Thursday, September 30, 2010

Survivors Require Quality Care Long After Active Phase of Cancer Treatment

The cancer survivor population in the U.S. is nearing 14 million and is growing at a rate of about 10% each year. Unfortunately, cancer patients who have completed treatment do not always have access to comprehensive, follow-up care. "Earlier detection and better treatment methods mean that two of every three adult cancer survivors are living five years after treatment," said Steven Castle, administrator of CJW Medical Center's Thomas Johns Cancer Hospital (TJCH) in Richmond, Va. "At TJCH, there are about 1,800 survivors finishing treatment each year."

The lack of follow-up care can result in suboptimal long-term outcomes, said Matthew P. Mumber, MD, a radiation oncologist with the Harbin Clinic in Rome, Ga. Very specific forms of followup care have a better chance of positively impacting a survivor's quality of life after treatment, Dr. Mumber added. "A successful survivorship system must connect and engage the oncologist and the patient with the primary care physician. So often, primary care physicians are left out of the loop with potentially serious consequences." Steven Castle.

Dr. Mumber cited studies showing that behavioral and lifestyle changes can have a significant impact on the progression of prostate and colon cancer. One showed that diet and lifestyle changes were directly correlated with prostate cancer patients' ability to prevent the progression of their disease (J Urol 174: 1065-1069, 2005). Another study found a significant increase in colon cancer recurrences and mortality among survivors with the highest intake of a high-fat western-patterned diet, with heavy consumption of red meat, sugary desserts, and refined grains (JAMA 298: 754-764, 2007).

Dr. Mumber advocated for "transformational" support that helps patients navigate through the physical, mental, emotional, and spiritual challenges involved in replacing old habits and patterns with newer, healthier ones. However, Dr. Mumber said that, in the current model for cancer treatment, there is little support for making the lifestyle changes that could positively impact survival. According to Mr. Castle, cancer survivors receive highest quality care during the active phase of their treatment, but can be lost in transition to the more passive follow up phase of survivorship. "Sometimes patients may feel abandoned or lost after their last radiation or chemotherapy treatment or their last appointment with the surgeon," he said.

Dr. Mumber pointed out that "patients in the acute phase of being treated for cancer are helped through the use of technology, tests, and procedures. This is a 'top down' sort of treatment, with an expert using his or her clinical judgment to make important decisions and guide the process. During the survivorship phase, a more patient-centric approach that supports survivors' efforts to make important lifestyle changes is more likely to have an impact," he said. Survivorship care can be organized into a multidisciplinary system. At TJCH, for instance, physicians have the option of either managing survivorship issues on their own or referring patients to the nurse practitioner, explained Tricia Cox, nurse practitioner with the survivorship program.

In addition, the survivorship care continuum must include the primary care physicians. "A successful survivorship system must connect and engage the oncologist and the patient with the primary care physician," Mr. Castle said. "So often, primary care physicians are left out of the loop with potentially serious consequences."  Survivors being followed at TJCH will soon receive secure access to their individual care plans over the Internet. "Having the plan online will enable two-way interaction between survivors and healthcare providers," Ms. Cox said. "Primary care physicians will also have a secure portal where they can view their patients' care plans and obtain information about post-treatment issues they may be experiencing."

The goal is to create a lifetime connection between survivors and healthcare providers. "We see the survivorship program as a means to grow loyal patient relationships," Mr. Castle said. Meeting the demands of survivors for individualized follow-up care is likely to increase their satisfaction and their well-being. Furthermore, better follow-up care and earlier intervention when health problems do arise can lower the overall long-term cost of healthcare for survivors."

Source: 2010 Varian Medical Systems Survivorship Forum. The TJCH survivorship program utilizes Varian's Equicare CS survivorship management software.

Tuesday, September 28, 2010

Less Recurrences for Thyroid Cancer Patients with Lymphocytic Infiltration

According to the results of a study reported at the 14th International Thyroid Congress, patients with thyroid cancer who show lymphocytic infiltration - a benign cluster of lymph cells - are more likely to have a favorable outcome.

The effect of coexistent lymphocyte infiltration (LI) on the prognosis of thyroid cancer remains controversial, as widespread lymphocyte infiltration is frequently seen in Hashimoto's thyroiditis, an inflammatory thyroid disease.

A retrospective study of 157 patients with thyroid cancer - which included papillary and follicular thyroid cancers - was conducted with all patients undergoing total or near-total thyroidectomy followed by radioiodine therapy.

The diagnosis of LI was made based on a review of the pathology reports on each patient. LI was classified according to diffuse, peritumoral - in or around the tumor - or absent.  A total of 93 patients had diffuse LI, 25 had peritumoral LI and 39 had no signs. The rate of tumor recurrence overall was 47 percent, which was lower in patients with peritumoral LI.

