Getting Started and Taking Charge: Coping with a Cancer Diagnosis

The most powerful tools to guide your journey through thyroid cancer is knowledge. Learning about your condition can give you confidence, comfort and help you feel more in control.

Your cancer diagnosis has no doubt brought uncertainty and questions into your life. It's easy to feel a bit out of control right now. With decisions to make about treatment  and care, figuring out where to begin and what to do next can be confusing.

It's important to remember that you are not alone. Your health care team is ready to create the best plan with you. The emotional support from your family and friends also will help you make sense of it all. By knowing your diagnosis and treatment options, finding answers to your concerns, and managing your information, you will have greater confidence, feel more empowered, and be comfortable with the choices you make.

UNDERSTANDING THE BASICS

What is Cancer?

Learning about your cancer is the first step in gaining knowledge and control over your situation. Your physician and other members of your health care team can supply you with trustworthy information and resources. Cancer is not ONE disease, but a group of diseases characterized by the abnormal growth of cells  in the body. This abnormal cell growth can result in the formation of malignant (cancerous) tumors (lumps, cysts, nodules, masses) in the body.

In some cancers, such as leukemia, the cancer cells do not form tumors. Known as hemotological malignantcies, they form instead specifically in the blood or bone marrow. Cancer TYPE refers to the organ or type of cell where the cancer started. One difference between cancerous and non-cancerous conditions is that cancer spread from where it started to different areas of the body. This process is called metastasis.

WHAT HAPPENS AFTER I HAVE BEEN DIAGNOSED?

Take time to learn as much as you can about your type of cancer. Ask a lot of questions. Your physician can help you understand your diagnosis and treatment goals. After understanding your diagnosis, the next important step is for your medical team to determine if your cancer has spread to any other parts of your body (metastasized). This will help to indicate what stage of cancer you have.

Each stage may require a different treatment approach. Some cancers, such as leukemia, may not have stages. To pinpoint the exact stage your doctor may order scans of different parts of your body, perform a clinical examination, and/or run various tests.

"TNM" IS THE MOST COMMON CANCER STAGING SYSTEM

[ T ] - Refers to the size of the tumor.

[ N ] - Indicates the number of lymph nodes involved.

[ M ] - Refers to the presence of metastasis.

TNM staging measures the extent of disease by evaluating these three aspects of the cancer. Generally, the lower the stage, the better the expected outcome or prognosis. More information is also gathered by the pathologist. 

The pathologist looks at your cancer cells under a microscope and performs laboratory tests on those cells. This doctor may be able to tell if you have a SLOWER-GROWING or a FASTER-GROWING cancer.  referred to as "the grade of cancer". Your pathologist might also look for characteristics known as "tumor markers."  All of this information is what helps your primary doctor and your oncologist work with you to select your therapy and develop a treatment plan.

STAGES OF CANCER

STAGE 0   Pre Cancer.

STAGE 1   Small Cancer found only in the organ where it started.

STAGE 2  Larger Cancer  found that may or may not have spread to the lymph nodes.

STAGE 3  Larger Cancer found that is also in the lymph nodes.

STAGE 4  Metastatic Cancer or cancer found  in a different organ from where it started.


For more information please talk to your family doctor.

Guidelines for Managing Thyroid Cancer Published

The American Thyroid Association has released new, revised Management Guidelines for the diagnosis and treatment of patients with thyroid nodules and thyroid cancer.

The new guidelines are published in Thyroid, a peer-reviewed journal published by Mary Ann Liebert, Inc. (www.liebertpub.com). Thyroid is the official journal of the American Thyroid Association (ATA).

The ATA's revised Management Guidelines and accompanying editorials are available free online at www.liebertpub.com/thy

The ATA Guidelines Taskforce updated and revised the initial management guidelines it released in 2006 because of the large number of new clinical research findings that have been published in the last three years. Thyroid nodules continue to be a common clinical problem, and the prevalence of differentiated thyroid cancer is rapidly increasing.

For managing thyroid nodules, the guidelines focus on the initial presentation, clinical and ultrasound evaluation, the decision to perform fine-needle biopsy and how to interpret the results, and the management of benign thyroid nodules.

The revised guidelines for managing thyroid cancer provide recommendations for optimal surgical management, the use of radioiodine remnant ablation, thyroid hormone suppression therapy, as well as long-term surveillance based on ultrasound, other imaging modalities, and laboratory testing.

