Understanding Thyroid Gland Surgery Options

There are several surgical pptions for the thyroid gland nodules, tumors and diseases. Which operation is performed on a thyroid gland depends upon two major factors:

1.    Thyroid disease present requiring surgery.

2.    Anatomy of the thyroid gland itself, tumor or nodule involved.

If a dominant solitary nodule is present in a single lobe, then removal of that lobe is the preferred operation (if an operation warranted).  

If a massive goiter is compressing the trachea and esophagus, the goal of surgery will be to remove the mass, and usually this means a sub-total or  total thyroidectomy (occasionally a lobectomy will suffice).

If a hot nodule is producing too much hormone resulting in hyperthyroidism, then removal of the lobe that harbors the hot nodule is all that is needed.

Most surgeons and endocrinologists recommend total or near total thyroidectomy in virtually all cases of thyroid carcinoma. In some patients with small papillary carcinomas, a less aggressive approach may be taken (lobectomy with removal of the isthmus).

A lymph node dissection within the anterior and lateral neck is indicated in patients with well differentiated (papillary or follicular) thyroid cancer if the lymph nodes can be palpated. This is a more extensive operation than is needed in the majority of thyroid cancer patients.

All patients with medullary carcinoma of the thyroid require total thyroidectomy and aggressive lymph node dissection.

Partial Thyroid Lobectomy: This operation is not performed very often because there are not many conditions which will allow this limited approach. Additionally, a benign lesion must be ideally located in the upper or lower portion of one lobe for this operation to be possible.

Thyroid Lobectomy: This is typically the "smallest" operation performed on the thyroid gland. It is performed for solitary dominant nodules, which may be thyroid cancer or those which are indeterminate following fine needle biopsy. This surgery may also be appropriate for follicular adenomas, solitary hot or cold nodules, or goiters which are isolated to one lobe (not common).

Thyroid Lobectomy with Isthmusectomy: This simply means removal of a thyroid lobe and the isthmus (the part that connects the 2 lobes). This removes more thyroid tissue than a simple lobectomy, and is used when a larger margin of tissue is needed to assure that the "problem" has been removed. Appropriate for those indications listed under thyroid lobectomy as well as for Hurthle cell tumors, and some very small and non-aggressive thyroid cancers.

Subtotal Thyroidectomy: Just as the name implies, this operation removes all the "problem" side of the gland as well as the isthmus and the majority of the opposite lobe. This operation is typical for small, non-aggressive thyroid cancers. Also a common operation for goiters that are causing problems in the neck or even those which extend into the chest (substernal goiters).

Total Thyroidectomy: This operation is designed to remove all of the thyroid gland. It is the operation of choice for all thyroid cancers which are not small and non-aggressive in young patients. Many surgeons prefer complete removal of thyroid tissue for all types of thyroid cancer.

Surgical Technique: The standard neck incision is made typically measuring about 4 to 5 inches in length, although many endocrine surgeons are now performing this operation through an incision as small as 3 inches in thin patients. This incision is made in the lower part of the central neck and usually heals very well. It is almost unheard of to have an infection or other problem with this wound. The surgeon will then typically remove part or all of the thyroid.

As mentioned above, for thyroid cancer, this will usually entail all of the thyroid lobe that harbors the malignancy, the isthmus, and a variable amount of the opposite lobe (ranging from 0% to 100%, depending on the size and aggressive nature of the cancer, the cancer type, and the experience of the surgeon).

The surgeon must be careful of the recurrent laryngeal nerves, which are very close to the back side of the thyroid and are responsible for movement of the vocal cords. Damage to this nerve will cause hoarseness of the voice, which is usually temporary but can be permanent. This is an uncommon complication (about 1% to 2% of patients experience this), but it is serious.

Your surgeon must also be careful to identify the parathyroid glands so their blood supply can be maintained. Another potential complication of thyroid surgery—although  rare—is hypoparathyroidism which is due to damage to all 4 parathyroid glands.  Usually the only thyroid operations that have even a slight chance of this complication is the total or subtotal thyroidectomy. 

