuanced differences between papillary and anaplastic thyroid cancers, while also addressing the growing incidence of thyroid cancer and the critical need for diligent follow-up care. Her insights reveal both the promise and challenges of evolving treatment strategies in this dynamic field.
As we round out the episode, the discussion turns to the broader endocrine implications of weight and environmental factors. Dr. Decker explains how conditions like parathyroid disease, obesity, and hormonal disruptors are interlinked with rising rates of thyroid disease. Uncover how adipose tissue plays a pivotal role in overall health, influencing thyroid, prostate, and breast conditions. This episode offers a comprehensive understanding of the hormone-cancer connection and emphasizes the importance of education and primary care in tackling these complex health challenges.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Doc Discussions.
I'm Dr Jason Edwards and thisis a podcast where I interview
other physicians.
I'm here with my good friendtoday, dr Ruth Decker.
Ruth, how are you doing?
Speaker 2 (00:10):
I'm doing great and thanks for having me, dr Edwards
, thank you.
Speaker 1 (00:13):
Ruth.
Now for those of you who don'tknow, dr Decker is a thyroid
surgeon.
She's a general surgeon, butshe specializes in thyroid and
parathyroid surgeries.
Is that accurate?
Speaker 2 (00:23):
Yeah, exclusively thyroid and parathyroid
surgeries.
Speaker 1 (00:26):
Is that accurate?
Yeah, exclusively thyroid andparathyroid.
Yeah, and that's reallyimportant because, as we know,
physicians who do a same surgerymultiple times or they do it
more times a year have betteroutcomes.
I think specifically withthyroid cancer or thyroid
surgeries it's 25 or more a yearare known to have better
outcomes.
Speaker 2 (00:45):
Yeah, that's correct, and because there's a lot of
nuances and over time, thenyou're prepared because you've
seen it before and you're justmore comfortable because it's
almost in your DNA.
Speaker 1 (00:58):
Yeah, you bet you bet We'll get into the nuts and
bolts of thyroid surgery.
But first, where are you from,Ruth?
Originally I'm from Sheboygan,Wisconsin.
Okay, and so is that insouthern Wisconsin.
Speaker 2 (01:10):
No.
It's north of Milwaukee.
It's kind of mid.
It's north of Milwaukee righton Lake Michigan.
Speaker 1 (01:15):
Okay, okay, so like south of Green Bay, north of
Milwaukee.
Speaker 2 (01:19):
Correct.
Speaker 1 (01:20):
Okay, very good, I would assume it's a nice
Midwestern city.
Speaker 2 (01:23):
Yeah, mostly blue collar.
Yeah, we're near the biggerindustries Kohler, Kohler of
Kohler.
Speaker 1 (01:29):
Kohler the tool.
Speaker 2 (01:32):
Well, they have generators, they do bathtubs,
toilets.
Okay, gotcha, yeah, that's abig employer.
Speaker 1 (01:38):
Okay gotcha, Most of the stuff in Home Depot is going
to be Kohler-like products.
Speaker 2 (01:44):
Yeah, most of the stuff in Home.
Speaker 1 (01:46):
Depot is going to be Kohler-like products.
Speaker 2 (01:48):
Yeah, maybe, maybe, yeah, and then where did you go
to school at Undergrad?
Yeah sure, I went to school atNorthwestern.
Speaker 1 (01:54):
Very good.
Speaker 2 (01:55):
In Evanston Illinois.
Speaker 1 (01:56):
Sure.
Speaker 2 (01:57):
And I also got an MBA there.
Speaker 1 (01:59):
Okay.
Speaker 2 (02:00):
I attended medical school at the University of
Wisconsin in Madison and thenalso completed a fellowship in
thyroid surgery here at BarnesHospital in St Louis.
And following my medicaltraining, I joined the faculty
at the University of Michigan inAnn Arbor in the Division of
Endocrine Surgery.
I also had a research lab whereI investigated the genetics of
(02:24):
an inherited form of medullarythyroid cancer.
My work was funded by the NIH,the American Cancer Society and
the American College of Surgeons, from whom I received a
National Faculty Award for myresearch.
And then, in 1996, I returnedto St Louis and came here to St
Luke's and I got a law degreefrom Washington University.
Speaker 1 (02:47):
Very good.
Speaker 2 (02:47):
So I've been in the Midwest the whole time.
Speaker 1 (02:51):
And so not a lot of physicians have law degrees
You're only the second one I'veever met and so how do you feel
like that's influenced yourpractice?
Speaker 2 (03:10):
like that's influenced your practice.
I think it.
To me it has reinforced theimportance of being very
consistent in how you describethings to patients, yeah, so
that when you actually operate,they have a feeling within that
they have made the rightdecisions, that they've been
given alternatives, and ifyou're consistent and I tend to
use my whiteboard verygenerously, I draw pictures, I
(03:34):
put down statistics and mostpatients come away actually
stating that for the first time,they understand exactly why
they're having surgery, and so Ifeel very comfortable in that
approach.
I don't, and even after surgerya time of discharge I stand at
(03:56):
the bedside and I have verydetailed written instructions
for their post-operative care.
However, I go through theinstructions line by line myself
.
So, I don't delegate.
I think it's important, and youhave enough respect for
patients, that you give them thetime they need to understand
(04:17):
why you're doing surgery which,when you think of I mean it's a
very invasive correct.
They're in a very fragilesituation, they're under
anesthesia, it can be very scary, and so you want them to feel
that you care for them as aperson as well as as a patient.
Speaker 1 (04:39):
Yeah, you know your whiteboard is legendary Patients
talk to me about yourwhiteboard and a lot of people
say Carl Rove stole it from you.
Speaker 2 (04:47):
And so.
Speaker 1 (04:47):
I don't know if that's true or not, but no, I
mean, that's the tricky thing,Thyroid surgery, I mean, as you
know, but to the audiencemembers that is kind of a high
real estate area in the neck.
