Julie Ann Sosa: Personalizing Treatment of Thyroid Cancer

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome Dr. Julie Sosa today. But first we like to check in on current hot topics in health and healthcare. It’s a brand new year, Harlan. Happy New Year to you and everybody out there. What do you have for us?

Harlan Krumholz: Oh, Happy New Year, Howie. And yeah, I’m really excited to hear Julie Ann, it’ll be terrific. But first I thought I would start off just briefly to say like, hey, have you noticed a lot of people have COVID now?

Howard Forman: Oh my God, yeah. I mean, everybody I know. Everybody I know.

Harlan Krumholz: And my mother. I mean, it’s just like so many people have come down with this now. And I was looking at the CDC stats, positivity is up 12%, emergency visits up 2.5%. That’s not as bad. But hospitalizations are up 17% and deaths are up 10%. But I think it’s important for us to take a broader view of this. And I was looking back at where we stood a year ago and then two years ago, and when you look at that, you really see that, take January 2022—we’re now in January 2024 of course—we were at a much higher level than we are now. I think the one thing to appreciate is that there’s been a lot of progress. And so people are getting sick.

My only concern is what I’m hearing from people is that they’re feeling sicker than people who’ve been infected maybe over the last year. You know what I mean? It’s sort of like there was a time when it was kind of harsh and then we’ve been through a period where people have gotten sick but hasn’t been very bad at all. And I think we’re now in a period where maybe it’s somewhat intermediate. Some people are getting very sick and some are being hospitalized. I mean, we at our own place, we’ve got people in the hospital.

Howard Forman: And the vaccination rate nationally is like what, 18%? It’s a very low number.

Harlan Krumholz: That’s a problem. People got complacent, I think, feeling that this wasn’t a big deal. I say that I think that the drift in the types of SARS-CoV-2, the cause of COVID are now changing towards something a little harsher, a little more significant. We’ll have to keep an eye on it. But I’m still pretty strong telling people that they should be vaccinated.

Howard Forman: And I will say for our listeners, I did get vaccinated and I made a decision to go for Novavax. I got it about three weeks ago. Happy about that. I had no significant side effects from that. And I would urge people, if anybody’s afraid of the reactogenic from the side effects from the mRNA vaccines, Novavax is out there. It’s one more option available.

Harlan Krumholz: That’s great. So I just wanted to quickly get into some, because I know we actually want to have a longer conversation with Julie Ann, so a friend of ours, chief of surgery at UCSF, you’re going to do the whole intro, but it’ll be a great conversation. Just wanted to say, so Howie, you exercise every day, don’t you?

Howard Forman: I do, yes.

Harlan Krumholz: What if I could give you a pill that could give you the same benefit? Would you still exercise?

Howard Forman: I probably would, yeah. I don’t think I would take a pill.

Harlan Krumholz: People are talking about whether or not we can start giving pills to people that substitute for exercise. And I was reading this article in The Guardian that was saying in a hospital in northern Norway, there’s an experiment taking place. And I looked it up on clinicaltrials.gov. This trial’s called ExPlas, exercised plasma, where the clinical trial involves taking blood plasma. So that’s basically taking blood from folks and processing it and just taking the plasma part of it, that’s not the red blood cells but the plasma part, the liquid and all the stuff that’s in it from young and healthy adults who exercise on a regular basis and injecting it into people age 50 to 75 in the early stages of Alzheimer’s disease. And to test whether or not actually they can tolerate it as a start. It really is about safety and then some efficacy of this transfusion from exercise-trained donors.

And we’ve been hearing about this before. I mean, I don’t know if you ever watched that show Silicon Valley, stuff where they take these rich Silicon Valley people and they would have young, healthy folks and take some of their blood and think that they were getting better off. But this is actually a trial that’s testing this strategy. And I just wanted to share for you at the beginning of the year because I just thought it was wild.

Howard Forman: That is wild. And look, anything that can make people healthier, I’m happy to see tested. But I think the benefits of exercise go way, way beyond the actual physiologic changes.