Although the complications mentioned can be serious, their risk should not be the sole determinant of whether or not to undergo surgery. Often, formal thyroid surgery is not needed to determine if a thyroid mass is cancerous. Because these masses are often palpable, a pathologist  can usually stick a small needle into it to sample cells for malignancy. This is called fine needle aspiration (FNA) biopsy.

The relationship of the thyroid gland to the voice box and parathyroid glands in the image above can be seen quite clearly.  Remember that they share the same blood supply, so the surgeon must take care to preserve the parathyroid artery and vein while ligating the vessels to the thyroid gland itself. This is usually not a problem, but sometimes it is not possible to save them all. In this case, the surgeon will usually implant the parathyroid gland into a muscle in the neck. The parathyroid will re-grow and attach itself there and function normally.

Don't be afraid to ask questions if you don't understand something about your thyroid surgery and what your doctors expectations are for your case. Your surgeon should be able to talk you clearly about all your thyroid surgery options, including total thyroidectomy.

STUDY: c-KIT receptor expression is strictly associated with the biological behaviour of thyroid nodules

A large amount of information has been collected on the molecular tumorigenesis of thyroid cancer. A low expression of c-KIT gene has been reported during the transformation of normal thyroid epithelium to papillary carcinoma suggesting a possible role of the gene in the differentiation of thyroid tissue rather than in the proliferation.

The initial presentation of thyroid carcinoma is through a nodule and the best way nowadays to evaluate it is by fine-needle aspiration (FNA). However many thyroid FNAs are not definitively benign or malignant, yielding an indeterminate or suspicious diagnosis which ranges from 10 to 25% of FNAs.

BRAF mutational analysis is commonly used to assess the malignancy of thyroid nodules but unfortunately it still leaves indeterminate diagnoses. The development of molecular initial diagnostic tests for evaluating a thyroid nodule is needed in order to define optimal surgical approach for patients with uncertain diagnosis pre- and intra-operatively. 

Methods: In this study we extracted RNA from 82 FNA smears, 46 malignant and 36 benign at the histology, in order to evaluate by quantitative Real Time PCR the expression levels of c-KIT gene. 

Results: We have found a highly preferential decrease rather than increase in transcript of c-KIT in malignant thyroid lesions compared to the benign ones. To explore the diagnostic utility of c-KIT expression in thyroid nodules, its expression values were divided in four arbitrarily defined classes, with class I characterized by the complete silencing of the gene. Class I and IV represented the two most informative groups, with 100% of the samples found malignant or benign respectively.  The molecular analysis was proven by ROC (receiver operating characteristic) analysis to be highly specific and sensitive improving the cytological diagnostic accuracy of 15%. 

Conclusion: We propose the use of BRAF test (after uncertain cytological diagnosis) to assess the malignancy of thyroid nodules at first, then the use of the c-KIT expression to ultimately assess the diagnosis of the nodules that otherwise would remain suspicious. The c-KIT expression-based classification is highly accurate and may provide a tool to overcome the difficulties in today's preoperative diagnosis of thyroid suspicious malignancies.

Authors:  Sara TomeiChiara MazzantiIvo MarchettiLeonardo RossiKatia ZavagliaFrancesca LessiAlessandro ApolloPaolo AretiniGiancarlo Di CoscioGeneroso Bevilacqua

Credits/Source: Journal of Translational Medicine 2012, 10:7

Genzyme Update: Thyrogen Supply 2012

Genzyme is reporting in a statement today that the global supply of Thyrogen will remain limited but improve for 2012. Genzyme anticipates meeting levels that approach 60-80% of that delivered in 2010 for the upcoming year. US supplies will likely be towards the upper end of this range. 

Genzyme recommends that physicians seek to obtain Thyrogen for their patient through their usual suppliers but wait until it is secured before scheduling Thyrogen use in their patients.

