Treating thyroid cancer

Friday 1 January, 2016

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On this page: Surgery | Thyroid hormone replacement therapy | Radioactive iodine treatment | External radiotherapy | Targeted therapies | Chemotherapy | Palliative treatment | Follow-up after treatment | Jen's story | Key points


The type of treatment your doctor recommends will depend on the type and stage of thyroid cancer you have.

Surgery

Surgery is the most common treatment for thyroid cancer. There are two main types of thyroid surgery. In some cases, lymph nodes may also need to be removed.

Total thyroidectomy

The whole thyroid gland (both lobes), including the isthmus, is removed. You will be given a general anaesthetic and a small cut will be made across your neck.

Partial or hemi-thyroidectomy

Only the affected lobe or section of the thyroid is removed. Sometimes this surgery is also used to diagnose thyroid cancer if a fine needle aspiration biopsy doesn’t provide enough tissue, or to treat small cancers if the other side of the thyroid looks normal on the ultrasound.

Lymph node removal

With either type of operation, nearby lymph nodes may be removed at the same time as the surgery. This is called a neck dissection. It is performed if the lymph nodes become enlarged from the cancer spreading. Occasionally, the nodes behind the thyroid are removed as a precautionary measure, even if the cancer doesn’t appear to have spread.

Other tissue

In very rare cases, the surgeon removes other tissue (for example, the thymus gland and vascular tissues) near the thyroid that has been affected by the cancer.

Before the operation

A member of the surgical team and, in some hospitals, a specialist nurse will talk to you about the operation. This is your opportunity to ask questions and discuss any concerns you have.

After the operation

You will probably stay in hospital for one or two nights to recover from surgery. Your neck wound will be closed with stitches, adhesive strips or small clips. Your nursing team will talk to you about caring for your surgical wound site. Your surgeon may order blood tests during this period to check on your recovery. See tips on managing side effects.

Further treatment after surgery

For some people, surgery is the only treatment they need. Others may require further treatment. This may include:

Managing the side effects of thyroid surgery
Sore neck

You will probably feel some pain or discomfort where the cut was made.

The position you are placed in for surgery can sometimes give you a stiff neck and back. This is temporary, and neck massage and physiotherapy may help loosen the muscles in your neck. You can also try using a triangle-shaped pillow to support your neck after surgery and/or ask for pain-relieving medicine.

Painful swallowing

You will find it painful to swallow for a few days. In some cases, you may be referred to a speech pathologist and/or dietitian.

Eating and drinking

Most people are able to eat or drink normally within a few hours after the operation. To help your body recover from surgery, you need to be well nourished. Try to swallow gently, and eat small amounts of healthy, nutritious food.

For more information see Nutrition and Cancer or call Cancer Council 13 11 20.

Hoarse voice

Sometimes thyroid surgery affects the nerves to the voice box, which can make your voice sound hoarse or weak. This is often temporary and improves with time. Your singing voice may be affected. This is often temporary, but sometimes it is permanent.

Scarring

You will have a horizontal scar on your neck above your collarbone. In most cases, the scar is about 5–7cm long and is often in a natural skin crease. At first, this scar will look red, but it should fade and become less noticeable with time. Your doctor may recommend using special tape on the scar to help it heal.

Keep the area moisturised to help the scar fade more quickly over time – ask your pharmacist or doctor to recommend a suitable cream.

Mood changes

Changes in hormone levels may affect your mood. If you feel anxious or have panic attacks, let your doctor or nurse know as they may recommend medicines to help.

Low calcium levels

If surgery affected the parathyroid glands, you will have low blood calcium levels (hypocalcaemia). This may cause headaches and tingling in your hands, feet and lips.

Your doctor will do blood tests to check your calcium levels, and you may be prescribed vitamin D and/or calcium supplements until your parathyroid glands recover. If the parathyroid glands don’t recover, calcium supplements need to be taken permanently.

