Thyroid Nodule and Thyroid Cancer Screening on Patients in Hospital Emergency Rooms

Screening for Thyroid Nodules and Thyroid Cancers Begins at HCA Hospital Emergency Rooms, made possible by a collaboration with the Clayman Thyroid Center and the Hospital for Endocrine Surgery

Thyroid nodules and thyroid growths occur in nearly half of all adults. Thyroid cancer is present within 10-15% of these nodules. Because thyroid nodules are so common, they are often discovered incidentally in many patients who go to an emergency room for some other reason. Unfortunately, world-wide the healthcare system is not really designed to look for and/or these unsuspected thyroid nodules. The patient didn’t come to the emergency room for the thyroid nodule—they came for some other reason. Therefore, the patient being treated for chest pain who is noted to have a thyroid nodule, typically has a proper cardiac workup but the thyroid nodule is often overlooked.  Usually, nothing happens or the patient is lost to follow up.  Either the patient does not even know about the finding or the patient's doctor is never told.

Typically, if the patient comes in with chest pain, the workup and diagnosis is centered around this problem, and the opportunity to find other problems like high calcium, a parathyroid tumor, a thyroid cancer, or an adrenal mass is missed. The purpose of the endocrine screening program is to find endocrine tumors many years sooner than they would otherwise be found. This could affect 100,000 people in the US annually, finding their parathyroid, adrenal or thyroid tumor years sooner providing huge benefits to quality of life and life expectancy for these patients. 

What is a Thyroid Nodule?

Thyroid nodules are lumps that occur in the thyroid gland. Thyroid nodules may be cystic (fluid filled), solid, or combination of both. Thyroid nodules can develop in any location within the thyroid gland. At least 85% of thyroid nodules are benign (non-cancerous) and are generally not considered a serious condition (2). Thyroid cancer only accounts for 10-15% of thyroid nodules.  Thyroid nodules are most often detected without producing any symptoms whatsoever. However, if they do produce symptoms, the most common ones are a fullness sensation or a lump in the neck (3,4).

Thyroid nodules are most commonly found when a doctor examines a patient's neck and actually feels the thyroid gland. Sometimes thyroid nodules are found when a patient gets x-rays or scans of the neck for some other reason, like when they go to the emergency room for some other problem. Sometimes it is a screening x-ray or scan for carotid arteries or neck pain that shows nodules in the thyroid. Other times it is a Chest CT that shows nodules growing into the chest cavity. Thyroid nodules that are large, that develop in women with thin necks, or those that are present in the middle portion of the thyroid gland (called the isthmus) may be visible and discovered as a lump in the neck.

Screening for Thyroid, Parathyroid, or Adrenal Tumors in the Emergency Room

This article provides the scientific basis for looking for endocrine tumors for all patients who come into hospital emergency rooms. Other articles will go into more detail about parathyroid tumors and adrenal tumors, with this article having a heavy emphasis on screening for thyroid nodules. Read more about screening for parathyroid tumors or screening for adrenal tumors.

When physicians look for a disease in a population of patients, it is called "screening".  Some forms of tumor screening are already well established. Mammograms performed on all women over 40-45 years old is a well-known screening program to detect breast cancer while it is still small. Colonoscopy at age 50 is another way that doctors use "screening" to look for a colon cancer that may or may not be present. We can do this same type of screening for endocrine tumors without the patient having to do anything--we do it for them when they come to an emergency room.

Endocrine tumors and the diseases they cause are unique in all of medicine in that they are often identified on routine lab tests or routine imaging.  More specifically, endocrine tumors are routinely identified on scans and blood tests performed on patients seeking emergency care for an unrelated complaint, injury, or illness.  This is referred to as an incidental finding. The fact that most endocrine tumors show up on routine scans and blood work performed in an emergency room means that these tumors are perfect for a screening program. The patient comes to the ER for "problem x" and while he/she is there also gets a scan and some blood work that shows "endocrine tumor Z" --something that nobody was looking for--but it showed up because that's what endocrine tumors do.

It sounds so simple, yet as straightforward and obvious as this is, no screening program for adrenal, thyroid, or parathyroid disease or tumors has ever been undertaken before.  It is very unfortunate that a thyroid cancer can be present for years without any symptoms but be present on scans without the patient even knowing. In fact, 50% of thyroid cancers are not even known until after surgical removal (1). The tumor can be present and yet most doctors ignored it because that was not what the patient was being seen for. This is the exact problem our new endocrine tumor screening program was designed to fix.

ER Screening for Thyroid Nodules

Thyroid nodules are found incidentally in various types of imaging performed for all different reasons.   Tens of thousands of patients visiting an ER will have one of these imaging tests performed, and thus represent a significant opportunity for case detection and diagnosis, leading to faster and better treatment of these patients who would otherwise have a failure or delay in diagnosis. Given the significant number of scans performed at HCA Emergency Departments, a systemic, comprehensive quality improvement program to identify and diagnose patients became a reality in June 2021 with collaboration and expertise provided by thyroid experts at The Clayman Thyroid Center.

We selected the trigger size for thyroid nodules to be 2.0 cm as this is a moderate size nodule that would likely need a biopsy.  The trigger level for the size of thyroid nodules can be set at any level. We know, of course that nodules less than 2.0 cm can be a thyroid cancer, but we are not trying to capture every single thyroid cancer.  We are screening for more obvious thyroid nodules and thyroid cancers that have been present for years that nobody has diagnosed and caught.  This is a fantastic start and huge progress for thyroid patients everywhere.

How Does the Thyroid Nodule Screening Program Work?