Accompanying the Management Guidelines published in Thyroid are four editorials that include commentary on the preparation of the revised guidelines, highlights of the 2009 revisions, the transition from consensus- to evidence-based best practices, and a surgical perspective. The editorials were written by Charles H. Emerson, MD, Editor-in-Chief of Thyroid and Professor Emeritus of Medicine at the University of Massachusetts School of Medicine, in Worcester; Leonard Wartofsky, MD, from Washington Hospital Center (District of Columbia); jointly by Efisio Puxeddu, MD, PhD, from University of Perugia, and Sebastiano Filetti, MD, from University of Rome, Italy; and jointly by Dana Hartl, MD, PhD, and Jean-Paul Travagli, MD, from Institut Gustave Roussy, Villejuif, France.

"The Taskforce worked very hard to draft guidelines that were clinically relevant and evidence-based. We hope that they will provide a framework for the care of patients with nodular thyroid disease and thyroid cancer that will be accepted throughout the world," said David S. Cooper, MD, ATA Guidelines Taskforce Chair and Professor of Medicine at Johns Hopkins University (Baltimore, MD).

"The newly revised ATA Task Force Guidelines are a worthy successor to the original guidelines published in 2006. They will be carefully scrutinized by clinical investigators and used on a daily basis by physicians as they evaluate thyroid nodules and manage thyroid cancer," said Charles H. Emerson, MD.

"Guidelines should be designed to guide, and this revision signals the maturation of internationally well received advice on the management of patients with potentially serious disease. Nobody should underestimate the danger of badly managed thyroid cancer and this American Thyroid Association Task Force has produced a first class guide for practitioners," said Terry Davies, MD, President of the American Thyroid Association and Florence and Theodore Baumritter Professor of Medicine, Mount Sinai School of Medicine (New York, NY).

SOURCE:  Mary Ann Liebert, Inc./Genetic Engineering News

Medications for Hyperthyroidism

• Beta-blockers: This class of medication works by blocking many of the body's responses to hyperthyroidism. It decreases tremor, nervousness, and agitation. It also reduces the fast heart rate. Beta blocker tablets are prescribed to a patient with mild to moderate symptoms of hyperthyroidism, and as an IV preparation to the person with the severe form of hyperthyroidism (thyrotoxic crisis).

• Propylthiouracil: This antithyroid drug works by blocking thyroid hormone synthesis. It takes several months after starting the medication for the full therapeutic effect to be achieved. Common mild side effects include an itchy rash. More rare, serious side effects include a decrease in white blood cell count, which can decrease the ability to fight off infection. Therefore, a high fever should prompt a call to the doctor. This medication can rarely cause liver dysfunction.

• Methimazole (Tapazole): This antithyroid drug also works by blocking thyroid hormone synthesis. It may take slightly longer than propylthiouracil to achieve its full effect. It has similar side effects as propylthiouracil.

• Iodide (Lugol's solution, Strong iodine):This medication works by inhibiting the release of thyroid hormone from the overfunctioning thyroid gland. It must be used in conjunction with an antithyroid drug because the iodine can be used to increase the amount of thyroid hormone produced and worsen the hyperthyroidism. Common side effects include nausea and a metallic taste in the mouth. 
  
  
• Radioactive iodine therapy: An endocrinologist or nuclear medicine specialist can treat overactive thyroid conditions with radioactive iodine swallow. This is generally a different type of radioactive iodine than used for diagnostic scans. This treatment takes several months to work by scarring down the thyroid gland, resulting in a smaller- sized gland, often accompanied by hypothyroidism.

Hyperthyroidism Causes

• Grave's disease: This thyroid condition results from abnormal stimulation of the thyroid gland by a material in the blood termed the thyroid stimulating immunoglobulin (TSI). TSI overstimulates the thyroid causing a goiter. It also causes Grave's eye disease, including a "bug-eyed" look and "frightened stare." This can progress to severe eye pain or eye muscle weakness causing tearing and double vision. It also causes raised, thickened skin over the shins or tops of the feet. 
  
  
• Toxic multinodular goiter: This occurs when part of the thyroid gland produces thyroid hormones all by itself, without regard to TSH stimulation. It usually occurs in people with a long-standing goiter, usually in the elderly. Toxic multinodular goiter is different from Grave's disease because of the general lack of eye complications and less severe signs of hyperthyroidism. 
  
