I recently returned from the Mayo Clinic where I received alcohol ablation for recurrent papillary thyroid cancer in two neck lymph nodes. Reflecting on my experience, I wonder why this treatment is not more widely available and why it isn’t more frequently considered.

I didn’t expect to start 2012 with the news that my FNA (Fine Needle Aspiration) biopsy results showed I had a recurrence of papillary thyroid cancer. Three plus years ago, I had gone through a thyroidectomy, neck dissection and 207 mCi  (millicurie) of radioactive iodine. My whole body scan of just a year ago was clean with no iodine uptake. Where were these cells hiding? How did they survive the treatment I had received?

When my physician called me with the news, I went to his office to discuss next steps.  He presented two options: (1) radioactive iodine first – it would only have a low probability of working but it would be a less invasive option. If it didn’t work, then we’d proceed to surgery; or (2) start with surgery followed by radioactive iodine treatment. He said I could think about the options, speak with the surgeon who had operated before, and then make up my mind about how to proceed.

The options sounded awful. Why would I go through radioactive iodine treatment again, if it didn’t work the first time and if it has a low chance of working the second time?  When I visited my surgeon, he recommended to proceed with surgery. The guilty lymph nodes were near the carotid and jugular vein – the thought of a slip of the knife made me wary of proceeding.

As I thought through my options, I started an online discussion on the ThyCa website (Thyroid Cancer Survivors’ Association) on a Saturday morning to find out about the experiences of others with recurrences. I was overwhelmed by how quickly people responded and the information they were willing to share. Several suggested that I look at the ATA (American Thyroid Association) guidelines.  When I reviewed them I found that the “preferred hierarchy” of treatment for metastatic disease is: surgery, radioactive iodine therapy, external beam radiation, and watchful waiting. Later on in the same section of the guideline, it states that “a small fraction of patients may benefit from radiofrequency ablation, ethanol ablation, or chemo-embolization.”

The comment on the ethanol ablation didn’t mean anything to me until Sunday night when one of the replies in my discussion group suggested that I consider ultrasound guided ethanol ablation. She said she was going to the Mayo Clinic and she provided me a link to the Mayo website.

The next day, I planned to call my endocrinologist to discuss this option but he beat me to it. He called me on Monday and strongly recommended that I go to the Mayo Clinic to see if I would be a candidate. He acknowledged that he had not included this among the initial options but he thought it would be a good alternative for me. 

It didn’t take long to get an appointment with Dr. Hay, the Mayo physician who pioneered this treatment.  The Mayo Clinic is one of the few facilities where this treatment is available. He has several publications on the treatment which he and his team have been performing for 20+ years!i  This is hardly a new development. The treatment is typically used for patients with a limited number of neck nodal metasteses.  It is far less invasive than surgery, requires minimal recovery time and is dramatically less expensive.  I considered this, by far, the best option.

My experience at the Mayo Clinic was awesome and it only lasted three days! It was everything we dream our health care system should be. The services were efficient, everything is electronic and Dr. Hay spent two hours with me during my first consultation. No one had ever spent that much time with me discussing my disease!  I received two treatments that were provided by an interventional radiologist. The procedure is very similar to an ultrasound guided biopsy. Other than a sore neck, there was no other complication and I could take a plane home the afternoon of the second treatment! I will be returning in three months for follow-up to confirm that the treatment worked – with a small chance that I may need another ablation.

In addition to information about alcohol ablation, Dr. Hay also shared his research on the need for more selective use of radioactive iodine treatment. His published research documents that there is no significant improvement in either tumor recurrence or cause-specific mortality with radioactive iodine treatment and he makes the case against its use in most patients.ii,iii  If I had gone to the Mayo Clinic for my initial treatment, it is unlikely that I would have received radioactive iodine ablation and two whole body scans – sparing me radioactivity exposure and saving my insurance company thousands of dollars.

Now that I am home and ready to return to work, I reflect on what I have learned from my medical journey. First, I should count my blessings: I have a slow-growing cancer with a very low mortality rate.  I can take the time to explore my options. I have good health insurance and I can afford the out-of-pocket costs for airfare and hotel to travel to Rochester, Minnesota. I have a loving husband who supported me and accompanied me on my medical journey. Second, alcohol ablation is an excellent example of high quality, low cost care. High quality means low morbidity, low mortality and high quality of life.  Alcohol ablation meant I missed one week of work and can return to work symptom free. Surgery would have meant a week out of work, another week with no driving and the potential need for physical therapy associated with arm and shoulder impairment. Radioactive iodine treatment would have added further time away from work and additional morbidity. Finally,  alcohol ablation, according to a 2011 article, costs $1,583 compared to $35 – 45,000 for surgery alone.iv  Which fits the definition of high quality, low cost care?  Why isn’t alcohol ablation more widely available?

  iHay ID, Charboneau JW 2011, The Coming of Age of Ultrasound-Guided Percutaneous Ethanol Ablation of Selected Neck Nodal Metastases in Well-Differentiated Thyroid Carcinoma. J Clin Endocrinol Metab 96(9): 2717-2720.
  iiHay ID, Hutchinson ME, Gonzalez-Losada T, et. Al.  2008, Papillary Thyroid Microcarcinoma: A Study of 900 Cases Observed in a 60-year Period.  Surgery December 2008: 980-988.
  iiiHay ID, McDougall IR, Sisson, J.  2008, Perspective: The Case Against Radioiodine Remnant Ablation in Patients with Well-Differentiated Thyroid Carcinoma.  The Journal of Nuclear Medicine: Vol. 49, No. 8: 1395-1397.
  ivHay ID, Charboneau JW, 2011.

Penny Mills is the EVP/CEO of the American Society of Addiction Medicine (ASAM), the leading professional society of physicians involved in addiction prevention, treatment, research, education and public policy. Penny has spent her entire career in health care including positions in consulting, administration and medical society management.Penny received a B.A. in Psychobiology from Oberlin College and an M.B.A. and Sloan Certificate in Health Services Administration from Cornell University.