Harlan Krumholz: Oh, we’re going to find out what it is, Howie, there’s something on the biological basis. And then you’ll be able to take a pill every day, and it’ll be just like you’ve been training.

Howard Forman: But what I’m saying is, I enjoy the time that I have to do exercise. It’s a head space thing as well as a physiologic thing for me.

Harlan Krumholz: And what if this pill could do the head space thing for you and then now you had 45—

Howard Forman: Then I would want the head space on top of the head space.

Harlan Krumholz: Anyway, it’s a brave new world, Howie.

Howard Forman: It is, it is.

Harlan Krumholz: Pretty soon we’ll be doing soma and all sorts of other stuff that Aldous Huxley was telling us about so many years ago. But we’ll see what happens with this. But I thought it was a very interesting trial. So anyway, that was my little tidbit for the day. And yeah, let’s get onto our interview.

Howard Forman: Dr. Julie Ann Sosa is the chair of the UCSF Department of Surgery where she’s also a practicing endocrine surgeon and the Leon Goldman Distinguished Professor of Surgery. Prior to joining UCSF, Dr. Sosa was chief of endocrine surgery at Duke University and prior to that was at Yale University, where we first met her when she was a practicing surgeon here. Dr. Sosa’s research focuses on treating and understanding advanced thyroid cancer, and she’s also published extensively on health system improvement. In addition to serving on the editorial boards of seven medical journals, she’s the elected editor-in-chief of the World Journal of Surgery and held previous positions as deputy editor of JAMA Surgery and associate editor of the Journal of Surgical Research.

She also serves on the boards of the Society of Surgical Oncology, International Thyroid Oncology Group, Association for Academic Surgery Foundation, and is treasurer of the American Thyroid Association. She holds a bachelor’s degree from Princeton University’s Woodrow Wilson School of Public and International Affairs and a master’s degree from Oxford University. She got her MD degree from Johns Hopkins and then completed a fellowship in clinical research through the Robert Wood Johnson Foundation as a clinical scholar.

So first I just want to welcome you to the podcast. It’s an absolute joy to have you here. And in doing the research for today’s segment, and you and I have known each other for decades at this point, but I learned so much about you, and I learned that you were not going to go be a physician when you were at Princeton. You had a very different career path in mind at that point. Do you want to just give us an idea of how that started and how you eventually did pivot to medicine?

Julie Ann Sosa: Yeah, so life is strange, and I think if a line is the shortest distance between two points, I’ve certainly never lived the life of a line. And when I graduated from Princeton, I was probably going to be a labor economist, and I took two years and wrote a book about the labor market for academic PhDs in the arts and sciences, meaning what would the labor market be for someone of my phenotype? And what I found out from my own research was I wasn’t going to have a job. I was probably going to be unemployed, maybe driving a taxi cab as a PhD in economics. And so I said to my parents, I said, “Mom, Dad, I got to do something different here.” And my dad is a physician; he’s actually a cardiologist. And he said, “Well, why don’t you be a doctor? You’ll always have a job.” And that is sort of how I wound up going into medicine.

Harlan Krumholz: We ask our student who works with us, Ines Gilles, to help prepare materials, and she did, as Howie said, put together a remarkable set of materials about you. It’s so interesting. But just to build on this, we always ask her to give us a few questions that she would like to ask. So I’m going to start the year with Ines’s question, and she says, “You’re someone who had this kind of idea that you went later.” She wants to know what is it that you’re thinking in terms of advice that you give people to stay open to different career paths. A lot of people in her position, she’s just finishing up her undergraduate career, feeling a lot of pressure to commit. And when you’re sitting down with people, you’re such an excellent mentor, how do you actually work with people so that you can understand what’s in their best interest and give them the freedom to be able to make the choices that they want to make?