PDF DOWNLOAD

Genzyme update on supply of Thyrogen® 
(thyrotropin alfa for injection)

PET Scans May Allow Early Prediction of Response to Targeted Therapy of Thyroid Cancer

Reston, Va. -- Positron emission tomography (PET) can image metabolic changes following treatment with the protein kinase inhibitor vandetanib, helping to define the therapy response or the effectiveness of the therapeutic agent, according to research published in the February issue of The Journal of Nuclear Medicine. Currently being tested in clinical trials, vandetanib inhibits the function of the RET (rearranged-during-transfection protein) proto-oncogene and other protein kinases involved in the development and progression of cancer.

"For the most part, clinical trials have been measuring the effectiveness of vandetanib by changes in tumor size. Based on the activating effects of mutated RET and other protein kinases on numerous intracellular metabolic pathways, we hypothesized that PET imaging could play a role in the early evaluation of response to vandetanib," said Martin A. Walter, MD, lead author of the study "Metabolic Imaging Allows Early Prediction of Response to Vandetanib."

The study examined the usefulness of metabolic imaging to determine response to vandetanib in three ways. First, medullary thyroid cancer cells were used to create an in vitro model. After cultivation, the cells were treated with vandetanib, and changes in the metabolic profile of the cells were successfully monitored by transcriptional profiling and by radiotracer uptake studies.

Using the same untreated cells, the researchers then created an in vivo model by injecting mice with the cancerous cells and treating them with vandetanib. Small animal PET/computed tomography (CT) imaging was performed and was found to reproduce the in vitro findings of metabolic activity after three days.

Finally, a 43-year old patient with biopsy-proven metastasized medullary thyroid cancer was treated with vandetanib. PET scans taken at 12 and 24 weeks after treatment were able to detect metabolic response to vandetanib, consistent with the in vitro and in vivo samples.

"With the increasing number of available treatment options, careful patient selection is necessary to ensure targeted therapy is administered to those most likely to gain clinical benefit," said Walter. "The identification of markers of treatment efficacy is a key factor for the success of these novel treatment approaches."

"Furthermore," he continued, "relating in-vivo PET imaging metabolic data with transcriptional profiling data using cluster analysis is an innovative concept that allows much potential in the field of molecular imaging."

SOURCE: Society of Nuclear Medicine

Understanding Cancer Care Disparities Today

While the United States offers the most advanced cancer treatment in the world, issues of race, culture, demographics, education, economic status, institutional prejudice and discrimination have lent themselves to the reality that not all Americans are offered the same resources for cancer prevention, diagnosis, treatment or follow-up. But in the past decade, cancer disparities in minority and underserved groups have become the focus of many of us in the cancer community.

Many of us acting as patient advocate pioneers in the nonprofit sector and/or medical field have implemented unique programs to improve cancer prevention through health education initiatives, access to care grants and programs, post treatment follow-up education and outreach in our communities and through social media networks. Many of us are very passionate and motivated by our own personal experiences or the experience of friends, family and loved ones.

While much attention has been focused in recent years to federal and state governments that provide nonprofits, medical clinics, hospitals and teaching institutions with annual grants and funding to create programs that assist the indigent with access to care and address the multicultural and psychosocial issues of general health education and cancer prevention the truth is these initiatives are simply not enough and have fallen short again and again from their stated goal -- they have made tremendous progress in their public relations and media image yet continue to "educate" patients "after the fact" and/or provide inadecuate services to their "target market".

In addition, research funded by the government aims to find underlying causes and solutions to overcome the barriers to equal cancer treatment (access to care) for all Americans. The statistics that prompted this funding initiative have been gathered by various entities for a number of years and will continue to be gathered, at the very least, for the next decade. The National Cancer Institute's Center to Reduce Cancer Health Disparities (crchd.nci.nih.gov), created to "reduce the unequal burden of cancer in our society" has gathered statistics showing that while all deaths from cervical cancer are preventable, 4,000 American women died of the disease as early as 2005.

What's more, researchers even know the predominant demographics of these women: African American women in the South, Hispanic women (specially along the Texas-Mexico border), Vietnamese women and Caucasian women in Appalachia and the rural Northeast. These findings should give us some pause for reflection and the clearly profound message the research has unwittingly revealed to us all. This is the United States of America yet we continue selectively ignore to openly discuss the racial divide that exists even in our most basic of human needs and rights, which is preventive healthcare.