"Although the role of the inflammatory immune cells is complex and not well understood, our data indicates that peritumoral LI cells influence tumor behavior, as these tumors [have] lower aggressive characteristics and recurrences," wrote Dr Villagelin of the Pontifica Catholic University Campinas in São Paulo, Brazil.
SOURCE: endocrineweb

Sunday, September 26, 2010

Subclinical Hypothyroidism May Affect Lipid Profile

According to findings of a recent study presented at the 14th International Thyroid Congress, subclinical hypothyroidism has been shown to have an effect on patterns of lipids in the blood with resulting cardiovascular dysfunction.

"The aim of our study was to compare the lipid profile of one group of patients with subclinical hypothyroidism to assess the effect on the lipid profile and C-reactive protein (CRP) and resulting outcome on endothelium function," wrote O. Pirhaji of the Department of Internal Medicine at Isfahan University of Medical Sciences in Isfahan, Iran.

Doctor's Guide reports that the study looked at 35 patients with subclinical hypothyroid and 103 patients with euthyroid. All patients enrolled were evaluated for triglycerides, low-density lipoprotein (LDL), high-density lipoprotein (HDL), total thyroxin, thyrotropin (TSH) and CRP.

The group of patients displaying subclinical hypothyroidism were found to have significantly lower HDL and higher triglycerides in fasting plasma, and higher CRP levels. LDL levels did not differ significantly between the 2 groups.

"These findings demonstrate that subclinical hypothyroidism significantly affects the cardiovascular function and endothelium function by increasing CRP and lipid profiles and suggests that treatment of subclinical hypothyroid in selected subjects recover from these increases following treatment," the authors wrote.

SOURCE: endocrineweb

Friday, September 24, 2010

Targeted therapy decreases progression rate in thyroid cancer

ROCHESTER, Minn. -- The drug pazopanib may help revolutionize the care of patients with metastatic, rapidly progressive differentiated thyroid cancers, say researchers at Mayo Clinic who are publishing findings of a phase II clinical trial in The Lancet Oncology.

The researchers studied 37 patients with the most aggressive form of this cancer -- developing in less than 5 percent of patients with differentiated thyroid cancer -- and found that about half (18) patients had a long-lasting response to pazopanib.

Of that group, 12 are still alive without disease progression. The median progression-free survival time was 11.7 months, with an overall survival rate of 81 percent at one year.

The researchers say that, to their knowledge, these findings represent by far the highest response rate yet reported in such aggressive cases of differentiated thyroid cancer. They caution however, that this drug is not meant to be used in slow-growing differentiated thyroid cancers and that they cannot assess the survival advantage pazopanib offers to the patients studied.

Determining survival benefit would require a randomized clinical trial testing the agent, which inhibits all three vascular endothelial growth factor (VEGF) receptors, compared to other treatments or a placebo.

"In this group of patients, we would have expected the cancer to have progressed in everyone within six months, but instead the median time to progression was almost a year in response to pazopanib therapy," says Keith Bible, M.D., Ph.D., a medical oncologist and researcher who led the multicenter clinical trial, funded by the National Cancer Institute.

Most of the patients treated were enrolled at Mayo Clinic campuses in Minnesota and Florida. But as encouraging as this response is, it does not come without the potential for significant side effects, Dr. Bible says.

The drug dose used in 16 patients had to be lowered because side effects were judged by oncologists to become potentially threatening or debilitating, and two patients experienced significant bleeding. Further, although two patients died in association with pre-existing disease while enrolled in the study, the agent could have contributed in some way, he says.

"Further studies of pazopanib in advanced thyroid cancer remain ongoing at Mayo Clinic and associated cancer centers to continue to learn more about how best to use the drug in these cancers," Dr. Bible says. "Such clinical trials also may provide patients access to this drug, which otherwise may be unobtainable due to cost, given that it is not yet approved for use in thyroid cancers."

Plans are underway for a larger phase III clinical trial with aggressive differentiated thyroid cancer patients that will be centered in Europe, with some sites to be opened in the U.S. However, given potential side effects, patients with slow-growing thyroid cancer should not use pazopanib. The authors declare no conflicts of interest. The manufacturer of pazopanib (GlaxoSmithKline) did not provide funding or other material support to the researchers and did not have access to the data.

VIDEO ALERT: Additional audio and video resources, including excerpts from an interview with Dr. Keith Bible describing the research, are available on the Mayo Clinic News Blog. Password: bible.

SOURCE: Mayo Clinic

Wednesday, September 22, 2010

Some Thyroid Cancers Have Higher Incidence of Nodal Metastases

A recent study published in Archives of Otolaryngology - Head and Neck Surgery suggests that malignant central nodal metastases - cancer that spreads to lymph nodes - are more likely to occur in patients with papillary thyroid carcinoma than those with follicular variant papillary thyroid carcinoma.