Julie Ann Sosa: Based on my own life experience, I think I spent much of my life living other people’s lives. And I think many of us, maybe most of us, do that, whether it’s for our parents, whether it’s for our teachers, our counselors, as you say, for our mentors, for our chair. And the problem is life is exquisitely short and it is absolutely essential to start your path with what’s inside of you, your own truth. And I think I didn’t do that for a very long time, for very good reasons. And what wound up happening is it took me a lot longer to get where I wanted to be, where I had joy in my life. And whether it was when I went to medical school because my dad was a cardiologist, I was like, “Oh, I am going to be an internist.” And I put off doing my surgical experience until September of my fourth year, and I spent three days on the GI gold service and I was like, “This is it actually, I need to become a surgeon.”

And I was not one of those people who wanted to be a surgeon in utero. And the reason I went into surgery, for better or worse, was for me, being in the operating room was like being on a roller coaster. Now, I know some people hate roller coasters. I love roller coasters. But the feeling I had being in the operating room was unparalleled by any, in fact all, medical school experiences I had had. And so again, I had to pivot. And I think the important thing learning from this experience is having an open mind more proximally in your life. If you’re open to new experiences, to new people, I think you may be caught off guard. And if you have an open mind, you’ll be able to advantage those. And I think eventually I got to where I needed to be, but I can’t say I’m an efficient person who’s lived my life efficiently.

Harlan Krumholz: There was what I felt to be a very important piece that came out recently in September that talked about sexual harassment, sexual assault, and rape by colleagues in the surgical workforce in the UK. And I’ve been surprised that nationally this didn’t get the attention or outcry or statements or comments or initiatives that I thought it should have. In this report, which looked at people who were surveyed in the UK surgical workforce, said 63% of women reported being the target of sexual harassment versus about a quarter of men—just say it’s not zero in men. But even more importantly, or just as importantly, 30% of women had been sexually assaulted versus 7% of men in the UK surgical workforce.

I don’t know, I felt like the whole profession should have frozen stop with this and said, “This can’t happen.” And yet it’s not just that it happens—it’s common! And you as a leader, both locally and nationally, what can we do to change the culture of, it’s not just surgery, by the way. I mean surgery’s where this focus is, but I believe it’s still endemic throughout our profession and what do we do about this?

Julie Ann Sosa: Yeah, so thank you for this question. And I don’t think surgery is unique. It is something I will tell you has truth for me in terms of my own career. Nary a day goes by when I don’t feel like I am the object of, at the very least, a microaggression. I will say, sadly, as I’ve become more senior, I actually think the issues have become worse. And I’m not sure why that is. I think in part it’s because I’m a little wiser, I’m a little less naïve, and I see things for what they are rather than when I was younger and sort of dismissed it as, “What was that? I didn’t understand that.” And I think the other reason perhaps I’m more aware is that the stakes have gone up as you become more senior. And people I think start to feel perhaps more vulnerable and more competitive.

And I will say that also in my personal life, we all strive to be great mentors, but the fact of the matter is there are many more bad mentors in the world than good mentors. And among the worst forms of bad mentorship are the mentors who mentor until the mentee becomes successful, whether it’s a man or a woman, and then you become vulnerable, and then rather than supporting you push down. I would say that data from the UK, similar data exists actually in the United States. And some of the best data from the United States are data looking at trainees, where women, where members, for instance, of the LGBTQ community and other minoritized groups of our community experience more bullying, more harassment, almost certainly as a result more attrition and more feelings of suicide, suicidality. And so it’s an international problem. I think it’s bigger than surgery. I feel it personally and professionally. So what to do about it?

So I think the first thing is to talk about it. Second thing is to speak up and speak out. So when these events happen and they happen, I will tell you, daily, it is either in real time or after the event to serve as a spokesperson, as an ally to say, “What happened here? Why did that happen?” And to establish parameters that this is not part of our culture, it is not part of our values, and it will not be tolerated. I think, though, that takes a lot of courage, right? And I’ll be honest with you, I didn’t have that courage when I was younger. And I think the only reason in the world to have power is to use power to empower those who have been disempowered, correct? I mean, at least that’s what I feel. Why have it if you’re not going to use it to help others?