Speaker 2 (05:00):
I mean you've got In a very small area, very small
area.
Speaker 1 (05:02):
You've got the airway , the carotid artery, the
jugular and the recurrentlaryngeal nerve, which is a big
deal for thyroid cancer.
For those of you who don't know, it's a nerve that comes out of
the neck down around thebronchus in the chest and then
comes back up to innervate thevocal cords Correct and it's
kind of on the backside of thethyroid gland Right.
(05:24):
So when you resect the thyroidgland, if you're too aggressive
you can clip those nerves andthen people have a loss of voice
, right.
Speaker 2 (05:31):
That's correct and part of it, and I do, in my
description, give a percentage,that the injury is about 1%.
But about 8% of patients canhave a transient problem, not
because the nerve has beensevered okay, but because there
might be a stretch injury,meaning the nerve is attached to
(05:54):
the back of the thyroid.
So when you rotate the glandthe nerve comes up with it and
then the sheath to the nervebecomes inflamed and that can
cause a transient change in thevoice.
Of course, this is verydisconcerting to patients and it
does require reinforcement.
(06:17):
This just takes time.
You know, reinforcement, thisjust takes time.
This will heal on its own.
We do give the patient a highdose of decadron to try to
decrease that swelling.
So, yeah, this needs to beexplained in detail because I,
rather than just againdelegating to another and
explaining the anatomy topatients, and some pick up on it
(06:40):
and they ask more questionsabout it, and even though one
can use nerve monitoring, duringsurgery it still does not
prevent those stretch phenomenon.
Right, Because you've identifiedthe nerve.
The problem is not whether ornot the nerve has been
identified, but how muchdissection has had to happen
around the nerve.
The problem is not whether ornot the nerve has been
identified, but how muchdissection has had to happen
(07:01):
around the nerve, especially ifyou're doing lymph node
dissections.
You're doing this dance aroundthe nerve because they tend to
hug the nerve, and so it's justa very fragile situation.
Speaker 1 (07:14):
Yeah, yeah, and you and I share a lot of patients.
I don't see the majority ofyour patients, probably, but a
fair amount of them have ahigher risk thyroid cancer.
Well, post-operatively, andit's actually.
I can't recall any patientswho've had any long-term damage
off the top of my head.
Speaker 2 (07:33):
I mean you do a great job.
Yeah, they do resolve.
The other thing I want to pointout is most patients are
asymptomatic when they present.
Speaker 1 (07:42):
You bet yeah.
Speaker 2 (07:44):
So this is a very difficult situation.
Plus, their thyroid levels aretypically normal.
And so you're coming to themand you're saying you need
surgery.
You know you have this biopsyand they feel no different.
I mean, it's rare that thepatient actually has hoarseness
or difficulty swallowing.
You know where they can senseyes, this has to happen.
(08:06):
Most of the time they feltperfectly fine and here they're
undergoing this surgery.
So, again, it takes educatingthe patient of why this has to
happen and, of course, as youknow, it's all about probability
.
Rarely do we have 100%certainty that, yes, this
(08:28):
patient has cancer, even thoughthe diagnostics have improved
and evolved to try to perfectthe probabilities.
To try to perfect theprobabilities still you might
have a situation where theprobability suggests that they
need the surgery, but yet on thefinal analysis that we get from
the pathologist, we find it's abenign event.
Speaker 1 (08:50):
Yeah, yeah, I mean, life is probabilistic, right.
Yeah absolutely Be weary ofanybody who ever says always or
never.
Yeah, I mean that's the way weshould talk, especially with
informed consent, is to say highprobability or low probability
and try to give that probabilityif we can.
Speaker 2 (09:06):
Yeah, and to make that very clear, and it may not
be in some cancers it may not bea one and done.
We may have to go back anddissect more lymph nodes, you
know, or for recurrent disease.
So the patient needs tounderstand that as well.
And maybe it was not detectedinitially with the current
(09:28):
sensitivities of the imagingstudies et cetera.
So if they're prepared for that, it's important.
Speaker 1 (09:34):
Yeah, if you know it's a possibility, it's easier
to accept when it happens.
Speaker 2 (09:38):
Yes.
Speaker 1 (09:38):
If you know it's a possibility, it's easier to
accept when it happens.
So, talking about imaging, therate of thyroid cancer has
increased over time, and there'ssome ideas of why that is.
Speaker 2 (09:52):
What are your thoughts on that?
Well again, because many of thepatients are asymptomatic, many
of them come to me with.
Well, I had this life screeningat work.
Speaker 1 (10:06):
Okay.
Speaker 2 (10:07):
Or I had a carotid study, or I had a chest CT and
it picked up this nodule.
Yeah, that is the more common.
And that is the more commonOnce in a while, depending again
on the astuteness of theprimary care that they will
actually feel a thyroid noduleand then go on to order an
ultrasound.
(10:27):
And of course, ultrasound, Ithink, has been with us since
the 1940s, but it has reallybeen the mainstay for diagnosing
thyroid nodules.
It continues to be.
Speaker 1 (10:39):
Yeah, and ultrasound technology has obviously
improved a fair amount too overthat time.
Right, you know especially mywife's an OB-GYN, and you know
the ultrasound of the fetusesare incredible these days, yeah,
yeah.
And so that's helped.
Yeah, so you're sayingincreased detection just from
these scans?
Incidentally, finding lesionsis maybe one of the reasons that
thyroid cancer is increasingand again.
Speaker 2 (11:00):
and if you talk about the legal implications of that,
I think gone are the days whereone can dismiss it.
Speaker 1 (11:08):
Yeah, correct yeah.
Speaker 2 (11:09):
You know.
So the referrals, either forthe thyroid FNA or to an
endocrinologist or to a surgeon,to assume that.