According to researchers from Oregon Health and Science University in Portland, the risk for metastases is associated with the size and location of the primary tumor.

During the study, researchers set out to determine the risk for nodal metastases in 115 patients undergoing central neck dissection for papillary thyroid carcinoma or its follicular variant between 2000 and 2007.

Primary outcome measures were the number of lymph nodes detected, their location and lymph node positivity for malignant disease based on the patients' age, gender, primary tumor size, histologic type and focality.

Results showed that 87 percent of patients had papillary thyroid carcinoma and 13 percent had the follicular variant of the disease. Of the patients with the first type, 69 percent had malignant lymph nodes in the bilateral central compartment of their neck, while 75 percent had malignant lymph nodes in the ipsilateral central neck compartment.

Researchers observed no malignant lymph nodes in patients with the follicular variant of this type of cancer carcinoma.

Monday, September 20, 2010

Vandetanib may be effective treatment for medullary thyroid cancer patients

A recent phase three trial conducted by the National Cancer Institute (NCI) suggests that vandetanib, a once-daily selective oral inhibitor of vascular endothelial growth - which describes the lining of cells, extended progression-free survival (PFS) in patients with medullary thyroid cancer, Endocrine Today reports.

The research, which was presented at the International Thyroid Congress, focuses on a study which included 331 adults with medullary thyroid cancer. Researchers assigned all patients to vandetanib or placebo between December 2006 and November 2007.

Two-year follow-up results showed that 37 percent of the patients had progression and 15 percent had died. Median PFS was 19.3 months in the placebo group, and it had not yet been found in the vandetanib group.

"The primary endpoint was met - vandetanib demonstrated a statistically significant advantage in progression-free survival versus placebo," wrote Samuel A. Wells, of the medical oncology branch of the NCI.  The researchers said overall survival data were "immature" at the time of data cutoff at 24 months.

A final survival analysis will take place after 59 percent of patients have died.  The American Cancer Society estimates that 44,670 new cases of thyroid cancer will be diagnosed nationwide this year.

Thursday, September 16, 2010

VIDEO: Understanding The Scope Of Thyroid Cancer

Dr. Mark Urken talks about the increasing incidence of thyroid cancer in the United States and the importance of the accurate assessment of the nodules so that the appropriate procedure will be performed. He also covers how the scope of the procedure may change if other structures are involved and how having the skill to deal with these problems is vital to a positive outcome. 

Tuesday, September 14, 2010

Thyroid Cancer and Depression

A diagnosis of thyroid cancer can bring about fear, sadness, and even depression. Finding the support you need and getting the best possible care can help you manage cancer-related depression.

If you're diagnosed with thyroid cancer and dealing with depression along with your thyroid cancer symptoms, making depression management part of your thyroid cancer treatment plan can help improve your outlook and provide a healthier state of mind.
When a doctor tells you that you have cancer, no matter the type, treatment, or prognosis, it's understandable that you will feel sad, possibly to the point of depression. "In the majority of people that I see, [feeling somewhat sad] is a rather normal response," says Carolyn Messner, DSW, director of education and training at CancerCare in New York.
Often people are caught off-guard by a cancer diagnosis, thinking theirs was simply a benign growth. "We see a cancer diagnosis as a life crisis," says Messner.
For people who used to be very high-energy individuals, the drop in energy level from cancer treatment can cause sadness or depression over the loss of who they were. "It's always put in a context of who is this person, what were they like, and how has this treatment impacted them," says Messner. "The questions people often ask are, 'Will I be okay, will I make it, will I be able to continue the things that give meaning and joy to my life, can I keep working and taking care of my children?’"
Symptoms of Depression
There can be many signs and symptoms of depression in patients diagnosed with thyroid cancer and battling a slew of thyroid cancer symptoms. For instance, people may feel like they're not in control of the situation, says Messner, or that their lives are completely changed forever and will never be the same.
Warning signs of depression in people with thyroid cancer can include:
  • Consistently feeling sad, empty, hopeless, helpless, or worthless
  • Thinking often about death or suicide
  • Significant changes in your weight
  • Not enjoying activities or hobbies
Feelings of fatigue, wanting to sleep all the time, difficulty concentrating, and feeling sluggish are also signs of depression. But those are also common side effects of thyroid cancer treatment if it requires that you stop taking your thyroid medications and become hypothyroid.
Treating Depression
Treatment and management of depression and its symptoms should always be a part of a treatment plan for thyroid cancer, says Messner. Fatigue and other treatment side effects can cause unwanted emotional side effects like depression. "All treatment side effects need to be addressed by the treating health care team," Messner explains.
Some light exercise, playing with your children, or even just accomplishing needed tasks around the house, like dusting or running a load of laundry, can be good ways of managing cancer-related depression symptoms.
Other ideas to manage thyroid cancer-related depression include:
  • Eating a healthy diet
  • Joining a support group to gain assistance from other thyroid cancer patients and survivors
  • Talking to friends and family about what's on your mind
  • Understanding that depression is a common part of dealing with cancer, but that it can and should be treated
Don't let your fear cause you to sink into depression or for your depression to become so deep that you can't battle thyroid cancer. Recognize that it's okay to be sad, and that those feelings of sadness may lead to depression, but that your treatment team is prepared to help you overcome it.
Last Updated: 09/28/2010