Feeling tired

Most people return to their usual activities within days of the surgery, but some people need more time to recover.

Thyroid hormone replacement therapy

After the whole thyroid is removed, your body will no longer produce the hormones that maintain your metabolism, and you will be prescribed a hormone tablet to replace thyroxine (T4). You will need to take this hormone replacement tablet every day for the rest of your life.

For many people who have a partial thyroidectomy, the remaining lobe will continue to make enough thyroid hormone, which means they won’t need daily tablets.

Taking thyroid hormone tablets can have two roles:

Keeping your body’s metabolism functioning at a normal healthy rate

Without hormone replacement medication, you will probably develop the symptoms of hypothyroidism, such as weight gain, constipation, brittle and dry hair and skin, depression, sluggishness and fatigue. In severe cases, heart problems could occur.

Reducing the risk of the cancer coming back

Taking the T4 hormone in tablet form stops your pituitary glands from producing another hormone called thyroid-stimulating hormone (TSH). It is thought that high levels of TSH may cause cancer cells to grow in other parts of the body. For this reason, if the doctor thinks the cancer has a medium to high risk of recurring, they will recommend you take a high dose of T4 to reduce the level of TSH. This is known as TSH suppression.

Finding the right dose

You’ll be carefully monitored when you start taking thyroid hormone replacement therapy. The starting dose of thyroxine (T4) is calculated based on your weight. You will have blood tests every 6–8 weeks to help your doctor adjust the dosage until it is right for you. Usually, the initial dose is close to the correct dose and requires only small adjustments.

A small number of people may experience hypothyroidism or hyperthyroidism during the adjustment period. However, once you are taking the right dose, you should not experience side effects.

Tips for taking T4 medicines
  • Store medicines in the fridge to maintain the T4 level in the tablets. If you are travelling, the medicine will last up to 30 days without refrigeration.
  • Take your T4 medicine at the same time every day to get into a routine. Take it on an empty stomach with water only and wait 30 minutes before eating.
  • If you miss a dose, take the missed dose as soon as you remember.
  • Wait 2 hours before taking calcium or iron supplements as these affect the stomach’s ability to absorb the T4.
  • Check with your doctor if it’s safe to continue taking other medicines or supplements.
  • Don’t stop taking the T4 medicine without discussing it with your doctor.
  • Tell your doctor if you are pregnant as you may need to take a higher dose.

Radioactive iodine treatment

Radioactive iodine (RAI) is a type of radioisotope treatment. Radioisotopes are radioactive substances given as capsules. Cancer cells absorb more radioisotope than normal cells, which causes the cancer cells to die. Radioactive iodine is also known as I131 or radioactive iodine ablation treatment. RAI is usually given to destroy tiny amounts of remaining cancer cells or healthy thyroid tissue left behind after surgery.

Radioactive iodine treatment is suitable for people diagnosed with papillary or follicular thyroid cancer. RAI doesn’t work for medullary or anaplastic thyroid cancer because these types do not take up iodine. The radioactive iodine treatment often starts 4–5 weeks or more after surgery.

If you are pregnant, you can’t have radioactive iodine treatment. If you are breastfeeding, you will have to stop nursing before starting treatment. Ask your doctor for more information.

Preparing for radioactive iodine treatment
Limiting foods high in iodine

A diet high in iodine makes RAI treatment less effective. You will need to start avoiding high-iodine foods two weeks before treatment. This includes foods such as seafood, iodised table salt, some dairy products, eggs, soy beans or soy-containing products and foods with E127 colouring. Your health care team can give you more information.

Raising TSH levels

For RAI treatment to work, you need a high level of TSH. There are two ways to increase the TSH level in your body, and the option recommended for you will depend on availability at your hospital and what is suitable for you.