And then the follow-up.
Let's say the initial biopsywas benign, but again you know
that is not a hundred percentaccurate and so there needs to
be some follow-up.
And that's the other thing toreinforce to patients.
(11:30):
You know that even if theinitial biopsy was okay, there
needs to be follow-up, and evenmore pressing in these times
where the treatment is actuallyless vigorous, I would say, than
it used to be.
Correct, okay, for smallcancers, this puts a bigger
(11:53):
burden on the physician forensuring compliance, because
let's say, you have a onecentimeter papillary, many of
those can now just be watchedand operative treatment is not
really recommended.
But that patient has to committo coming back and repeating the
(12:13):
ultrasound.
Okay, and even in somecountries now it's even going to
two centimeters.
Speaker 1 (12:20):
But you have to have a responsible patient.
I mean, if we've all hadpatients who have kind of social
situations that don't lendthemselves to showing up for
treatments and things like that,or maybe it's a personality and
those people aren't a goodcandidate to watch or to
deescalate the intensity of thetreatment and we're seeing
deescalation of care, like withrectal cancer.
(12:42):
You know some patients willhave a complete response to
chemo radiation and not needsurgery.
But you have to follow veryclosely.
It's more work on our end, butit saves the patient a surgery,
Right?
Yeah, no, I think that's.
And yeah, there's plenty ofpatients that you see a nodule
on the thyroid on a scan andyou're like it's probably
(13:03):
nothing, but you can't neglectit and five years later they
come back with a gigantic masson their neck.
You're going to be held reallyculpable for that with a
gigantic mass on their neck.
Speaker 2 (13:10):
you know you're going to be held culpable for that.
And it's interesting becausesince, of course, now we have
the TI-RADS scoring of thesenodules, and so that is some
protection or assurance.
Again, you're dealing withprobabilities correct yeah.
Not absolutes, because patientsmay say, well, and some of
(13:33):
those nodules are fairly, fairlylarge, but they're either cis
or they're tr2, the scoring, andthen you have to explain the
scoring to the patient becausethen they don't understand why,
why you know why this it's small.
Why does this need to bebiopsied?
Speaker 1 (13:44):
etc.
So the tirads is kind ofsimilar to the birads which is
used in breast, and that's whenthe radiologist gives an
assessment of what's thelikelihood of the lesion to be a
cancer.
Speaker 2 (13:54):
Right, right, and the whole point is the feeling that
thyroid cancers were beingover-treated at a time when the
incidence was increasing.
Speaker 1 (14:04):
Yeah, and the cure rate for thyroid cancer is
really high for most thyroidcancers.
Speaker 2 (14:09):
Right, but the other thing is, what about the patient
that said, well, I heard, thisis really a good cancer.
Yeah, what is the answer tothat?
Speaker 1 (14:20):
So, I mean, this is my take on it.
So for a papillary thyroidcancer the cure rate is really
high.
It's like 99%, right, Right.
Speaker 2 (14:33):
But if they're treated, if they're treated,
yeah, okay.
Speaker 1 (14:38):
Now, psychologically I try not to downplay any cancer
to a patient becausepsychologically they hear cancer
.
It makes them examine their ownmortality.
Mentally and emotionally theydon't feel how they feel is not
commensurate with theprobability of cure.
You know they feel horriblewhen they have it.
One of the weird things aboutthyroid is the best.
(14:59):
It's papillary thyroid cancersabout the cancer with the
highest probability of cure, anda plastic thyroid cancer, which
is a more aggressive, is theabsolute worst cancer you can
get.
It has the fastest mortalityrate, I think it's six months.
And so it's just weird onegland can have the best and
worst cancer with regard to curerate.
Speaker 2 (15:21):
And the anaplastic.
The progenitor of that ispapillary.
Yeah, so I've had patients thathad within the same gland.
You would see this progressionwithin the gland, where they
would start out with normalpapillary and then it would
watershed area where it wasde-differentiating, and then
there was an area of anaplasticfrankly anaplastic and
(15:43):
fortunately that doesn't happenvery often.
But, yeah, usually when it'sconsumed with all anaplasia,
then the mortality is usually,though, from recurrence of
distant disease, not fromtreatment of the primary, is my
understanding.
Speaker 1 (16:00):
And the treatment of the primary is really difficult
to do a complete thyroidectomybecause the tissue goes down
into the chest, as you know, andso it's hard to get it all.
And then we use chemoradiationand that's a horrendous
treatment, but fortunately wedon't see a lot of those.
Speaker 2 (16:18):
I think I've had a couple and this might have been
prior to your time here where wedid have survival of 12 months
or more, you know what.
Speaker 1 (16:27):
There's one patient who's cured of it.
Was it a woman?
No, it was not.
Speaker 2 (16:33):
It was not okay.
Speaker 1 (16:35):
But it's a difficult treatment and that's rare.
I mean, that's super rare.
Speaker 2 (16:39):
Yeah.
Speaker 1 (16:39):
But we you know.
Speaker 2 (16:41):
I think it's interesting because that is the
one cancer where you actuallyneed to you know, within a week
need to you know within a weekhave a complete plan between the
surgeon, the radiationoncologist, the chemotherapy,
the medical oncologist, and youhave to come up, you know, core
biopsy, what are the tumormarkers?
Speaker 1 (17:06):
Very different from the other cancers, because time
is critical in that situation.
Yeah, that's you know,fortunately we don't see those
very often.
That situation, yeah, yeah,that's you know, fortunately we
don't see those very often.
And so the so and then can youtalk to me about parathyroid
disease.
So that's, you know, way out ofmy wheelhouse and so but.
But I know it has to do withcalcium regulation and whatnot.
But can you go into that alittle bit for me?