Sunday, September 12, 2010

Thyroid Cancer: Early Detection

Many cases of thyroid cancer can be found early. In fact, most thyroid cancers are now found much earlier than in the past and can be treated successfully. Most early thyroid cancers are found when patients ask their doctors about lumps or nodules they have noticed. Others are found by health care professionals during a routine checkup. Although it's unusual, some thyroid cancers may not cause symptoms until after they reach an advanced stage.

If you have unusual symptoms such as a lump or swelling in your neck, you should make an appointment to see your doctor right away.

During routine physical exams, be sure your doctor does a cancer-related checkup that includes an examination of the thyroid. Some doctors recommend that people examine their own necks twice a year to look for any growths or lumps.

Early thyroid cancers are sometimes found when people have ultrasound tests for other health problems, such as narrowing of carotid arteries (which pass through the neck to supply blood to the brain) or for enlarged or overactive parathyroid glands.

Although blood tests or thyroid ultrasound often find changes in the thyroid, these tests are not recommended for early detection unless there is a reason (such as family history) to suspect a person is at increased risk for thyroid cancer.

People with a family history of medullary thyroid carcinoma (MTC) with or without type 2 multiple endocrine neoplasia (MEN 2) may be at very high risk for developing this cancer. Most doctors recommend genetic testing for these people when they are young to see if they carry the gene changes linked to MTC.

For people who may be at risk but don't get genetic testing, blood tests are available that can help find MTC at an early stage when it may still be curable. Thyroid ultrasounds may also be done in high risk people.

Friday, September 10, 2010

Thyroid Cancer Causes: What You Should Know

Although scientists have found that thyroid cancer is linked with a number of other conditions, the exact cause of most thyroid cancers is not yet known.

Researchers have made great progress in understanding how certain changes in a person's DNA can cause thyroid cells to become cancerous. DNA is the chemical in each of our cells that makes up our genes -- the instructions for how our cells function. We usually resemble our parents because they are the source of our DNA. However, DNA affects more than how we look. It also can influence our risk for developing certain diseases, including some kinds of cancer.

Some genes contain instructions for controlling when our cells grow and divide. Certain genes that speed up cell division or cause cells to live longer than they should are called oncogenes. Others that slow down cell division or cause cells to die at the appropriate time are called tumor suppressor genes. Cancers can be caused by DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes.

People inherit 2 copies of each gene -- one from each parent.

People can inherit damaged DNA from one or both parents, which accounts for inherited cancers. Most cancers, though, are not inherited. In these cases, a person's DNA is damaged by exposure to something in the environment, like smoking or radiation. Sometimes DNA mutates for no apparent reason.

Papillary Thyroid Cancer: Several DNA mutations have been found in some forms of papillary thyroid cancer. Many of these cancers have changes in specific parts of the RET gene. The altered form of this gene, known as the PTC oncogene, is found in about 10% to 30% of papillary thyroid cancers overall, and in a larger percentage of these cancers found in children and/or linked with radiation exposure. These RET mutations usually are acquired during a person's lifetime rather than being inherited. They are present only in the cancer cell and are not passed on to the patient's children.
  • Many (30% to 70%) papillary thyroid cancers contain a mutation of the BRAF gene. The BRAF mutation is less common in thyroid cancers in children and in those thought to arise from exposure to radiation. Cancers with BRAF changes tend to have more aggressive growth and a greater likelihood of spreading to other parts of the body.

  • Both BRAF and RET/PTC changes are thought to cause cells to grow and divide. It is extremely rare for papillary cancers to have changes in both the BRAF and RET/PTC genes.
  • Changes to other genes have also been tied to papillary thyroid cancer, including those in the NTRK1 gene and the MET gene.

Follicular Thyroid Cancer: Acquired changes in the RAS oncogene have a role in causing some follicular thyroid cancers.

Anaplastic Thyroid Cancer: These cancers tend to have some of the mutations described above and often have changes in the p53 tumor suppressor gene as well. This gene is the most commonly mutated gene in human cancers and is not specifically associated with anaplastic thyroid cancer.