Another study found that African American patients are less likely than whites to receive recommended chemotherapy for stage 3 colon cancer. Indeed, an African American man is more likely to die of cancer than his caucasian counterpart despite an overall decline in the rate of death from cancer. African Americans (regardless of sex) experience higher mortality with cancers of the prostrate, colon, breast, cervix and lung than a white patient with a comparable tumor and medical history !

Native Americans, which include more than 560 federally recognized tribes that speak 217 native languages, have the poorest survival rates from all cancers combined than any other ethnic groups here in the United States of America. Similarly, less educated Americans who live in rural areas are less likely to have a family doctor and follow prevention and screening recommendations for the general population.

Statistics for the Hispanic population are equally disappointing. According to data compiled by the Intercultural Cancer Council (http://www.iccnetwork.org/) cervical cancer incidence is two to three times higher in Hispanic women than in white women and only 38 percent of Hispanic women age 40 and older have regular mammograms. While Hispanics represent about 12 percent of the U.S. population, they make up 25% (percent) of the country's uninsured.

According to a report on cancer health disparities commissioned by the Department of Health and Human Services in 2005, minority and underserved populations are more likely to be diagnosed with and die from preventable cancers and be diagnosed with late stage disease for cancers that are detectable through screenings at an early stage !

In addition, these populations receive either no treatment or treatment that does not meet current standard of care practices and die of generally curable cancers because they do not have the benefit of coordinated specialty care early on in their cancer journey. What's more co-existing disorders are often untreated, they don't receive the benefit of adecuate pain management and/or palliative care.

The research in cancer healthcare disparities continues as the healthcare reform debate rages on. It may be many decades years, even decades before we fully understand and address this aspect of our national health crisis but as of today the general consensus is that there are multiple contributors to healthcare disparities ranging from language issues to biases based on cultural or racial differences, the complexity of the current healthcare system combined with the simple economics equated to the number of uninsured in America today versus the cost of effective cancer care.

No matter what you choose to believe as an individual, I, as a cancer survivor, caregiver and patient care advocate - see the issue clearly defined and ever present everydat as one of the simplest things to ignore and "dress-up" behind all the excuses, complicated research and political debate -- it boils down to the almighty dollar and something as basic as free access to community health education programs.

Treatment Options for Thyroid Cancer

Thyroid cancer is like skin cancer in terms of prognosis: most cases are mild and cured easily with surgery, while others are deadly. Approximately 85 percent of thyroid cancer patients are diagnosed with limited disease that requires only surgical removal. The remaining 15 percent have persistent, recurrent, or metastatic disease. The lungs are the most common site for metastases, followed by the bones.

Treatment options depend on the subtype. Reference 1 explains how thyroid cancer can arise by several different pathways. Thyroid tissue contains two main types of cells: follicular cells, which produce iodine-containing hormones, and C cells, which perform support services. There are several genetic mutations by which follicular cells can transform into papillary carcinoma. Different pathways lead to follicular carcinoma. Either of these cancer cell types can transform, by further genetic mutation, into anaplastic carcinoma.

The C cell, on the other hand, can transform into medullary carcinoma. Papillary and follicular carcinomas are called “well differentiated”, and have the best overall prognosis. Medullary carcinoma is less common but more difficult to treat. Anaplastic carcinoma is rare, but is one of the most deadly cancers: the median survival time is less than one year.

After surgery, radioactive iodine can be used to kill well differentiated thyroid cancer cells. Thyroxine treatment is used to suppress thyroid stimulating hormone (TSH) production. This approach does not work for medullary and anaplastic carcinomas, because these cells do not take up iodine to produce the T3 and T4 hormones.