  
• Thyroiditis: This inflammatory disorder of the thyroid gland includes such conditions as de Quervain's thyroiditis or Hashimoto's thyroiditis. In these conditions, you may have periods of increased thyroid hormone release due to the inflammation, causing a hyperthyroid state. As thyroid failure occurs due to the inflammatory response, hypothyroidism may occur. 
  
  
• Pituitary adenoma: This tumor of the pituitary gland causes independent TSH production leading to overstimulation of the thyroid gland. 
  
  
• Drug-induced hyperthyroidism: This is most commonly caused the heart medication amiodarone (Cordarone). It may be prevented by monitoring this possible side effect and weighing them against the benefits of using this heart medication.

Hyperthyroidism (Overactive Thyroid) Signs and Symptoms

Symptoms of hyperthyroidism in children include:

• Symptoms similar to adult symptoms
  
• Declining school performance
  
• Behavior problems

Symptoms of hyperthyroidism in adults include:

• Insomnia
  
• Hand tremors
  
• Nervousness
  
• Feeling excessively hot in normal or cold temperatures
  
• Frequent bowel movements
  
• Losing weight despite normal or increased appetite
  
• Excessive sweating
  
• Menstrual period becomes scant, or ceases altogether
  
• Joint pains
  
• Difficulty concentrating
  
• Eyes seem to be enlarging

Symptoms of hyperthyroidism in the elderly may cause:

• Worsening of angina (chest pain) in persons with heart disease
  
• Worsening of shortness of breath in persons with heart failure
  
• Muscle weakness, especially in the shoulders and thighs

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.

Hypothyroidism Causes

• Loss of thyroid tissue: Treatment of hyperthyroidism by radioactive destruction of thyroid tissue or surgical removal of thyroid tissue can result in hypothyroidism.
  
• Antithyroid antibodies: These may be present in people who have diabetes, lupus, rheumatoid arthritis, chronic hepatitis, or Sjogren's syndrome. These antibodies may cause decreased production of thyroid hormones.
  
• Congenital: Hypothyroidism can be present from birth. This is commonly discovered early with nationwide newborn screening for this disease.
  
• Defects in the production of thyroid hormone: Hashimoto's thyroiditis occurs when there are defects in the production of thyroid hormone, resulting in an increased amount of TSH. The increased TSH results in a goiter (enlargement of the thyroid gland itself that can be seen as an obvious swelling in the front of the neck).
  
• Medications: Some medications, particularly lithium (Eskalith, Lithobid), may cause a drug-induced hypothyroidism.

Hypothyroidism (Low Thyroid Hormone Level) Signs and Symptoms

Symptoms of hypothyroidism in infants can include:

• Constipation
  
• Poor feeding
  
• Poor growth
  
• Jaundice (yellow discoloration of the skin and eyes)
  
• Excessive tiredness

Symptoms of hypothyroidism in children include:

• Symptoms similar to adult symptoms
  
• Excessive fatigue
  
• Poor growth
  
• Poor school performance

Symptoms of hypothyroidism in adults include:

Early symptoms

• Easy fatigue, exhaustion
  
• Poor tolerance to cold temperatures
  
• Constipation
  
• Carpal tunnel syndrome (pain at the wrists and numbness of the hands)

Advanced  symptoms

• Poor appetite
  
• Weight gain
  
• Dry skin
  
• Hair loss
  
• Intellectual ability worsens
  
• Deeper, hoarse voice
  
• Puffiness around the eyes
  
• Depression
  
• Irregular menstrual periods or lack of menstrual periods

What is the thyroid gland? Signs and Symptoms of Disease

The thyroid gland is a small, butterfly-shaped gland located in the base of the neck just below the Adam's apple. 

Although relatively small, the thyroid gland influences the function of many of the body’s most important organs, including the heart, brain, liver, kidneys and skin. Ensuring that the thyroid gland is healthy and functioning properly is important to the body's overall well- being.