Speaker 2 (17:29):
Yeah, it's interesting because I would say,
when you talk about theevolution of a career, it seems
like I'm seeing quite moreparathyroid disease.
Speaker 1 (17:37):
Is that?
Speaker 2 (17:37):
right, Right, and it used to be, I would say, see 10
women for one male.
But it seems to be more commonnow in the male population as
well, and of course the malepopulation as well, and of
course the treatment for thatthe mainstay is surgical,
(18:01):
obviously, and we've had somebetter resolution as far as
imaging the SPECT imaging, theparathyroid nuclear imaging.
That has it, and now the 4D CTscanning A patient I did this
morning.
The Sestamib nuclear scan didnot show an abnormality.
The ultrasound did not show anabnormality, but the 4DCT did,
and that's exactly where theadenoma rested.
Parathyroid cancer is very,very rare, Thank God.
Speaker 1 (18:24):
But parathyroid disease is different than
parathyroid cancer.
Right.
Speaker 2 (18:27):
Yeah, and of course the implications.
There is the bone deterioration, risk of kidney stones.
And again, some patients havesoft findings.
They don't have kidney stones,they don't have osteoporosis,
but they're very tired you knowand you know, we pursue
(18:48):
operative resolution for thosethat desire it.
Some patients don't, and a partof that also depends on the
primary care, because yearsprior patients would be referred
for maybe they waited untilcalcium was 12 or so.
And now that's not true.
A lot of the patients I seehave are in the upper limits of
(19:09):
normal, or actually within therange of 10 to 11.
And do you?
Speaker 1 (19:13):
ever see any patients with mental issues.
Speaker 2 (19:18):
Yeah.
Chronic fatigue yeah, Loss offocus.
Speaker 1 (19:21):
Yeah.
Speaker 2 (19:22):
They have, they can't seem to they memory problems.
Some people have depression.
Yeah, so yeah, and but they,and insomnia is common From
medical school.
Speaker 1 (19:33):
I remember the moans, groans and stones it was
psychological moans groans frombone pain and then kidney stones
.
Speaker 2 (19:40):
Yeah, and of course in the dialysis patient a recent
woman that I did.
She had terrible bone groansand puritis generalized and she
didn't realize it was due tothis calcium issue and she was
instantly cured of that post-op.
Speaker 1 (19:55):
Yeah, she was so grateful.
Speaker 2 (19:58):
I mean it was a major lifestyle.
It's immediate.
I mean the bone can beimmediate.
The next day it's gone.
How wonderful, yeah, so thoseare the happy campers, yeah.
Speaker 1 (20:09):
And so we've talked about, you know, the thyroid
disease and thyroid cancer, therate going up because of
increased detection.
What other things do peoplethink are contributing to that?
Speaker 2 (20:20):
Well, I think, more and more the literature is
suggesting that, because there'sactually, you know, endocrine
receptors, as you know on thethyroid gland including estrogen
et cetera, and that thingsenvironmentally that are
hormonal disruptors areincreasing the incidence and
(20:43):
growth of thyroid nodules.
Speaker 1 (20:45):
And this would be like chemicals and microplastics
and stuff like that.
Speaker 2 (20:48):
Right and I have like , for instance it's not only
that, it's increased weight, soobesity.
Speaker 1 (20:54):
Sure.
Speaker 2 (20:54):
Because it increases the inflammatory state of the
body.
The adipose tissue is actuallyconsidered now an organ in and
of itself.
Speaker 1 (21:02):
Okay.
Speaker 2 (21:03):
And the disruptors from an increase in that tissue
may also be affecting not onlythyroid, but prostate and breast
yeah, I believe yeah and sothat literature.
Because the thing is, as ourpopulation has a, b, as you have
an increase in obesity, you'refinding an increase in thyroid
(21:24):
cancers, and so the question isis there some relationship and
that, and what are the mediatorsof that right?
Speaker 1 (21:34):
Yeah, for sure.
I actually was involved in astudy where we would harvest fat
cells and then spin down stemcells out of mature adipose
cells.
And stem cells have a ton ofhormones in them, and so does
adipose tissue.
So you've got all thesehormones floating around sheerly
because of the adipose tissueand you don't know.
(21:54):
You know, is the thyroid cancercausing the obesity?
Is the obesity causing thyroidcancer?
Probably the latter, but that'sthe tricky thing with science
is trying to figure out whichway the arrow is pointing.
Yeah, which came?
Speaker 2 (22:07):
first yeah, but you know.
The other thing is, you know,although the link between
smoking and lung cancer is verysolid, Very solid.
Some of these others.
I mean, you know, as a surgeonwould you say, well, you need to
lose weight.
I mean that's not going to bethe resolution of the problem
(22:28):
that's before me, no, no, theresolution of the problem that's
before me, no, no, you know.
So that would be more generaleducation, maybe at the primary
care level.
Speaker 1 (22:37):
Yeah.
Speaker 2 (22:37):
And it probably will happen, you know, as more
information becomes available.
Speaker 1 (22:42):
Yeah, we definitely think that the diet is
contributing to colon cancer.
I mean, that's, that's, that's,you know, less fiber in the
diet.
In general Right and and andthen we know that more fat on
the body increases estrogenlevels, which can increase
endometrial cancer, which we'veknown for a long time and
contribute to breast cancer tooyou know it's interesting.
Speaker 2 (23:00):
It's interesting too because they they say that um
once puberty um appears, is whenthe incidence of thyroid
problems appears in women.
Speaker 1 (23:12):
Okay.
Speaker 2 (23:13):
And now you don't see that in men, you don't see that
kind of, and then thatincreases until the
postmenopausal stage.
Speaker 1 (23:21):
Yeah, it's kind of 20 to 55, right I mean it's like
somewhere in there where it'sthe high point for thyroid
cancer, which kind of isconsistent with the hypothesis
that it's driven by hormones tosome extent.