  • Recombinant human thyroid-stimulating hormone (rhTSH) injections
    You will be prescribed an injection of a man-made type of thyroid-stimulating hormone called recombinant human thyroid-stimulating hormone (rhTSH) or Thyrogen®. You will need an injection once a day for the two days before you start RAI treatment.
  • Thyroid hormone replacement
    You stop taking your thyroid hormone replacement medicine for a few weeks. This often causes the side effects of hypothyroidism, and some people find it difficult to cope with this, while others don’t notice any side effects. For more details about stopping thyroid hormone replacement, see follow-up and talk to your endocrinologist.
Having radioactive iodine treatment

You will usually be admitted to hospital on the day of the radioactive iodine treatment. RAI treatment will make you radioactive for a few days, and you may have to stay in hospital for all or part of this time. See below for an outline of the safety measures that will be in place while you are having treatment.

Once the radiation has dropped to a safe level, you will be able to go home. If you are taking Thyrogen®, this is usually within 36–48 hours.

After radioactive iodine treatment

You will have a full body radioisotope scan. There is often a small amount of normal thyroid in your neck after surgery, which will be destroyed by the RAI. The scan can also help detect if any cancer cells are left in the body. It may also show if the cancer has spread to your lymph nodes or other areas of your body, such as your lungs or bones.

Safety measures in hospital

Your medical team, family members and friends will have to take precautions to limit their exposure to radiation.

The safety measures vary for each hospital, and the staff looking after you will discuss the specific details with you before treatment starts. Safety measures usually include:

  • keeping you in an isolated, shielded room
  • restricting visitors to the room – particularly children and pregnant women
  • asking visitors to stay 2–3 metres away from you
  • limiting the time visitors can stay in the room
  • measuring your radiation levels with an instrument called a Geiger counter – this is usually done daily
  • wearing gloves to clean up body fluids (e.g. urine, sweat, saliva and blood) and leftover food and drink.

Following these safety measures may make you feel frightened and lonely. It’s a good idea to take a book or something to do. Discuss any concerns you have with your doctors, nurses or a counsellor.

Safety measures at home

When you go home, you may have to continue following some safety measures. For example, you may have to sleep alone, wash your clothing separately, prepare your own food and take care with body fluids for a certain period of time. It’s usually required that you sit to urinate, and you put the lid down and flush the toilet several times after use.

If these precautions are necessary, your medical team will discuss them with you before treatment.

Side effects

Usually, being temporarily radioactive is the only major side effect of RAI treatment. Other side effects are often caused by thyroid hormone withdrawal. This may make you feel thirsty, tired, nauseated or breathless. You may also have a dry mouth, or have taste and smell changes for about 24 hours after treatment.

Managing side effects of RAI
  • Drink lots of water to help the RAI treatment pass out of your body faster. This also reduces the bladder’s exposure to radiation.
  • Ask for medicine if the side effects continue.
  • If you or your partner want to have a baby after RAI treatment, talk to your doctor. You may have to use barrier contraception such as condoms for six months or more.

External radiotherapy

External radiotherapy is the use of high-energy x-rays or electron beams to kill or damage cancer cells.

Most people diagnosed with thyroid cancer do not need radiotherapy treatment. In a small number of cases, it may be give in the following circumstances:

  • after surgery
  • in addition to radioactive iodine treatment if the cancer has not been completely removed
  • if there is a high risk of the cancer coming back (recurrence)
  • if the cancer has spread to nearby tissue or structures.

External radiotherapy is commonly used to treat anaplastic thyroid cancer because radioactive iodine treatment is usually not effective.

Planning treatment

Before the treatment starts, you will have a planning (simulation) session. The radiation therapist will take CT scans to determine the exact area to be treated, and may make small marks or tattoos on your skin. This ensures the same part of your body is targeted during each treatment session.

You may be fitted for a mask to wear during treatment. This will help make sure that you keep still and the radiation beams treat the same area of your neck at each session. You can see and breathe through the mask, but you may feel strange and uncomfortable at first. The radiotherapy team can help you manage this.

