| Q & A with Dr. Scott Blanke |
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| QUESTION: Does thyroid cancer affect men and women differently? |
| ANSWER: Except for the prevalence rate with 22,590 predicted cases of thyroid cancer found in women and 7,590 particular cases found in men, thyroid cancer presents in both sexes with painless neck lumps. |
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| QUESTION: Is there an age group it affects particularly? |
| ANSWER: Thyroid cancer is also often divided into before 45 and after 45 years of age for prognosis. However, I see thyroid cancer in children and incidental papillary thyroid cancer in the very elderly while doing goiter surgery. Finding very small papillary carcinomas in the middle of a large goiter is not uncommon. Neck lymphomas, not thyroid cancers in general, are often detected between the ages of 18 and 40 and all good neck exams should be mandatory in this age group. |
| QUESTION: What is a cure rate for this cancer? |
ANSWER: Thyroid cancer can be broken up into four different types. The survival rate for thyroid cancer is somewhat confusing because after 10 years of remission, other solid tumor cancers like breast and colon cancers are considered cured. Thyroid cancer still can recur even after 10 years; in fact there have been reported instances of thyroid cancers recurring as late as 50 years later.
Lifelong surveillance is mandatory. It is felt that 50 percent of tumors will recur within the first 5 years of initial therapy, but long-term surveillance is still needed. Therefore, considering the chance for long-term recurrences, the survival rate for papillary cancer is still considered to be 92 percent to 97 percent; follicular cancer 87 percent to 91 percent; nonmetastatic medullary thyroid cancer, 78 percent to 81 percent; and anaplastic cancer cure rate is considered to be 0 to 11 percent.
Although anaplastic thyroid cancer is always considered the deadliest form of cancer, it is still the rarest and it is known that 70 percent of all thyroid cancer deaths are still found to be coming from well differentiated thyroid cancers such as papillary or follicular. It is also known that the anaplastic cancer can actually arise from de-differentiated common form of papillary or follicular cell carcinoma. It can also sometimes rise from the nine goiters that are long standing. |
| QUESTION: What does surgery involve? What is the hospital stay? |
ANSWER: The surgery for thyroid cancer is done in an inpatient setting under general anesthesia. After the patient is incubated and the airway is protected, an incision or cut is made above the clavicles through a neck wrinkle down through the skin. The midline neck muscles are saved and the thyroid is exposed with the nodule/cancerous area. The very important voice box nerve, the recurrent laryngeal nerve, is carefully dissected out and meticulously preserved.
Sometimes the nerve is dissected with the help of a nerve integrity monitor or NIM. The parathyroids or the calcium glands are also attempted to be preserved with their blood supply, and then the nodule or cancer is now confirmed by the pathology department to be a true cancer or a benign nodule.
If it is a cancer then the entire thyroid or as much as possible is removed again being very careful to preserve the nerves going to the voice box and the parathyroid glands -- and the surgeon pays careful attention to whether there are any obvious lymph nodes in the area that look or feel enlarged.
If they look or feel enlarged in the initial operation then they are sampled and if they are positively confirmed to be full of cancer then a selective neck dissection is preformed at the initial operation. The way of the future is going to newer and smaller incisions. Some surgeons are trying to remove thyroid cancers with the use of endoscopes through four small stab incisions instead of the large incision above the clavicles.
Some surgeons are also trying to use harmonic scalpels or blades, an instrument that actually seals blood vessels while they are being cut decreasing the chance for bleeding. The typical operation takes between two to four hours and the need for blood transfusion is very rare. Thyroid cancer surgery involves a 1 to 3 day stay in the hospital and in some centers it is now being attempted to do the thyroidectomy surgery as a day surgery. Post-operatively the preservation of the breathing passage and the voice is monitored immediately, and the calcium metabolism is monitored over the next couple days. |
| QUESTION: What other therapies are used with surgery? |
ANSWER: The thyroid cancer surgery is a true team approach. The thyroid surgeon will often team up and help treat the patient post-operatively with the help of the metabolism doctor or the endocrinologist and occasionally with the help of the radiation therapy doctor.
The patient will often be placed on a thyroid replacement hormone which is quickly absorbed called Cytomel. Approximately 4 to 6 weeks after the initial surgery the patient will be taken off of Cytomel, and several days later will undergo a radioactive iodine body scan. If the scan seems to indicate that there is still areas of the body that are taking up the radioactive iodine indicative of some cancer still in the body, the patient will receive usually more radioactive iodine by mouth to destroy the remaining thyroid cancer.
If the amount of thyroid cancer left behind is too great for oral radioactive iodine, then occasionally the patient will have external beam radiation therapy. The medical oncologist is starting to get involved with thyroid cancer with newer and newer cancer drugs coming out that are very effective for the more aggressive and fatal thyroid cancers.