Right yeah, Right yeah, it'svery interesting.
Well, Ruth, I want toappreciate all the good care
that you've given our mutualpatients over the years.
(23:43):
You are an absolute expert inthyroid and parathyroid surgery
and your results speak forthemselves.
Thanks so much for coming onthe podcast.
Speaker 2 (23:52):
You're welcome.
Welcome to Doc Discussions.
I'm Dr Jason Edwards and thisis a podcast where I interview
other physicians.
I'm here with my good friendtoday, dr Ruth Decker.
Ruth, how are you doing?
Speaker 2 (00:10):
I'm doing great and thanks for having me, dr Edwards
, thank you.
Speaker 1 (00:13):
Ruth.
Now for those of you who don'tknow, dr Decker is a thyroid
surgeon.
She's a general surgeon, butshe specializes in thyroid and
parathyroid surgeries.
Is that accurate?
Speaker 2 (00:23):
Yeah, exclusively thyroid and parathyroid
surgeries.
Speaker 1 (00:26):
Is that accurate?
Yeah, exclusively thyroid andparathyroid.
Yeah, and that's reallyimportant because, as we know,
physicians who do a same surgerymultiple times or they do it
more times a year have betteroutcomes.
I think specifically withthyroid cancer or thyroid
surgeries it's 25 or more a yearare known to have better
outcomes.
Speaker 2 (00:45):
Yeah, that's correct, and because there's a lot of
nuances and over time, thenyou're prepared because you've
seen it before and you're justmore comfortable because it's
almost in your DNA.
Speaker 1 (00:58):
Yeah, you bet you bet We'll get into the nuts and
bolts of thyroid surgery.
But first, where are you from,Ruth?
Originally I'm from Sheboygan,Wisconsin.
Okay, and so is that insouthern Wisconsin.
Speaker 2 (01:10):
No.
It's north of Milwaukee.
It's kind of mid.
It's north of Milwaukee righton Lake Michigan.
Speaker 1 (01:15):
Okay, okay, so like south of Green Bay, north of
Milwaukee.
Speaker 2 (01:19):
Correct.
Speaker 1 (01:20):
Okay, very good, I would assume it's a nice
Midwestern city.
Speaker 2 (01:23):
Yeah, mostly blue collar.
Yeah, we're near the biggerindustries Kohler, Kohler of
Kohler.
Speaker 1 (01:29):
Kohler the tool.
Speaker 2 (01:32):
Well, they have generators, they do bathtubs,
toilets.
Okay, gotcha, yeah, that's abig employer.
Speaker 1 (01:38):
Okay gotcha, Most of the stuff in Home Depot is going
to be Kohler-like products.
Speaker 2 (01:44):
Yeah, most of the stuff in Home.
Speaker 1 (01:46):
Depot is going to be Kohler-like products.
Speaker 2 (01:48):
Yeah, maybe, maybe, yeah, and then where did you go
to school at Undergrad?
Yeah sure, I went to school atNorthwestern.
Speaker 1 (01:54):
Very good.
Speaker 2 (01:55):
In Evanston Illinois.
Speaker 1 (01:56):
Sure.
Speaker 2 (01:57):
And I also got an MBA there.
Speaker 1 (01:59):
Okay.
Speaker 2 (02:00):
I attended medical school at the University of
Wisconsin in Madison and thenalso completed a fellowship in
thyroid surgery here at BarnesHospital in St Louis.
And following my medicaltraining, I joined the faculty
at the University of Michigan inAnn Arbor in the Division of
Endocrine Surgery.
I also had a research lab whereI investigated the genetics of
(02:24):
an inherited form of medullarythyroid cancer.
My work was funded by the NIH,the American Cancer Society and
the American College of Surgeons, from whom I received a
National Faculty Award for myresearch.
And then, in 1996, I returnedto St Louis and came here to St
Luke's and I got a law degreefrom Washington University.
Speaker 1 (02:47):
Very good.
Speaker 2 (02:47):
So I've been in the Midwest the whole time.
Speaker 1 (02:51):
And so not a lot of physicians have law degrees
You're only the second one I'veever met and so how do you feel
like that's influenced yourpractice?
Speaker 2 (03:10):
like that's influenced your practice.
I think it.
To me it has reinforced theimportance of being very
consistent in how you describethings to patients, yeah, so
that when you actually operate,they have a feeling within that
they have made the rightdecisions, that they've been
given alternatives, and ifyou're consistent and I tend to
use my whiteboard verygenerously, I draw pictures, I
(03:34):
put down statistics and mostpatients come away actually
stating that for the first time,they understand exactly why
they're having surgery, and so Ifeel very comfortable in that
approach.
I don't, and even after surgerya time of discharge I stand at
(03:56):
the bedside and I have verydetailed written instructions
for their post-operative care.
However, I go through theinstructions line by line myself
.
So, I don't delegate.
I think it's important, and youhave enough respect for
patients, that you give them thetime they need to understand
(04:17):
why you're doing surgery which,when you think of I mean it's a
very invasive correct.
They're in a very fragilesituation, they're under
anesthesia, it can be very scary, and so you want them to feel
that you care for them as aperson as well as as a patient.
Speaker 1 (04:39):
Yeah, you know your whiteboard is legendary Patients
talk to me about yourwhiteboard and a lot of people
say Carl Rove stole it from you.
Speaker 2 (04:47):
And so.
Speaker 1 (04:47):
I don't know if that's true or not, but no, I
mean, that's the tricky thing,Thyroid surgery, I mean, as you
know, but to the audiencemembers that is kind of a high
real estate area in the neck.
Speaker 2 (05:00):
I mean you've got In a very small area, very small
area.
Speaker 1 (05:02):
You've got the airway , the carotid artery, the
jugular and the recurrentlaryngeal nerve, which is a big
deal for thyroid cancer.