HCA Healthcare, the largest hospital company in the US, with 196 hospitals in 21 states has invested heavily in the endocrine disease field beginning in 2020. In 2021 they built a new hospital in Tampa, Florida dedicated to endocrine tumors: the Hospital for Endocrine Surgery.  In keeping with this commitment to improving the diagnosis and treatment of endocrine tumors, HCA worked with Drs Jim Norman, Gary Clayman, and Tobias Carling to adapt their award winning "Care Assure" screening program for lung tumors and heart rhythm problems so it could be used to detect endocrine tumors.

Detecting Thyroid Nodules

Many patients will have chest x-rays, CT scans, or neck ultrasounds when they are in the emergency room and the HCA team developed software to examine all thyroid nodules over 2.0 cm.   Since a 2.0 cm thyroid nodule in any individual is not normal, we chose this as our starting point. The HCA Care Assure team is comprised of a nurse at every participating hospital who is notified when a patient "triggers" one of the parameters suggesting an endocrine tumor (calcium above 11.0; adrenal tumor on CT scan of 1cm or larger, or a thyroid nodule larger than 2.0 cm). The day after the patient is seen in the ER, the nurse contacts the patient to explain the findings, then contacts their primary care doctor. The nurse then sets up an appointment with an endocrinologist to help confirm the diagnosis with further testing. It is up to the primary care doctor and the endocrinologist to determine the course of action, if any, that should be followed. The surgeons at the Hospital for Endocrine Surgery do not play any role in this process. If surgery is needed, the endocrinologist is free to send the patient to a surgeon of their choice.

How Common are Endocrine Tumors?

• Adrenal:  An adrenal "incidentaloma" is defined as a clinically unapparent adrenal mass greater than 1 cm in diameter detected during imaging performed for reasons other than for suspected adrenal disease. in other words, a patient had a CT scan for some other reason and the scan showed an adrenal mass or tumor. Adrenal incidentalomas occur in 3% of the population and 4.5% patients older than 55 years of age.
• Parathyroid: As noted above, hyperparathyroidism due to a parathyroid tumor occurs in one in 50 women in their lifetime (2% risk), and one in 200 men (0.5% risk). It is estimated that 75% of people walking around with high blood calcium and hyperparathyroidism don't know they have it because no doctor has ever gotten excited about the high calcium. This is simply terrible and what the screening program is trying to address.
• Thyroid: Thyroid nodules are common and occur in 15% of adult women (one in 6.6) and 2% of men. The vast majority of these should be biopsied to make sure they are not cancer.

Screening for Thyroid and other Endocrine Tumors Requires Doctor and Surgeon Expertise

On March, 2021 the Endocrine Tumor Screening Program was begun at 19 hospitals on the west coast of Florida, expanding to 50 hospitals throughout Florida in the summer of 2021, and then to the southeast US, and eventually nationwide. To get this huge program underway HCA hospitals (the nation's largest hospital system with about 200 hospitals) asked the doctors at the new Hospital for Endocrine Surgery to help out. The expert endocrine surgeons there are by far the most experienced endocrine surgeons in the world, and are affiliated with the:

• Norman Parathyroid Center
• Clayman Thyroid Center
• Suh Scarless Robotic Thyroid Center
• Carling Adrenal Center

The purpose of the thyroid and endocrine screening program these groups started was to find endocrine tumors many years sooner than they would otherwise be found. Endocrine tumors cause significant morbidity and therefore make people feel miserable.  Endocrine glands are those that produce hormones, and thus, tumors of endocrine glands (thyroid, parathyroid, adrenal) will often cause many symptoms due to excessive hormone production from the tumor. This happens for 100% of parathyroid tumors, and about 15% of adrenal tumors and thyroid tumors.

Endocrine tumors can also be cancer. Thyroid cancer is the most common--virtually every adult will know somebody with thyroid cancer. Adrenal cancer is uncommon, only seen in a small percent of adrenal tumors. Unfortunately, adrenal cancer can be a very serious cancer.

You can read more about the HCA Endocrine Screening Program at the Screening Page of the Hospital for Endocrine Surgery website.

• Become our patient at www.thyroidcancer.com/become-a-patient
• More about the The Clayman Thyroid Center at www.thyroidcancer.com
• More about the Hospital for Endocrine Surgery

 References:

1. A large multicenter correlation study of thyroid nodule cytopathology and histopathology. Wang CC, Friedman L, Kennedy GC, Wang H, Kebebew E, Steward DL, Zeiger MA, Westra WH, Wang Y, Khanafshar E, Fellegara G, Rosai J, Livolsi V, Lanman RB. Thyroid. 2011 Mar;21(3):243-51. PubMed PMID:21190442.
2. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: executive summary of recommendations. Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, Vitti P. J Endocrinol Invest. 2010;33(5 Suppl):51-6. PubMed PMID:20543551.
3. Thyroid carcinoma. Tuttle RM, Ball DW, Byrd D, Dilawari RA, Doherty GM, Duh QY, Ehya H, Farrar WB, Haddad RI, Kandeel F, Kloos RT, Kopp P, Lamonica DM, Loree TR, Lydiatt WM, McCaffrey JC, Olson JA Jr, Parks L, Ridge JA, Shah JP, Sherman SI, Sturgeon C, Waguespack SG, Wang TN, Wirth LJ. J Natl Compr Canc Netw. 2010 Nov;8(11):1228-74. PubMed PMID:21081783.
4. Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched pair analysis. Shah, JP, Loree, TR, Dharker, D, and Strong, EW. American Journal of Surgery. 1993; 166: 331–335.
5. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Thyroid. 2009 Nov;19(11):1167-214. PubMed PMID:19860577.
6. The Bethesda System for Reporting Thyroid Cytopathology. Cibas ES, Ali SZ. Thyroid. 2009 Nov;19(11):1159-65. PubMed PMID:19888858.