Medullary Thyroid Cancer: People who have medullary thyroid carcinoma (MTC) have mutations in different parts of the RET gene compared with papillary carcinoma patients. Nearly all patients with the inherited form of MTC and about 1 of every 10 with the sporadic (non-inherited) form of MTC have a mutation in the RET gene.

Most patients with sporadic MTC have acquired mutations present only in their cancer cells. Those with familial MTC and MEN 2 inherit the RET mutation from a parent. These mutations are present in every cell of the patient's body and can be detected by testing the DNA of blood cells.

In people with inherited mutations of RET, one RET gene is usually normal and one is mutated. Because every person has 2 RET genes but passes only one of them to a child (the child's other RET gene comes from the other parent), the odds that a person with familial MTC will pass a mutated gene on to a child are 1 in 2 (or 50%).

Wednesday, September 8, 2010

Thyroid Cancer: Signs and Symptoms

Prompt attention to signs and symptoms is the best way to diagnose most thyroid cancers early. Thyroid cancer can cause any of the following local signs or symptoms:
  • A nodule, lump, or swelling in the neck, sometimes growing rapidly.
  • Pain in the front of the neck, sometimes going up to the ears.
  • Hoarseness or other voice changes that do not go away.
  • Trouble swallowing.
  • Breathing problems (feeling as if one were "breathing through a straw").
  • A cough that continues and is not due to a cold.

If you have any of these signs or symptoms, talk to your doctor right away. Many non-cancerous conditions (and some other cancers of the neck area) can cause some of the same symptoms.

Remember thyroid nodules are common and are usually benign. But the only way to find out for sure is to have a medical evaluation. The sooner you receive a correct diagnosis, the sooner you can start treatment and the more effective your treatment will be.

Monday, September 6, 2010

Thyroid Cancer Risk Factors

A risk factor is anything that affects a person's chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for a number of cancers.

But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may not have had any known risk factors. Even if a person with thyroid cancer has a risk factor, it is very hard to know how much that risk factor may have contributed to the cancer.

Scientists have found a few risk factors that make a person more likely to develop thyroid cancer.

Gender and age:

  • For unclear reasons thyroid cancers (like almost all diseases of the thyroid) occur about 3 times more often in women than in men.

  • Thyroid cancer can occur at any age, but risk peaks for women when they are between the ages of 45 and 49 years.

  • For men, risk peaks between the ages of 65 and 69 years.

  • A diet low in iodine

Follicular thyroid cancers are more common in areas of the world where people's diets are low in iodine. In the United States, dietary iodine is plentiful because iodine is added to table salt and other foods. A diet low in iodine may also increase the risk of papillary cancer if the person also is exposed to radioactivity.


  • Exposure  to radiation is a proven risk factor for thyroid cancer. Sources of such radiation include certain medical treatments, common dental x-rays  and radiation fallout from power plant accidents or nuclear weapons. Having had head or neck radiation treatments in childhood is a risk factor for thyroid cancer. Risk depends on how much radiation is given and the age of the child.

  • In general, the risk increases as the dose increases, also the risk is higher with lower (younger) ages at treatment. In the past, children were sometimes treated with low doses of radiation for things we wouldn't use radiation for now, like acne, fungus infections of the scalp (ringworm), an enlarged thymus gland, or to shrink tonsils or adenoids. Years later, the people who had these treatments were found to have an increased risk of thyroid cancer.

  • Radiation therapy in childhood for some cancers such as lymphoma, Wilms tumor, and neuroblastoma also increases risk. Thyroid cancers associated with prior radiation therapy are not more serious than other thyroid cancers.

Being exposed to radiation as an adult carries much less risk of thyroid cancer.

Several studies have pointed to an increased risk of thyroid cancer in children because of radioactive fallout from nuclear weapons or power plant accidents. For instance, thyroid cancer is several times more common than normal in children living near Chernobyl, the site of a 1986 nuclear plant accident that exposed millions of people to radioactivity.

Adults involved with the cleanup after the accident and those who lived near the plant have also had a higher rate of thyroid cancer. Children with more iodine in their diet appeared to have a lower risk.

Some radioactive fallout occurred over certain regions of the United States after nuclear weapons were tested in western states during the 1950s. This exposure was much, much lower than that around Chernobyl. A higher risk of thyroid cancer has not been proven at these low exposure levels. If you are concerned about possible exposure to radioactive fallout, discuss this with your doctor.

Hereditary conditions:

Several inherited conditions have been linked to different types of thyroid cancer.

Medullary thyroid cancer: About 1 out of 4 medullary thyroid carcinomas (MTCs) result from inheriting an abnormal gene. These cases are known as familial medullary thyroid carcinoma (FMTC). FMTC can occur alone, or it can be seen along with other tumors.