After radiation the patient will be switched over to an artificial form of thyroid replacement and they will stay on it for the rest of their lives. They will have frequent monitoring with the thyroid surgeon or the endocrinologist. A simple blood test called a thyroid-stimulating hormone will be preformed frequently and a thyroid tumor marker blood test will also be done several times a year. Regular life-long surveillance is mandatory. |
| QUESTION: Is there any medication to take after surgery? |
ANSWER: If the patient has any difficulties with their calcium metabolism after the thyroid surgery, they will often be placed on a vitamin D and calcium replacement therapy. To prepare them for the thyroid scan, they will often be placed on the Cytomel and after the scan they will be on a metabolic medication, called Synthroid or levoxyl, for the rest of their lives. |
| QUESTION: Is there any genetic link to this cancer? |
| ANSWER: Both the NIH SEER data in 2002 and American Thyroid Association Task Force reprinted in 2006 feel that thyroid cancer is on the rise. One of the reasons for the increased incidence of the thyroid cancer is feeling that there is a somewhat genetic link in at least some of the types of thyroid cancer found in certain families. |
QUESTION: What is a thyroid and what does it do?
ANSWER: The thyroid is a midline neck gland that takes chemical messages from your brain and creates chemicals that help regulate your metabolism.The thyroid is composed of three lobes, looks just like a butterfly and sits on top of your windpipe. Your important voice box nerve runs right under the thyroid, your major artery to the brain runs right next to the thyroid and your calcium glands sit on top of your thyroid.
QUESTION: How does thyroid cancer develop?
ANSWER: When one of the cell types of the thyroid turns into an aggressive cancer, it invades or goes outside the lining of the thyroid called the capsule. It can sometimes jump to lymph nodes (metastasis) and even can jump to the lung at a more advanced stage. The cell type depends on which kind of cancer is diagnosed.
QUESTION: What are the symptoms of thyroid cancer?
ANSWER: The problem with the early detection of thyroid cancer is that the symptoms are a painless neck mass in the lower one-third of your neck. Thyroid cancers rarely present with changes in your metabolism either rapid or slowed. They are rarely present with skin changes, and unfortunately they are rarely present with significant pain.
The rarest kind of thyroid cancer, anaplastic, often grows so quickly that it can present with pain at the site of the large neck mass and occasionally even presents with pain going to the patient’s ear.
QUESTION: How common is it? I heard it’s on the rise.
ANSWER: It is estimated that there will be diagnosed over 30,000 new cases of thyroid cancer this year. Thyroid cancer is considered the fastest rising incidence among cancers in the United States, with new cases increasing at a rate of approximately 4 percent per year.
According to the National Cancer Institute, thyroid cancer is the fastest-growing cause of cancer-related death among men. It is predicted that about 350,000 people in the United States are living with the diagnosis of thyroid cancer now.
Thyroid cancer occurs three times more often in women than in men, and it is in the top 10 of all cancer diagnoses for women. Some autopsy studies show that 1 out of every 10 Americans have thyroid lumps or nodules and 5 percent to 10 percent of all thyroid nodules can be cancerous.
Some predisposing factors for thyroid cancer include radiation exposure, especially childhood radiation therapy; prolonged thyroid-stimulating hormone stimulation either through radiation treatment or a heredity factor; and finally family predisposition to thyroid cancer or chronic goiters. The largest rise in thyroid cancer is believed to be the result of environmental radiation exposure such as the Chernobyl disaster. The rise in thyroid cancer in Eastern Europe is huge.
QUESTION: How is it detected early?
ANSWER: Good neck exams should be done monthly by all high-risk age groups, especially people who have been exposed to radiation therapy. Routine physicals must include neck exams and even sports physicals in the high school should include a good neck exam, looking for any thyroid lumps.
Finding a painless neck lump doesn’t always mean thyroid cancer, but ignoring a painless lump is fraught with danger and an appropriate referral to the thyroid specialist for workup is mandatory. The workup could include an ultrasound of the thyroid, blood tests and often a relatively painless needle biopsy done in the specialist’s office.
QUESTION: What can be done if it is detected early?
ANSWER: Early detection of thyroid cancer will allow a smaller neck operation than either a total or near total thyroidectomy operation. The need for a neck dissection for a lymph node metastasis is not mandatory if the thyroid cancer is detected early. Other therapies are not as necessary if thyroid cancer is detected early. Only surgery is performed if there are no lymph node metastasis.
It is also important to know if the primary cancer site has not grown outside the thyroid capsule. The use of lumpectomies or even partial thyroidectomies is still controversial, and even with early thyroid cancer detection, it is not known whether a partial thyroidectomy in a younger person is an adequate enough surgery.
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