For those of you who don't know, it's a nerve that comes out of
the neck down around thebronchus in the chest and then
comes back up to innervate thevocal cords Correct and it's
kind of on the backside of thethyroid gland Right.
(05:24):
So when you resect the thyroidgland, if you're too aggressive
you can clip those nerves andthen people have a loss of voice
, right.
Speaker 2 (05:31):
That's correct and part of it, and I do, in my
description, give a percentage,that the injury is about 1%.
But about 8% of patients canhave a transient problem, not
because the nerve has beensevered okay, but because there
might be a stretch injury,meaning the nerve is attached to
(05:54):
the back of the thyroid.
So when you rotate the glandthe nerve comes up with it and
then the sheath to the nervebecomes inflamed and that can
cause a transient change in thevoice.
Of course, this is verydisconcerting to patients and it
does require reinforcement.
(06:17):
This just takes time.
You know, reinforcement, thisjust takes time.
This will heal on its own.
We do give the patient a highdose of decadron to try to
decrease that swelling.
So, yeah, this needs to beexplained in detail because I,
rather than just againdelegating to another and
explaining the anatomy topatients, and some pick up on it
(06:40):
and they ask more questionsabout it, and even though one
can use nerve monitoring, duringsurgery it still does not
prevent those stretch phenomenon.
Right, Because you've identifiedthe nerve.
The problem is not whether ornot the nerve has been
identified, but how muchdissection has had to happen
around the nerve.
The problem is not whether ornot the nerve has been
identified, but how muchdissection has had to happen
(07:01):
around the nerve, especially ifyou're doing lymph node
dissections.
You're doing this dance aroundthe nerve because they tend to
hug the nerve, and so it's justa very fragile situation.
Speaker 1 (07:14):
Yeah, yeah, and you and I share a lot of patients.
I don't see the majority ofyour patients, probably, but a
fair amount of them have ahigher risk thyroid cancer.
Well, post-operatively, andit's actually.
I can't recall any patientswho've had any long-term damage
off the top of my head.
Speaker 2 (07:33):
I mean you do a great job.
Yeah, they do resolve.
The other thing I want to pointout is most patients are
asymptomatic when they present.
Speaker 1 (07:42):
You bet yeah.
Speaker 2 (07:44):
So this is a very difficult situation.
Plus, their thyroid levels aretypically normal.
And so you're coming to themand you're saying you need
surgery.
You know you have this biopsyand they feel no different.
I mean, it's rare that thepatient actually has hoarseness
or difficulty swallowing.
You know where they can senseyes, this has to happen.
(08:06):
Most of the time they feltperfectly fine and here they're
undergoing this surgery.
So, again, it takes educatingthe patient of why this has to
happen and, of course, as youknow, it's all about probability
.
Rarely do we have 100%certainty that, yes, this
(08:28):
patient has cancer, even thoughthe diagnostics have improved
and evolved to try to perfectthe probabilities.
To try to perfect theprobabilities still you might
have a situation where theprobability suggests that they
need the surgery, but yet on thefinal analysis that we get from
the pathologist, we find it's abenign event.
Speaker 1 (08:50):
Yeah, yeah, I mean, life is probabilistic, right.
Yeah absolutely Be weary ofanybody who ever says always or
never.
Yeah, I mean that's the way weshould talk, especially with
informed consent, is to say highprobability or low probability
and try to give that probabilityif we can.
Speaker 2 (09:06):
Yeah, and to make that very clear, and it may not
be in some cancers it may not bea one and done.
We may have to go back anddissect more lymph nodes, you
know, or for recurrent disease.
So the patient needs tounderstand that as well.
And maybe it was not detectedinitially with the current
(09:28):
sensitivities of the imagingstudies et cetera.
So if they're prepared for that, it's important.
Speaker 1 (09:34):
Yeah, if you know it's a possibility, it's easier
to accept when it happens.
Speaker 2 (09:38):
Yes.
Speaker 1 (09:38):
If you know it's a possibility, it's easier to
accept when it happens.
So, talking about imaging, therate of thyroid cancer has
increased over time, and there'ssome ideas of why that is.
Speaker 2 (09:52):
What are your thoughts on that?
Well again, because many of thepatients are asymptomatic, many
of them come to me with.
Well, I had this life screeningat work.
Speaker 1 (10:06):
Okay.
Speaker 2 (10:07):
Or I had a carotid study, or I had a chest CT and
it picked up this nodule.
Yeah, that is the more common.
And that is the more commonOnce in a while, depending again
on the astuteness of theprimary care that they will
actually feel a thyroid noduleand then go on to order an
ultrasound.
(10:27):
And of course, ultrasound, Ithink, has been with us since
the 1940s, but it has reallybeen the mainstay for diagnosing
thyroid nodules.
It continues to be.
Speaker 1 (10:39):
Yeah, and ultrasound technology has obviously
improved a fair amount too overthat time.
Right, you know especially mywife's an OB-GYN, and you know
the ultrasound of the fetusesare incredible these days, yeah,
yeah.
And so that's helped.
Yeah, so you're sayingincreased detection just from
these scans?
Incidentally, finding lesionsis maybe one of the reasons that
thyroid cancer is increasingand again.
Speaker 2 (11:00):
and if you talk about the legal implications of that,
I think gone are the days whereone can dismiss it.
Speaker 1 (11:08):
Yeah, correct yeah.
Speaker 2 (11:09):
You know.
So the referrals, either forthe thyroid FNA or to an
endocrinologist or to a surgeon,to assume that.
And then the follow-up.
Let's say the initial biopsywas benign, but again you know
that is not a hundred percentaccurate and so there needs to
be some follow-up.
And that's the other thing toreinforce to patients.
(11:30):
You know that even if theinitial biopsy was okay, there
needs to be follow-up, and evenmore pressing in these times
where the treatment is actuallyless vigorous, I would say, than
it used to be.
