Managing differentiated thyroid cancer
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7344.988 (Published 27 April 2002) Cite this as: BMJ 2002;324:988All rapid responses
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Management of thyroid cancer usually requires prolonged &
lifelong courses of treatment. Hence adequate compliance and proper follow
up (FU) are needed to achieve proper outcome.
Despite thyroid cancer is one of the curable cancers with an excellent
prognosis, the management statigies is not universally applied. Treating
team performance and compliance with the updated diagnostic, therapeutic
& FU guidlines is still behined expectations.
One of the sensitive problem is the patient's compliance. The most
important way of improving patient compliance is to simplify the treatment
protocol.
Several methods have been described to improve treating team &
patients compliance with updated guidlines:
(a) Education (PCC Team)
(b) FNA: all solitary, multiple or recurrent thyroid nodules should be
examined by FNA biopsy
(c) Proper Thyroid resection by an Expert Surgeon
(d) Adequate Thyroxine or RAI Therapy
(e) Thyroid Cancer Groups help in lifelong FU and
(f) Supervision & Feedback from tertiary referral centers and Thyroid
Cancer Society.
Competing interests: No competing interests
Thyroid cancer management in primary care
Editor - Thyroid cancer is rare, representing 1% of all malignancies.
Fortunately, the majority of thyroid cancers are well-differentiated
papillary/follicular cancers which grow slowly, metastasize late and
respond well to treatment. When correctly managed, prognosis is excellent.
UK guidelines 1 2 recommend thyroidectomy and radioiodine ablation as
first-line treatment for tumours larger than 1cm. High dose Thyroxine is
then advocated to completely suppress thyroid stimulating hormone (TSH) to
less than 0.1mU/L. Life-long TSH suppression is necessary as thyroid
cancer can recur decades after the initial event and annual follow up in a
specialist center is recommended. 3 The rationale for complete TSH
suppression is that differentiated thyroid cancer cells increase adenylate
cyclase activity and grow in response to TSH. 4 In a study of
differentiated thyroid cancer patients treated with thyroidectomy plus
Thyroxine, relapse-free survival was significantly longer in groups with
constant or near-maximal suppression of TSH (¡Ü0.05mU/L, ¡Ü0.1mU/L) than
in a group with non-suppressed TSH (¡Ý1 mU/L). 5
Over the past few years, we have noticed an increase in thyroid
cancer patients whose Thyroxine dose has been reduced by their GP in the
interval between outpatient visits. We performed an audit of patients
attending the thyroid clinic over a one year period. Of 303 patients being
followed up for papillary/follicular thyroid cancer in 2005, 23 (7.6%) had
had their Thyroxine dose inappropriately reduced by the GP, or the GP had
expressed a desire to reduce it, in the year preceding the clinic visit.
These 23 patients had previously been stabilised on TSH-suppressing doses
of Thyroxine. Two of the 23 patients subsequently developed grossly
elevated thyroglobulin levels, indicating disease recurrence.
The importance of shared care protocols in the management of thyroid
cancer patients and adequate information to GPs and patients regarding
Thyroxine doses and TSH suppression is emphasised by this audit.
References
1. National Institute of Clinical Excellence (NICE) guidelines.
Guidance on Cancer Services ¨C Improving Outcomes in Head and Neck
Cancers ¨C The Manual. November 2004. Accessed at: http://www.nice.org.uk
2. British Thyroid Association (BTA) Guidelines. Guidelines for the
management of differentiated thyroid cancer in adults. 2002. Accessed at:
http://www.british-thyroid-association.org/guidelines.htm
3. Mazzaferri EL and Kloos RT. Current Approaches to Primary Therapy
for Papillary and Follicular Thyroid Cancer. J Clin Endocrinol Metab
2001;86:1447-1463.
4. Mandel SJ, Brent GA and Reed Larson P. Levothyroxine Therapy in
Patients with Thyroid Disease. Ann Intern Med 1993;119:492-502
5. Pujol P, Daures JP, Nsakala N, Baldet L, Bringer J and Jaffiol C.
Degree of Thyrotropin Suppression as a Prognostic Determinant in
Differentiated Thyroid Cancer. J Clin Endocrinol Metab 1996;81:4318-4323
Competing interests:
None declared
Competing interests: No competing interests