Chemotherapy and external beam radiation therapy are used in some patients, but their success rates are low. Current research is focused on targeted therapy drugs. These drugs are intended to disrupt the function of cancer cells specifically, while leaving healthy cells alone. Several of these have been approved for other cancers and are now being tested on thyroid cancer:

1. Sorafenib (Nexavar), approved for liver and kidney cancer

2. Sunitinib (Sutent), approved for kidney cancer and gastrointestinal stromal tumor

3. Gefitinib (Iressa), approved for non-small cell lung cancer

4. Vorinostat (Zolinza), approved for cutaneous T-cell lymphoma

5. Romidepsin (Istodax), approved for cutaneous T-cell lymphoma

6. Decitabine (Dacogen), approved for myelodysplastic syndromes

Check with your doctor to see what the latest results mean for you.

References:

1. Romagnoli S et al, “Targeted molecular therapies in thyroid carcinoma”, Bras Endocrinol Metab. 2009; 53(9): 1061-73.

2. Pacini F et al, “Targeted therapy in radioiodine refractory thyroid cancer”, Q J Nucl Med Mol Imaging 2009; 53: 520-5.

3. Woyach JA et al, “New therapeutic advances in the management of progressive thyroid cancer”, Endocrine-Related Cancer 2009; 16: 715-31.

SOURCE: Linda Fugate is a scientist and writer in Austin, Texas. She has a Ph.D. in Physics and an M.S. in Macromolecular Science and Engineering. Her background includes academic and industrial research in materials science. She currently writes song lyrics and health articles.

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

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.

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.

Thyroid Cancer Treatment - The Nebraska Medical Center

Thyroid cancer is one of the most treatable and curable forms of cancer. Dr. Bill Lydiatt, a surgical oncologist and thyroid cancer survivor, explains the symptoms, treatment and why it's important to catch thyroid cancer early. The first sign of a  cancer in the thyroid gland is a painless lump in the neck.  However, each individual may experience symptoms differently. 

Other symptoms may include: 

• hoarseness or loss of voice as the cancer presses on the nerves to the voice box 
• difficulty swallowing as the cancer presses on the throat

For more information or to make an appointment, call 1-800-922-0000

or visit http://www.nebraskamed.com.

Hypothyroidism Medications

• L-thyroxine (Synthroid, Levoxyl, Levothroid, Unithroid): This medication is the mainstay of thyroid hormone replacement therapy in hypothyroidism. This is a synthetic form of thyroxine. This is exactly the same hormone that the thyroid makes. The body tissues convert it to the active product L-triiodothyronine. Side effects are rare, and it has an excellent safety record.

• L-triiodothyronine: This is rarely used alone as thyroid hormone replacement, because it has a much shorter persistence in the blood than L-thyroxine. Its use can cause rapid increases in L-triiodothyronine concentration, which can be dangerous in the elderly and in people with cardiac disease. It may be used in combination with L-thyroxine for people who have poor symptomatic relief with L-thyroxine alone.
  
  
• Thyroid extract or "natural" thyroid hormone: This is dried and powdered pig thyroid gland. The hormone is not purified and the exact amount of T4 and T3 can be variable. This is not recommended as a thyroid hormone replacement. There is an excess of T3 in this preparation.

Seeking a Second Opinion

A diagnosis of cancer can be scary and agreeing to a treatment plan confusing. It is wise to seek a second opinion or advice from another qualified cancer specialist or group of specialists before or even after you begin treatment.

"We need to let our intuition guide us, and then be willing to follow that guidance directly and fearlessly." - Shakti Gawain

Newly diagnosed cancer patients are often overwhelmed with uncertainty, disbelief, and fear and look to cancer specialists for hope and direction. Some are looking for proof of their diagnosis before beginning treatment , while others are looking for support and guidance to sort out difficult choices. Getting a second opinion involves asking another physician or group of specialists to review your medical records and confirm your doctor's diagnosis and treatment plan as well as answer questions you may have not thought of when you first heard the news of your cancer diagnosis.

Never feel foolish or uncomfortable seeking a second opinion, regardless of the existing qualifications your current doctor has. Many doctors welcome another doctor's opinion because another specialist can in fact confirm that you have cancer or agree with the recommended treatment plan your existing relationship with your doctor may very well become stronger. On the other hand a second opinion doctor may suggest changes or advise you of additional options to the existing or proposed treatment plan you otherwise never know about at the onset of your journey.