Correct, okay, for smallcancers, this puts a bigger
(11:53):
burden on the physician forensuring compliance, because
let's say, you have a onecentimeter papillary, many of
those can now just be watchedand operative treatment is not
really recommended.
But that patient has to committo coming back and repeating the
(12:13):
ultrasound.
Okay, and even in somecountries now it's even going to
two centimeters.
Speaker 1 (12:20):
But you have to have a responsible patient.
I mean, if we've all hadpatients who have kind of social
situations that don't lendthemselves to showing up for
treatments and things like that,or maybe it's a personality and
those people aren't a goodcandidate to watch or to
deescalate the intensity of thetreatment and we're seeing
deescalation of care, like withrectal cancer.
(12:42):
You know some patients willhave a complete response to
chemo radiation and not needsurgery.
But you have to follow veryclosely.
It's more work on our end, butit saves the patient a surgery,
Right?
Yeah, no, I think that's.
And yeah, there's plenty ofpatients that you see a nodule
on the thyroid on a scan andyou're like it's probably
(13:03):
nothing, but you can't neglectit and five years later they
come back with a gigantic masson their neck.
You're going to be held reallyculpable for that with a
gigantic mass on their neck.
Speaker 2 (13:10):
you know you're going to be held culpable for that.
And it's interesting becausesince, of course, now we have
the TI-RADS scoring of thesenodules, and so that is some
protection or assurance.
Again, you're dealing withprobabilities correct yeah.
Not absolutes, because patientsmay say, well, and some of
(13:33):
those nodules are fairly, fairlylarge, but they're either cis
or they're tr2, the scoring, andthen you have to explain the
scoring to the patient becausethen they don't understand why,
why you know why this it's small.
Why does this need to bebiopsied?
Speaker 1 (13:44):
etc.
So the tirads is kind ofsimilar to the birads which is
used in breast, and that's whenthe radiologist gives an
assessment of what's thelikelihood of the lesion to be a
cancer.
Speaker 2 (13:54):
Right, right, and the whole point is the feeling that
thyroid cancers were beingover-treated at a time when the
incidence was increasing.
Speaker 1 (14:04):
Yeah, and the cure rate for thyroid cancer is
really high for most thyroidcancers.
Speaker 2 (14:09):
Right, but the other thing is, what about the patient
that said, well, I heard, thisis really a good cancer.
Yeah, what is the answer tothat?
Speaker 1 (14:20):
So, I mean, this is my take on it.
So for a papillary thyroidcancer the cure rate is really
high.
It's like 99%, right, Right.
Speaker 2 (14:33):
But if they're treated, if they're treated,
yeah, okay.
Speaker 1 (14:38):
Now, psychologically I try not to downplay any cancer
to a patient becausepsychologically they hear cancer
.
It makes them examine their ownmortality.
Mentally and emotionally theydon't feel how they feel is not
commensurate with theprobability of cure.
You know they feel horriblewhen they have it.
One of the weird things aboutthyroid is the best.
(14:59):
It's papillary thyroid cancersabout the cancer with the
highest probability of cure, anda plastic thyroid cancer, which
is a more aggressive, is theabsolute worst cancer you can
get.
It has the fastest mortalityrate, I think it's six months.
And so it's just weird onegland can have the best and
worst cancer with regard to curerate.
Speaker 2 (15:21):
And the anaplastic.
The progenitor of that ispapillary.
Yeah, so I've had patients thathad within the same gland.
You would see this progressionwithin the gland, where they
would start out with normalpapillary and then it would
watershed area where it wasde-differentiating, and then
there was an area of anaplasticfrankly anaplastic and
(15:43):
fortunately that doesn't happenvery often.
But, yeah, usually when it'sconsumed with all anaplasia,
then the mortality is usually,though, from recurrence of
distant disease, not fromtreatment of the primary, is my
understanding.
Speaker 1 (16:00):
And the treatment of the primary is really difficult
to do a complete thyroidectomybecause the tissue goes down
into the chest, as you know, andso it's hard to get it all.
And then we use chemoradiationand that's a horrendous
treatment, but fortunately wedon't see a lot of those.
Speaker 2 (16:18):
I think I've had a couple and this might have been
prior to your time here where wedid have survival of 12 months
or more, you know what.
Speaker 1 (16:27):
There's one patient who's cured of it.
Was it a woman?
No, it was not.
Speaker 2 (16:33):
It was not okay.
Speaker 1 (16:35):
But it's a difficult treatment and that's rare.
I mean, that's super rare.
Speaker 2 (16:39):
Yeah.
Speaker 1 (16:39):
But we you know.
Speaker 2 (16:41):
I think it's interesting because that is the
one cancer where you actuallyneed to you know, within a week
need to you know within a weekhave a complete plan between the
surgeon, the radiationoncologist, the chemotherapy,
the medical oncologist, and youhave to come up, you know, core
biopsy, what are the tumormarkers?
Speaker 1 (17:06):
Very different from the other cancers, because time
is critical in that situation.
Yeah, that's you know,fortunately we don't see those
very often.
That situation, yeah, yeah,that's you know, fortunately we
don't see those very often.
And so the so and then can youtalk to me about parathyroid
disease.
So that's, you know, way out ofmy wheelhouse and so but.
But I know it has to do withcalcium regulation and whatnot.
But can you go into that alittle bit for me?
Speaker 2 (17:29):
Yeah, it's interesting because I would say,
when you talk about theevolution of a career, it seems
like I'm seeing quite moreparathyroid disease.
Speaker 1 (17:37):
Is that?
Speaker 2 (17:37):
right, Right, and it used to be, I would say, see 10
women for one male.