The combination of FMTC and tumors of other endocrine glands is called multiple endocrine neoplasia type 2 (MEN 2). There are 2 subtypes, MEN 2a and MEN 2b, both are caused by mutations (defects) in a gene called RET.

•In MEN 2a, MTC occurs along with pheochromocytomas (tumors that make adrenaline) and with parathyroid gland tumors.

•In MEN 2b, MTC is associated with pheochromocytomas and with benign growths of nerve tissue on the tongue and elsewhere called neuromas. This subtype is much less common than MEN 2a.

In these inherited forms of MTC, the cancers often develop during childhood or early adulthood and can spread early. MTC is most aggressive in the MEN 2b syndrome. If MEN 2a, MEN 2b, or isolated FMTC runs in your family, then you may be at very high risk of developing MTC.

Ask your doctor for information about having regular blood tests or ultrasound exams to look for problems and the possibility of genetic testing.

Other thyroid cancers: People with certain inherited medical conditions are at higher risk for more common forms of thyroid cancer. Higher rates of the disease occur among people with uncommon genetic conditions such as:

•Familial adenomatous polyposis (FAP):

People with this syndrome develop colon polyps and have a very high risk of colon cancer. They also have an increased risk of some other cancers, including papillary thyroid cancer. Gardner syndrome is a subtype of FAP in which patients also get certain benign tumors. Both Gardner syndrome and FAP are caused by defects in the gene APC.

Cowden disease:

People with this syndrome have increased risk of thyroid, endometrial (uterine), and breast cancers. The thyroid cancers tend to be either of the papillary or follicular type. This syndrome is caused by defects in the gene PTEN.

Carney complex, type I:

People with this syndrome may develop a number of benign tumors and hormone problems. They also have an increased risk of papillary and follicular thyroid cancers. It is caused by defects in the gene PRKAR1A.

If you suspect you may have a familial condition, discuss it with your doctor who might recommend genetic counseling if your medical history warrants it.

Papillary and follicular thyroid cancers do seem to run in some families without a known inherited syndrome; this may account for about 5% of thyroid cancers. The genetic basis for these cancers is not totally clear and may just be related to the fact that thyroid cancers are common cancers.

Last Medical Review: 05/12/2010

Last Revised: 07/20/2010

Saturday, September 4, 2010

Thyroid Cancer: Testing & Diagnosis

If you have any signs or symptoms that suggest you might have thyroid cancer, your health care professional will want to take a complete medical history. You will be asked questions about your possible risk factors, symptoms, and any other health problems or concerns.

Medical history and physical exam: If someone in your family has had thyroid cancer (especially medullary thyroid cancer) or adrenal gland tumors called pheochromocytomas, it is important to tell your doctor as this might indicate you are at high risk for this disease. A physical exam will give more information about signs of thyroid cancer and other health problems. During the exam, your doctor will pay special attention to the size and firmness of your thyroid and any enlarged lymph nodes in your neck.

 Blood Tests:
  • Thyroid stimulating hormone (TSH) :  No blood test can tell whether a thyroid nodule is cancerous. However, tests of blood levels of thyroid-stimulating hormone (TSH or thyrotropin) may be used to check the overall activity of your thyroid gland.
This information can be used to help choose imaging tests (ultrasound or nuclear scans) for the initial evaluation of a thyroid nodule. Levels of thyroid hormones (T3 and T4) may also be measured to get a sense of thyroid gland function.
  • Thyroglobulin: Thyroglobulin is a protein made by the thyroid gland. Its measurement in the blood cannot be used to diagnose thyroid cancer. But it can be helpful after treatment. 
A common way to treat thyroid cancer is to remove most of the thyroid by surgery and then use radioactive iodine (using the high doses for treatment) to destroy any remaining thyroid cells.

These treatments should lead to a very low level of thyroglobulin in the blood. If it is not low, this might mean that thyroid cancer is still present. If the level rises again after being low, it is a sign that the cancer may be coming back.
  • Calcitonin: If medullary thyroid carcinoma (MTC) is suspected or if you have a family history of the disease, blood tests for calcitonin levels can help tell whether MTC might be present. This test is also useful to look for the possible recurrence after treatment of MTC. Because calcitonin can affect blood calcium levels, these may be checked as well.
  • Carcinoembryonic antigen (CEA): People with MTC often have high blood levels of a protein called carcinoembryonic antigen (CEA). Tests for CEA can sometimes help tell if cancer is present.
  • Other tests: You may have other blood tests as well. For example, if you are scheduled for surgery, tests will be done to check your blood cell counts, to look for bleeding disorders, and to check the function of your liver and kidneys.
Diagnostic Radiology:
  • Ultrasound: Ultrasound, or sonography, uses sound waves to create images of your body. For this test, a small, microphone-like instrument called a transducer is placed on the skin in front of your thyroid gland. It gives off sound waves and picks up the echoes as they bounce off the thyroid. The echoes are converted by a computer into a black and white image that is displayed on a computer screen. You are not exposed to radiation during this test.
This test is helpful in determining if a thyroid nodule is solid or filled with fluid. It can also be used to check the number and size of thyroid nodules. Ultrasound features can sometimes suggest a nodule is likely to be a cancer, but ultrasound can't tell for sure. 