There are lots of reasons for seeking a second opinion. Some doctors are cautious in their approach to treatment, while others might suggest a more aggresive approach. You need to hear argument for ALL of your treatment options. A second opinion is a way to make sure you are getting the latest and most effective treatments treatments and that you are made aware of clinical trials that you may want to consider participation in.

Your primary care doctor or specialist may be able to offer the name of a qualified specialist if you ask or refer you to a team of cancer specialists to give you another point of view to help you decide on the best course of treatment. A second opinion is specially important if your doctors has little or no experience with your type of cancer or if he/she offers you little hope that treatment will benefit you. Look at all your options with an open mind and do your homework (or assign a trusted family member or friend who can do it for you) by following up on references and clinical outcomes reports, it could save your life or better protect your quality of life !

Remember another doctor's opinion may change the diagnosis or reveal a treatment your doctor was not aware of. One surgeon may find that your tumor is inoperable (cannot be succesfully operated on), while another may be able to remove it ! If you are asked to consider alternatives, such as surgery, radiation, chemotherapy, hormone therapy or immunosuppressant therapy you may want to hear from each type of oncologist who provides that treatment.

Second opinions are also valuable if you live in a small town or rural area where there may not be many oncology specialists. If so, you may want to get an opinion from specialists at a large academic medical center with expertise in treating your particular type of cancer. In addition another opinion is important if you have a rare cancer and you can identify a noted expert in that cancer to give you advice or consult with your doctor.

Remember: you must tell your doctor you are seeking a second opinion because he /she must make available your clinical history and latest diagnosis, all tests results (blood work and pathology reports) copies of relevant diagnostic testing originals such as radiological films (ultrasound, x-ray, cat scan or mri) and surgical reports; including your treatment plan to the doctor or doctors giving the second opinion.

Additional Sources of Information

• The R.A. Bloch Cancer Foundation, Inc., lists institutions across the United States that provide second opinions from multidisciplinary groups of cancer specialists at their website.

• The Second Opinion Source  is a San Francisco based service provided by the Regional Cancer Foundation that offers second opinions from multidisciplinary team of physicians to California adults diagnosed with new or recurring cancers.

Understanding Prognosis and Cancer Statistics

Patients and their loved ones face many uncertainties when dealing with cancer. It is natural for anyone facing cancer to be concerned about what the future holds. Understanding the nature of cancer and what to expect can help patients and their loved ones plan treatment, anticipate lifestyle changes, and make quality of life and financial decisions. Cancer patients frequently ask their physicians or search on their own for statistics to answer the question:

"What is my prognosis?"

Prognosis of cancer patients - the prediction of the future course and outcome of a cancer and an indication of the likelihood of recovery from that cancer. The doctor may speak of a favorable prognosis, if the cancer is expected to respond well to treatment, or an unfavorable prognosis, if the cancer is difficult to achieve cancer control. However, prediction is a prediction. When Oncologists discuss a cancer patient's prognosis, they are attempting to project what is likely to occur for that individual patient based on available data on record and past experience with patients in very similar circumstances.

Many factors affect a person’s prognosis. Some of the most important are the type and location of the cancer, the stage of the disease (the extent to which the cancer has metastasized, or spread if at all), and its grade (how abnormal the cancer cells look and how quickly the cancer is likely to grow and spread). In addition, for hematologic cancers (cancers of the blood or bone marrow) such as leukemias and lymphomas, the presence of chromosomal abnormalities and abnormalities in the patient’s complete blood count (CBC) can affect a person’s prognosis. Other factors that may also affect the prognosis include the person’s age, general health, and response to treatment.

You must remember and be very clear because we cannot stress this enough; when doctors discuss a person’s prognosis, they carefully consider all factors that could affect that person’s disease and treatment and then try to predict what might happen. The doctor bases the prognosis on information researchers have collected over many years about hundreds or even thousands of people with cancer but one can predict with 100% certainty what will happen in your care.