But it seems to be more commonnow in the male population as
well, and of course the malepopulation as well, and of
course the treatment for thatthe mainstay is surgical,
(18:01):
obviously, and we've had somebetter resolution as far as
imaging the SPECT imaging, theparathyroid nuclear imaging.
That has it, and now the 4D CTscanning A patient I did this
morning.
The Sestamib nuclear scan didnot show an abnormality.
The ultrasound did not show anabnormality, but the 4DCT did,
and that's exactly where theadenoma rested.
Parathyroid cancer is very,very rare, Thank God.
Speaker 1 (18:24):
But parathyroid disease is different than
parathyroid cancer.
Right.
Speaker 2 (18:27):
Yeah, and of course the implications.
There is the bone deterioration, risk of kidney stones.
And again, some patients havesoft findings.
They don't have kidney stones,they don't have osteoporosis,
but they're very tired you knowand you know, we pursue
(18:48):
operative resolution for thosethat desire it.
Some patients don't, and a partof that also depends on the
primary care, because yearsprior patients would be referred
for maybe they waited untilcalcium was 12 or so.
And now that's not true.
A lot of the patients I seehave are in the upper limits of
(19:09):
normal, or actually within therange of 10 to 11.
And do you?
Speaker 1 (19:13):
ever see any patients with mental issues.
Speaker 2 (19:18):
Yeah.
Chronic fatigue yeah, Loss offocus.
Speaker 1 (19:21):
Yeah.
Speaker 2 (19:22):
They have, they can't seem to they memory problems.
Some people have depression.
Yeah, so yeah, and but they,and insomnia is common From
medical school.
Speaker 1 (19:33):
I remember the moans, groans and stones it was
psychological moans groans frombone pain and then kidney stones
.
Speaker 2 (19:40):
Yeah, and of course in the dialysis patient a recent
woman that I did.
She had terrible bone groansand puritis generalized and she
didn't realize it was due tothis calcium issue and she was
instantly cured of that post-op.
Speaker 1 (19:55):
Yeah, she was so grateful.
Speaker 2 (19:58):
I mean it was a major lifestyle.
It's immediate.
I mean the bone can beimmediate.
The next day it's gone.
How wonderful, yeah, so thoseare the happy campers, yeah.
Speaker 1 (20:09):
And so we've talked about, you know, the thyroid
disease and thyroid cancer, therate going up because of
increased detection.
What other things do peoplethink are contributing to that?
Speaker 2 (20:20):
Well, I think, more and more the literature is
suggesting that, because there'sactually, you know, endocrine
receptors, as you know on thethyroid gland including estrogen
et cetera, and that thingsenvironmentally that are
hormonal disruptors areincreasing the incidence and
(20:43):
growth of thyroid nodules.
Speaker 1 (20:45):
And this would be like chemicals and microplastics
and stuff like that.
Speaker 2 (20:48):
Right and I have like , for instance it's not only
that, it's increased weight, soobesity.
Speaker 1 (20:54):
Sure.
Speaker 2 (20:54):
Because it increases the inflammatory state of the
body.
The adipose tissue is actuallyconsidered now an organ in and
of itself.
Speaker 1 (21:02):
Okay.
Speaker 2 (21:03):
And the disruptors from an increase in that tissue
may also be affecting not onlythyroid, but prostate and breast
yeah, I believe yeah and sothat literature.
Because the thing is, as ourpopulation has a, b, as you have
an increase in obesity, you'refinding an increase in thyroid
(21:24):
cancers, and so the question isis there some relationship and
that, and what are the mediatorsof that right?
Speaker 1 (21:34):
Yeah, for sure.
I actually was involved in astudy where we would harvest fat
cells and then spin down stemcells out of mature adipose
cells.
And stem cells have a ton ofhormones in them, and so does
adipose tissue.
So you've got all thesehormones floating around sheerly
because of the adipose tissueand you don't know.
(21:54):
You know, is the thyroid cancercausing the obesity?
Is the obesity causing thyroidcancer?
Probably the latter, but that'sthe tricky thing with science
is trying to figure out whichway the arrow is pointing.
Yeah, which came?
Speaker 2 (22:07):
first yeah, but you know.
The other thing is, you know,although the link between
smoking and lung cancer is verysolid, Very solid.
Some of these others.
I mean, you know, as a surgeonwould you say, well, you need to
lose weight.
I mean that's not going to bethe resolution of the problem
(22:28):
that's before me, no, no, theresolution of the problem that's
before me, no, no, you know.
So that would be more generaleducation, maybe at the primary
care level.
Speaker 1 (22:37):
Yeah.
Speaker 2 (22:37):
And it probably will happen, you know, as more
information becomes available.
Speaker 1 (22:42):
Yeah, we definitely think that the diet is
contributing to colon cancer.
I mean, that's, that's, that's,you know, less fiber in the
diet.
In general Right and and andthen we know that more fat on
the body increases estrogenlevels, which can increase
endometrial cancer, which we'veknown for a long time and
contribute to breast cancer tooyou know it's interesting.
Speaker 2 (23:00):
It's interesting too because they they say that um
once puberty um appears, is whenthe incidence of thyroid
problems appears in women.
Speaker 1 (23:12):
Okay.
Speaker 2 (23:13):
And now you don't see that in men, you don't see that
kind of, and then thatincreases until the
postmenopausal stage.
Speaker 1 (23:21):
Yeah, it's kind of 20 to 55, right I mean it's like
somewhere in there where it'sthe high point for thyroid
cancer, which kind of isconsistent with the hypothesis
that it's driven by hormones tosome extent.
Right yeah, Right yeah, it'svery interesting.
Well, Ruth, I want toappreciate all the good care
that you've given our mutualpatients over the years.
(23:43):
You are an absolute expert inthyroid and parathyroid surgery
and your results speak forthemselves.
Thanks so much for coming onthe podcast.
Speaker 2 (23:52):
You're welcome.
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