For thyroid nodules that are too small to be felt, this test can be used to guide a biopsy needle into the nodule to obtain a sample. Even when a nodule is large enough to feel, some doctors prefer to use ultrasound to guide the needle.

Ultrasound can also help determine whether any nearby lymph nodes are enlarged because the thyroid cancer has spread. Many thyroid specialists recommend ultrasound for all patients with thyroid nodules large enough to be felt.
  • Chest X-Ray: A plain x-ray of your chest may be done to see if cancer has spread to your lungs, especially if you have follicular thyroid cancer.
  • Imaging Tests: Imaging tests may be done for a number of reasons, including to find out whether a suspicious area might be cancerous, to learn how far the cancer may have spread, and to help determine if treatment has been effective.
  • Computed tomography: The computed tomography (CT or CAT) scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. Unlike a regular x-ray, a CT scan creates images of the soft tissues in the body.
You may be asked to drink a contrast solution or receive an IV (intravenous) line through which a different contrast dye is injected. This helps better outline structures in your body.

The injection may cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions like trouble breathing or low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in while the pictures are being taken.

The CT scan can help determine the location and size of thyroid cancers and whether they have spread to nearby areas, although ultrasound is usually the test of choice. A CT scan can also be used to look for spread into distant organs such as the lungs.

In some cases, a CT scan can be used to guide a biopsy needle precisely into a suspected area of cancer spread. For a CT-guided needle biopsy, you remain on the CT scanning table, while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors can see that the needle is within the mass. A biopsy sample is then removed and looked at under a microscope.

One disadvantage of CT scans for differentiated thyroid cancer is that the CT contrast dye contains iodine, which interferes with radioiodine scans. For this reason, many doctors prefer MRI scans instead of CT scans.
  • Magnetic Resonance Imaging or MRI:  Like CT scans, magnetic resonance imaging (MRI) scans can be used to look for cancer in the thyroid, or cancer that has spread to nearby or distant parts of the body. But ultrasound is usually the first choice for looking at the thyroid. MRI can provide very detailed images of soft tissues such as the thyroid gland. MRI scans are also particularly helpful in looking at the brain and spinal cord.
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material called gadolinium is often injected into a vein before the scan to better see details.

MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Second, you have to lie inside a narrow tube, which is confining and can upset people with claustrophobia (a fear of enclosed spaces).Special, "open" MRI machines can sometimes help with this if needed. The machine also makes buzzing and clicking noises that you may find disturbing. Some centers provide headphones with music to block this noise out.
  • Nuclear Medicine Scans: Nuclear medicine (radionuclide) scans involve putting substances with small amounts of radiation into the body and then detecting where the substances go with special cameras. These tests can help locate cells in the body that are not behaving normally, although they don't provide very detailed images.
Pathology Evaluation:
  • Biopsy: The actual diagnosis of thyroid cancer is made from the results of a biopsy, in which cells from the suspicious area are removed and looked at under a microscope. The simplest way to find out if a thyroid lump or nodule is cancerous is with a fine needle aspiration (FNA) of the thyroid nodule.
This type of biopsy can usually be done in your doctor's office or clinic. Your doctor will place a thin, hollow needle directly into the nodule to take out (aspirate) cells and a few drops of fluid into a syringe. The doctor usually repeats this procedure 2 or 3 times during the same appointment to take samples from several areas of the nodule. The cells can then be looked at under a microscope to see if they look cancerous or benign.

Before the biopsy, local anesthesia (numbing medicine) may be injected into the skin over the nodule, but in some cases an anesthetic may not be needed at all. A potential complication of the biopsy is prolonged bleeding, but this is rare except in people with bleeding disorders. Be sure to tell your doctor if you have a bleeding disorder.

This test is generally done on all thyroid nodules that are big enough to be felt. This means that they are larger than about 1 centimeter (about 1/2 inch) across. If a nodule is too small for the doctor to feel, sometimes FNA biopsies can be done using an ultrasound machine to help the doctor find the right place to put the needle. 

About 2 tests in every 10 may need to be repeated because the sample ends up not containing enough cells. About 7 of 10 FNA biopsies will show that the nodule is benign. Cancer is clearly diagnosed in only 1 of every 20 FNA biopsies.