Whenever possible, the doctor uses statistics based on groups of people whose situations are most similar to that of an individual patient. Several types of statistics might be used to discuss prognosis. Some commonly used statistics are described below:

• Survival rate indicates the percentage of people with a certain type and stage of cancer who survive for a specific period of time after their diagnosis. For example, 55 out of 100 people with a certain type of cancer will live for at least 5 years, and the other 45 people will not. Survival statistics may further categorize the people who die by cause of death because some will die from unrelated causes. For example, of the 45 people mentioned above, 35 may die from their cancer and 10 may die from other causes.

• The 5-year survival rate indicates the percentage of people who are alive 5 years after their cancer diagnosis, whether they have few or no signs or symptoms of cancer, are free of disease, or are having treatment. Five-year survival rates are used as a standard way of discussing prognosis as well as a way to compare the value of one treatment with another. It does not mean that a patient can expect to live for only 5 years after treatment or that there are no cures for cancer.

• Disease-free or recurrence-free survival rates represent how long one survives free of the disease, rather than until death.

Because survival rates are based on large groups of people, they cannot be used to predict what will happen to a particular patient. No two patients are exactly alike, and treatment and responses to treatment vary greatly.

The doctor may speak of a favorable prognosis if the cancer is likely to respond well to treatment. The prognosis may be unfavorable if the cancer is likely to be difficult to control. It is important to keep in mind, however, that a prognosis is only a prediction. Again, doctors cannot be absolutely certain about the outcome for a particular patient.

Is it helpful to know the prognosis?

Cancer patients and their loved ones face many unknowns. Understanding cancer and what to expect can help patients and their loved ones plan treatment, think about lifestyle changes, and make decisions about their quality of life and finances. Many people with cancer want to know their prognosis. They find it easier to cope when they know the statistics. They may ask their doctor or search for statistics such as survival rates on their own. Other people find statistical information confusing and frightening, and they think it is too impersonal to be of use to them.

The doctor who is most familiar with a patient’s situation is in the best position to discuss the prognosis and to explain what the statistics may mean for that person. At the same time, it is important to understand that even the doctor cannot tell exactly what to expect. In fact, a person’s prognosis may change if the cancer progresses or if treatment is successful.

Seeking information about the prognosis is a personal decision. It is up to each patient to decide how much information he or she wants and how to deal with it.

Making The Right Decisions for Your Treatment

The number of treatment choices you will have depend on the type of cancer, the stage of the cancer and other individual factors such as your age, other health factors and personal needs.

THERE IS NO MORE "ONE-SIZE-FITS-ALL" CANCER CARE

Don't be afraid to ask as many questions as you need to. Make sure you understand all your options and the reasons for your personal treatment plan.

A cancer diagnosis almost always makes people feel they must get treatment as soon as possible or they will be more likely to die. You must believe and trust that you have the necessary time to consider all the options available to you so that you can make well informed decisions about your care and treatment plan.

Cancer treatment often means that you will have more than one health care provider. You may have a team of doctors and nurses, as well as other people involved in your care. Although you may get information from several sources, it is a good idea to choose one provider to be the person you turn to with your questions and concerns. This provider may or may not be the one you see most often but it must be the one you feel most comfortable talking to. Only you can decide and choose which provider will be your main source of information.

You should feel at ease with your primary care provider or team leader. Developing a good relationship with your provider is worth the effort. This means taking the time to ask your questions and making your concerns known. Likewise, your provider must take the time to answer your questions and listen to your concerns. If you and your provider feel the same way about sharing information you will probably have a good relationship.

Before starting treatment, you might want a second opinion about both your diagnosis and treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if you or your doctor request it. There are a number of ways to find a doctor for a second opinion.

(1) Your doctor may refer you or you may ask for a referral to one or more specialists.

(2) At cancer centers, several specialists often work together as a team. The team may include a surgeon, radiation oncologist, medical oncologist, speech pathologist, nutritionist, social workers and psychologists.

In some cancer centers, hospital clinics and doctors offices, you may be able to see several specialists on the same day.