So I think I see my role as a chair, as a member of the house of surgery, as someone to speak about my own experiences and then to speak up and speak out locally but also nationally and internationally. And I don’t think you have to be a woman to do it. I don’t think you have to be a member of a community that has been victimized, but rather allyship is so powerful. But it takes courage and it takes skills. And I’m still trying to acquire skills each and every day. I think it’s a lifelong process. And I would implore all of our colleagues in medicine to gain the fund of knowledge, the skills, and work on the courage to create a culture that is supportive and inclusive.

Howard Forman: Doing the intro does no adequate justice to how much of an expert you are in thyroid and endocrine surgery. I know this from reading both your scholarship but also from knowing you personally and knowing what your practice is. As a radiologist, we see, increasingly, nodules on the thyroid. Part of it is because we image better than we used to, but part of it is possibly that we’re just seeing actually more, these patients are recommended for biopsies and follow-ups. It becomes very complicated. Can you give our audience a very simple view of what it means to have a thyroid workup? What do these nodules mean? Why do people worry or not worry?

Julie Ann Sosa: Yeah, so there are different estimates around what proportion of people have a thyroid nodule. And the best estimates, I think, put it at around maybe 50%, half of Americans have a thyroid nodule. Now the good news is that an exquisitely small minority of these nodules are clinically significant and represent cancers. Probably 95% to 98% of thyroid nodules are benign, not cancer. Having said that, though, thyroid cancer has increased in incidence, and I used to say there’s a pandemic of thyroid cancer because literally every developed and developing country in the world has experienced an increase in thyroid cancer. In the United States, it was like 300% over 30 years. And there were a lot of hypotheses as to what was going on. And honestly, I think it’s a mixed picture, and I think there are multiple explanations, but clearly one is the phenomenon of overdiagnosis and overdiagnosis resulting in overtreatment.

And where does it come from? Well, you fall down, you scratch your knee, you call up your primary care physician. They either send you for a blood test or for an imaging study. And what happens is we unmask these thyroid nodules, and then the quandary is, what do we do about them? And until very recently, we worked them up extensively, including with ultrasound and biopsy. And then we realized that we were spending a lot of money and exposing people to a lot of anxiety around nodules that were clinically insignificant. So what we’ve done as a profession is to establish criteria and guidelines to avoid overdiagnosis and therefore overtreatment. How have we done it? We’ve increased the size threshold for when we interrogate a thyroid nodule, such that nodules that are less than 1 to 1½ centimeters in size and that do not have worrisome radiologic appearance, we let them be. We don’t biopsy them.

Well, some people may say, “Well, aren’t you going to miss some small cancers?” And the fact of the matter is, I wouldn’t say “miss,” but yeah, we are not going to diagnose some small thyroid cancers. But where we are going as a medical and surgical community is actually towards something called active surveillance. And I’m helping to write the next iteration of the American Thyroid Association guidelines around the management of differentiated thyroid cancer. I expect active surveillance, meaning not doing upfront surgery for known or suspected tiny thyroid cancers but rather watching them carefully and if they do not grow, if they do not spread, if they do not metastasize, potentially letting them be. Now, is that the right thing for all patients? Absolutely not. And I think what it speaks to is the need for personalized treatment, meaning choosing the treatment that resonates best with patients within certain scientific parameters. But in this whole area, I’ll be honest with you, there’s a significant amount of evidential equipoise where I think patients have the opportunity to leverage their preferences, their values, their attitudes. And is thyroidology alone in this? No. For those of us who do cancer, we know similar trends are occurring in prostate cancer, breast cancer, and now in thyroid cancer.

Howard Forman: Can I pivot just a little bit? Because we are aware that women in medicine and in any profession don’t cease to be child-bearing and child-rearing, and they are primary caregivers in many cases, and it has a real impact on career development and a host of other things. You recently wrote a piece about elder care and the similar sort of gender-based disequities that occur because of that same issue, basically, that women end up playing a disproportionate role in caring for parents and other family members. Can you speak to what prompted you to write that piece and what you hope can change from writing that?

