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October 28, 2013

My Thyroid Story

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
JAMA Intern Med. 2013;173(19):1769. doi:10.1001/jamainternmed.2013.9279

When I was a first-year medical student just learning physical examination skills, a classmate felt a lump in my neck. A radioactive iodine scan revealed a “hot” nodule. I was advised that the nodule was likely benign, but I needed to have my thyroid checked and thyroid function tested annually. For 20 years I followed this advice, more or less, although I did not have my thyroid function tested annually. In 2000, during a visit to my primary care physician for an unrelated issue, she felt my neck and told me the lump seemed bigger. My endocrinology colleagues had been suggesting a fine-needle biopsy, but I had always quietly demurred. Now, it was my esteemed primary care physician who wanted me to have the biopsy performed. So I did, thinking it would show the benign nodule that I had had forever.

You can imagine my shock and dismay when I got a call from her a few days later, telling me I had “thyroid cancer.” Honestly, I do not think I heard anything except the word cancer. My thoughts leapt to my 2 young daughters, to who would help my husband raise them, and to how much I wanted to be around for their graduation, marriage, and grandchildren. I became a compliant patient and did everything I was told.

First there was the total thyroidectomy. I had a wonderful surgeon, and all went well, although I was out of work for a few weeks. A year or so later I had a follow-up scan, which required eating a zero-salt diet for 3 weeks. That is when I learned what a difference a little salt makes. When my endocrinologist told me the following year that we needed to repeat the scan, I told him I would rather take my chances with recurrent thyroid cancer, knowing that my chances of recurrence were very low.

In the years since my operation, I have wondered if a thyroidectomy was the right decision. There has been a large increase in the diagnosis of thyroid cancer. For example, among white women aged 40 to 59 years, the incidence of papillary thyroid cancer approximately quadrupled, rising from 7 per 100 000 to 28 per 100 000 between 1980/1983 and 2003/2005.1 There has been a parallel increase in thyroid surgery, with no change in thyroid cancer mortality. Are we benefiting patients by removing all of those thyroids? There is always some risk, even for a low-risk surgery like thyroidectomy, not to mention the stress it causes. Certainly, I had a few weeks of anxiety leading up to the surgery and then lost a few weeks to recuperation afterwards. Now I must always remember to pack my thyroid medication, and I worry that if I am ever stranded in a disaster, I will run out of medicine and become incapacitated by hypothyroidism.

As a physician, I knew back then that thyroid cancer is generally benign. But hearing a diagnosis of cancer makes most people, including me at the time, not consider whether there is evidence to support or to question the need for aggressive treatments. We were all, my physicians and I, well intentioned and operating under the best information available, but I do not think I took the time to truly weigh the potential benefits and harms of thyroidectomy. Better data for such decisions and encouragement of opportunities for such discussion would be welcomed by patients and their physicians.

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Article Information

Corresponding Author: Rita F. Redberg, MD, MSc, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, M1180, San Francisco, CA 94143-0124 (redberg@medicine.ucsf.edu).

Published Online: August 26, 2013. doi:10.1001/jamainternmed.2013.9279.

Conflict of Interest Disclosures: None reported.

Enewold  L, Zhu  K, Ron  E,  et al.  Rising thyroid cancer incidence in the United States by demographic and tumor characteristics, 1980-2005.  Cancer Epidemiol Biomarkers Prev. 2009;18(3):784-791.PubMedGoogle ScholarCrossref