Sometimes the test results come back as suspicious or atypical. This happens when the FNA findings can't show for sure if the nodule is benign or malignant. In these cases, a more involved biopsy may be needed to get a better sample, particularly if the doctor has reason to think the nodule may be cancerous.

This might include a biopsy using a larger needle or a surgical "open" biopsy or a lobectomy (removal of the gland on one side of the windpipe). Surgical biopsies are done in an operating room while you are under general anesthesia (in a deep sleep).

Nuclear Medicine: 
  • Radioiodine Scan: For this test, a small amount of radioactive iodine (called I-131) is swallowed (usually as a pill) or injected into a vein. Radioactive iodine is also used to treat differentiated thyroid cancer (papillary, follicular, and Hurthle cell), but in much higher doses. The iodine is absorbed by the thyroid gland (or thyroid cells anywhere in the body) over time, and a special camera is used several hours later to see where the radioactivity has gone.
For a thyroid scan, the camera is placed in front of your neck to measure the amount of radiation in the gland. Abnormal areas of the thyroid that contain less radioactivity than the surrounding tissue are called cold nodules, and areas that take up more radiation are called hot nodules.

Hot nodules usually are not cancerous, but cold nodules can be either benign or cancerous. Because both benign and cancerous nodules can appear cold, this test by itself can't diagnose thyroid cancer.

Radioiodine scans are often used in the care and management of patients with differentiated thyroid cancer. Because medullary thyroid cancer cells do not take up iodine, radioiodine scans are not used for this cancer.

If a biopsy has determined that a thyroid cancer is present, whole-body radioiodine scans are very useful to follow-up potential spread throughout the body from differentiated thyroid cancers. Scans after surgery can also help determine how far a thyroid cancer has spread, if at all.

If the entire thyroid gland has been removed because of cancer, radioiodine scans may be done frequently. The scan becomes more sensitive in this instance because more of the radioactive iodine is picked up by thyroid cancer cells that have spread elsewhere.

Radioiodine scans work best if patients have high blood levels of thyroid-stimulating hormone (TSH, or thyrotropin). TSH levels may be increased by stopping thyroid hormone pills for a few days to a few weeks before the test.

This lowers thyroid hormone levels and causes the pituitary gland to release more TSH, which in turn stimulates the cancer cells to take up the radioactive iodine. Although this intentional hypothyroidism is temporary, it can cause symptoms like tiredness, depression, weight gain, sleepiness, constipation, muscle aches, and reduced concentration.

An injectable form of thyrotropin is now available that can increase patients' TSH levels before radioiodine scanning, so withholding thyroid hormone for a long period of time may not be necessary.

Because iodine that is already in the body can interfere with this test, people are usually told not to ingest foods or medicines that contain iodine in the days before the scan.
  • Positron Emission Tomography: For a positron emission tomography (PET) scan, glucose (a form of sugar) that contains a radioactive atom is injected into the blood. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. A special camera can then create a picture of areas of radioactivity in the body.
This test can be very useful if your thyroid cancer is one that doesn't take up radioactive iodine. In this situation, the PET scan may be able to tell whether the cancer has spread.

PET scans do not show anatomical details as clearly as a CT or MRI, but some newer machines are able to perform both a PET and CT scan at the same time (PET/CT scan). This lets the doctor see areas that "light up" on the PET scan in more detail.
  • Octreotide Scan: Sometimes an octreotide scan, which uses a radioactively tagged hormone, may be done to look for the spread of medullary thyroid cancer. These cancers don't take up iodine, so radioiodine scans can't be used for them.
Last Revised: 07/20/2010

Friday, September 3, 2010

The Cost of Life - The Stolen Dreams Short Films Competition

As you will learn in this video out-of-pocket expenses for cancer treatment can quickly add up and affect your family budget. These costs are also the reason some people don’t follow or complete their cancer treatment plan. However, not following your treatment plan for any reason could put your health at risk and lead to even higher health care costs in the future.
For these reasons Stevie JoEllie's Cancer Care Fund is working to develop and launch an access to care grant program for thyroid cancer patients and survivors nationwide. Please consider supporting our unique initiative that includes a set aside fund for healthcare access to assist thyroid cancer survivors with medical costs associated with follow up treatment, annual exams,  diagnostics and medications. 

Stevie JoEllie's Cancer Care Fund is a project of United Charitable Programs Inc., a 501(c) 3 Public Charity.   Donations are tax deductible as allowed by law and all funds raised by Stevie JoEllie's Cancer Care Fund are received by United Charitable Programs and become the sole property of UCP, which, for internal operating purposes, allocates the funds to the Project (SJCCFThyNet). The Program (SJCCFThyNet) Manager makes recommendations for disbursements which are reviewed by UCP for approval.