Julie Ann Sosa: Yeah, so thank you for that. And I would say I would love to be able to separate personal and professional identities and lives, but in the end, they’re integrated and the right and the left hands, they’re like this. And so I think professionally, the most impactful work I’ve done has always been motivated by my own truth and my own life experience. And whether it’s being a woman in American surgery, whether it’s been an immigrant, whether it’s being Latina, whether it’s being a member of the LBBTQ community, all of these are my identities and color how I practice surgery, for the better or the worse. And I always like to say I treat all of these identities as superpowers because they ultimately, I think, give you insight into the unique worlds of your patients as well as your colleagues.

So the last year and a half of my life, personal now and professional, have been colored by the health experiences of my aging parents. And I have an 87-year-old mother and a 93-year-old father who in 2022 saw the bottom fall out during the pandemic, which I think happened to many elderly who were isolated. And quickly, I had to figure out how to take care of them financially, how to supervise their healthcare, basically how to save their lives. And I’m a physician. I’m the chair of the department of surgery at UCSF, and I’ll tell you, I could not figure any of these things out when I started. And so I had to figure out how to bring together my personal and professional lives. And it’s proven to be at times seemingly impossible.

And as I shared my life experience with colleagues and friends, and fortunately I did that, I think many of us live in closed worlds where we feel shame or embarrassment of the personal challenges that we’re experiencing. I always say I need the strength of colleagues, I need the support of colleagues, and I certainly have needed those things over the last year and a half. But as I spoke about the challenges, what I found is that so many others are experiencing similar challenges. Now, we’ve been talking a lot—I think fortunately—over the last several years about child-bearing and child-rearing, and I think we need to spend more time talking about these things. But elder care is oft neglected. And I think it’s like the elderly in our culture are oft neglected, which is very different from many other cultures around the world. And what I realized is that in particular, women colleagues have been caught in this sandwich where they focus in the early part of their careers on taking care of their children, and then that isn’t even finished and they need to do the heaviest lifting, not the only lifting but often the heavier or heaviest lifting for their parents.

And so I wrote the piece from my heart together with Dr. Mangurian who is experiencing similar challenges. And the purpose is not to whine and complain; rather, the purpose of this piece and the purpose of my advocacy is to elicit change. And I think we need to start in academic medicine, but academic medicine is a very small fraction of all of American medicine, and we’re starting with a discussion for our faculty colleagues. But I think ultimately these conversations need to include trainees, learners, as well as our staff. And what do I think we need to do? I think it starts with talking about the challenges but then resourcing people to be more successful. And if they are more successful personally supporting elderly, aging, and sick parents, then I think they will be more successful professionally and not have to leave our profession.

And what does that mean? It means providing resources. Where do you take elderly parents for care? How do you create an estate? How do you get power of attorney? How can we support people to take time away from their work to spend with parents, either transporting them, providing the care, doing activities of daily living? So I think this is a starting point. I think I usually try to do a version 1.0 and then build up. And so my focus right now is how to do a better job in our department and in our institution. But ultimately, we’re not an island. I think these are national issues.

Howard Forman: You are an absolute force of good in the world, and we are so lucky to have you and to have worked with you and to continue to know you as a friend. So thank you so much for joining us today on the Health & Veritas podcast.

Harlan Krumholz: Terrific, terrific to see you again.

Julie Ann Sosa: Thank you so much.

Harlan Krumholz: Hey, that was a great, great interview. I’m so happy that we had her on. And she’s a great leader, but she also shows a little bit of vulnerability, willing to share of herself. It’s so wonderful to see leaders today who are able to be strong leaders but also show that strength doesn’t always mean that you can’t talk about personal issues. Also, you can do both, sort of a Bre Brown kind of approach. You can be vulnerable and you can be a great strong leader. Both things can be true. So Howie, what’s on your mind in this new year?