Common Signs and Symptoms of Thyroid Disease

Hyperthyroidism:  When hyperthyroidism develops, a goiter (enlargement of the thyroid) is usually present and may be associated with some or many of the following features:

• Fast heart rate, often more than 100 beats per minute
• Becoming anxious, irritable, argumentative
• Trembling hands
• Weight loss, despite eating the same amount or even more than usual
• Intolerance of warm temperatures and increased likelihood to perspire
• Loss of scalp hair
• Tendency of fingernails to separate from the nail bed
• Muscle weakness, especially of the upper arms and thighs
• Loose and frequent bowel movements
• Smooth skin
• Change in menstrual pattern
• Increased likelihood for miscarriage
• Prominent "stare" of the eyes
• Protrusion of the eyes, with or without double vision (in patients with Graves’ disease)
• Irregular heart rhythm, especially in patients older than 60 years of age
• Accelerated loss of calcium from bones, which increases the risk of osteoporosis and fractures

Hypothyroidism:  In its earliest stage, hypothyroidism may cause few symptoms, since the body has the ability to partially compensate for a failing thyroid gland by increasing the stimulation to it, much like pressing down on the accelerator when climbing a hill to keep the car going the same speed. As thyroid hormone production decreases and the body’s metabolism slows, a variety of features may result.

• Pervasive fatigue
• Drowsiness
• Forgetfulness
• Difficulty with learning
• Dry, brittle hair and nails
• Dry, itchy skin
• Puffy face
• Constipation
• Sore muscles
• Weight gain and fluid retention
• Heavy and/or irregular menstrual flow
• Increased frequency of miscarriages
• Increased sensitivity to many medications

Hashimoto’s Thyroiditis:  Hashimoto’s thyroiditis may not cause symptoms for many years and remain undiagnosed until an enlarged thyroid gland or abnormal blood tests are discovered as part of a routine examination. When symptoms do develop, they are either related to local pressure effects in the neck caused by the goiter itself, or to the low levels of thyroid hormone.

The first sign of this disease may be painless swelling in the lower front of the neck. This enlargement may eventually become easily visible. It may be associated with an uncomfortable pressure sensation in the lower neck. This pressure on surrounding structures may cause additional symptoms, including difficulty swallowing.

Although many of the features associated with thyroid hormone deficiency occur commonly in patients without thyroid disease, patients with Hashimoto’s thyroiditis who develop hypothyroidism are more likely to experience the following:

• Fatigue
• Drowsiness
• Forgetfulness
• Difficulty with learning
• Dry, brittle hair and nails
• Dry, itchy skin
• Puffy face
• Constipation
• Sore muscles
• Weight gain
• Heavy menstrual flow
• Increased frequency of miscarriages
• Increased sensitivity to many medications

The thyroid enlargement and/or hypothyroidism caused by Hashimoto’s thyroiditis progresses in many patients, causing a slow worsening of symptoms. Therefore, patients with either of these findings should be recognized and adequately treated with thyroid hormone. Optimal treatment with thyroid hormone will eliminate any symptoms due to thyroid hormone deficiency, usually prevent further thyroid enlargement, and may sometimes cause shrinkage of an enlarged thyroid gland.

Thyroid Nodule:  Most patients with thyroid nodules have no symptoms whatsoever. Many are found by chance to have a lump in the thyroid gland on a routine physical exam or an imaging study of the neck done for unrelated reasons (CT or MRI scan of spine or chest, carotid ultrasound, etc.).

In addition, a substantial number are first noticed by patients or those they know who see a lump in the front portion of the neck, which may or may not cause symptoms, such as a vague pressure sensation or discomfort when swallowing. Obviously, finding a lump in the neck should be brought to the attention of your physician, even in the absence of symptoms.

Family History:  A familiar place to look for thyroid disorder signs and symptoms is your family tree. If you have a first degree relative (a parent, sibling, or child) with thyroid disease, you would benefit from thyroid evaluation. Women are more prominent thyroid patients than men; however, the gene pool runs through both. According to a national survey by the American Association of Clinical Endocrinologists (AACE), more than three-fourths (76%) of the population do not know that thyroid disease runs in families.

Other Reasons to Consider a Thyroid Evaluation

• Prescription Medications: If you are taking Lithium, Amiodarone, Antithyroid drugs (either PTU or Tapazole), or Levothyroxine, you should consider a thyroid evaluation.

• Radiation Therapy to the Head or Neck: If you have had any of the following radiation therapies, you should consider a thyroid evaluation: radiation therapy for tonsils, radiation therapy for an enlarged thymus, or radiation therapy for acne.

• Chernobyl: If you have leaved near Chernobyl at the time (1986) of the nuclear accident, you should consider a thyroid evaluation.