Howard Forman: Yeah, so we’ve talked about the Medicaid disenrollment thing several times over the last year, and our listeners should know, the current figure is that 13.4 million people have now been disenrolled from Medicaid, and we know that’s even a stale number. It’s from like December 20th, but even December 20th, it was already stale, so it’s much higher than that number, which is to say a very large number. And with the end of the pandemic public health emergency earlier last year, the states were required to clean up their Medicaid roles. And this is easier said than done. Some disenrollment is absolutely necessary. Some individuals now get new jobs, they have new health insurance, some have died, some have aged out of their enrollment, et cetera. And in short, disenrolling itself is fair and consistent with the way the statute and regulations were written.

But what’s concerning to me is that many individuals are being disenrolled due to procedural reasons. They may have moved. They may not have received a notice to renew. They may not be mentally or physically able to handle the paperwork or properly engaged with the process, et cetera, et cetera. Many procedural disenrollment may actually be individuals who remain eligible. And so that’s a problem. 71% of all disenrollments have been for procedural reasons thus far. Utah, Idaho, Georgia, New Hampshire, Oklahoma leading the way in procedural disenrollment.

Medicaid matters. If you remember in episode 101, Katherine Baicker, the provost of University of Chicago, told us about the Oregon health insurance experiment and pointed out that new Medicaid enrollees experienced lower rates of depression and better access to healthcare than matched uninsured individuals who had applied but did not get Medicaid in the state of Oregon. Does it extend life? We really don’t know, but it takes anxiety and financial insecurity away or at least reduces them. We will not know for quite some time whether this particular current process has resulted in substantial changes in the uninsured in this country. We have witnessed an absolute record low in uninsurance since the pandemic began. It accelerated, in fact during the pandemic, and that pandemic emergency ended on May 11th, 2023.

As of that date, we had a record number of Medicaid CHIP and Exchange enrollment. It’s very possible that many of these newly disenrolled folks are otherwise insured. If that’s the case, then the process is effective. But it is more than likely that many people are falling off the rolls. This is a problem. We should continue to not just watch it but think about how do we address that and why are states so variable in the way they’re dealing with this.

Harlan Krumholz: Well, Howie, I’m really glad you approached this topic. It did concern me when I saw this. The large numbers of people were falling off of insurance, and I’m a fan of people being on insurance, of course. There’s just the kind of insecurity people feel when they don’t have insurance. But I am distressed by the fact that when we get people on insurance, we’re not seeing the kind of gains in health outcomes that we might expect. And it makes me wonder whether or not insurance may be necessary but not sufficient, at least the kinds of insurance that we’re currently providing. And we need to be able to be thinking more creatively about the ways in which Medicaid itself and other types of insurance can not only help people’s mental health but also substantively improve their life expectancy and quality of life, their health outcomes.

So we need to work on both sides. I mean, obviously the minimum is that people at least need to be shielded from financial toxicity. And even though you and I both know there’s underinsurance, so even people with insurance still can experience this, but then how can we make sure that if you get access to healthcare that you’re actually getting benefits from it?

Howard Forman: That’s right.

Harlan Krumholz: These are, I think, frontiers for us maybe to talk a lot about in 2024. But there’s a lot to improve and no question about it.

Howard Forman: No, and again, for our listeners to know, most of the major health improvements that have occurred over the last 100 or so years have been public health measures and social determinants of health, not healthcare per se. But look, the big news stories are always around healthcare, always around interventions.

Harlan Krumholz: Well, and that’s where the money’s being spent, for sure.

Howard Forman: That’s right. That’s right.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, I’m going to recommend you email us at health.veritas@yale.edu, but you can also find us on Twitter or X. You can find us on LinkedIn. We’re on Threads now. Look for us, email us, text us. We’d love to hear from you.

Harlan Krumholz: I’m @ H-M-K-Y-A-L-E. That’s @HMKYale.

Howard Forman: And I’m still @theHowie. That’s at T-H-E-H-O-W-I-E. Aside from Twitter and the podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs or check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. They’re the ones who make this program as good as it is. Thank you so much. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan, and and to everybody out there, Happy and Healthy New Year, and to you and Miranda and Ines and Sophia, Happy and Healthy New Year to you also. Talk to you all soon.

Harlan Krumholz: Happy New Year. Happy New Year, everyone.