Having treatment

Radiotherapy is usually given five days a week over several weeks. Treatment sessions usually take about 10 minutes, but it will take longer to position the machine correctly.

Side effects

The side effects of external radiotherapy treatment vary. Most are temporary and disappear within a few weeks or months after treatment. Common side effects include feeling tired, pain and difficulty swallowing, sore throat, dry mouth, and red, dry, itchy, sore or ulcerated skin.

For ways to reduce or manage any side effects you experience, talk to your doctor and nurses, see Understanding Radiotherapy or call Cancer Council 13 11 20.

Targeted therapies

Some newer types of drug treatments, called targeted therapies, attack specific cancer cells or blood vessels to stop or slow down growth or reduce the size of the tumour. Targeted therapies may be recommended for people with advanced thyroid cancer or as part of a clinical trial.

The most common type of targeted therapies used are tyrosine kinase inhibitors (TKIs). These block the signals that tell cancer cells to grow and divide, and are used to treat certain types of thyroid cancer. Some research shows that tyrosine kinase inhibitors help by targeting new blood vessels or certain mutations.

The drug sorafenib is used for papillary thyroid cancers. Vandetanib and cabozantinib are used to treat some medullary thyroid cancers. However, they aren’t available in all cases and may be expensive because they aren’t on the Pharmaceutical Benefits Scheme. Talk to your medical team for more information.

Chemotherapy

Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. While it is not often used to treat thyroid cancer, chemotherapy may sometimes be used to treat advanced thyroid cancer that is not responding to radioactive iodine treatment.

The drugs are usually given intravenously (injection into a vein). You will probably have several treatment sessions over a few weeks – your medical team will determine the schedule.

Side effects

The aim of chemotherapy is to kill cancer cells while doing the least possible damage to healthy cells. However, treatment can affect your healthy cells, and this may cause side effects.

The side effects of chemotherapy vary according to the drugs that are used. Common side effects include fatigue, nausea, appetite loss, diarrhoea, hair loss, hearing loss, mouth sores and anaemia.

Most side effects are temporary and there are ways to prevent or reduce them. Your doctor will talk to you about how to manage any side effects you experience. You could be prescribed medicines to treat the side effects, or a different type of treatment, or your doctor may recommend a break from treatment.

For more information see Understanding Chemotherapy or call Cancer Council 13 11 20.

Palliative treatment

Palliative treatment helps improve people’s quality of life by alleviating symptoms of cancer, when it’s not possible to cure the disease. It is particularly important for people with advanced cancer, however, it can be used at any stage of cancer.

Often palliative treatment is concerned with pain relief and symptom control, but it can also involve the management of other physical and emotional problems. Treatment may include targeted radiotherapy, chemotherapy or other medicine.

For more information see Understanding Palliative Care or Living with Advanced Cancer or call Cancer Council 13 11 20.

Most people with thyroid cancer do not need to access palliative care services because five-year survival rates are high.

Follow-up after treatment

After your treatment, you will need regular check-ups. You may have the following tests:

Neck ultrasound

An ultrasound is used to see if there is any cancer left in the area where the thyroid was removed and to check the lymph nodes around the neck.

Blood tests

If you have been treated for papillary or follicular thyroid cancer, you will have blood tests to check the levels of thyroglobulin (Tg). This protein is made by normal thyroid tissue and it may also be made by papillary or follicular thyroid cancer cells. After a total thyroidectomy you should have little or no Tg in your body, but levels will rise if the cancer comes back. If Tg is found in your blood, your doctor may suggest having some scans.

For medullary thyroid cancer, blood levels of calcitonin and carcinoembryonic antigen (CEA), which is a protein produced by some cancer cells, will be measured periodically. Blood tests are also done regularly to check if you are on the right dose of thyroid hormone replacement. When it’s stable, thyroid function blood tests are needed only every 6–12 months.

Radioisotope scan

This test is used to check if there are any cancer cells remaining in your body after treatment. A small amount of radioactive liquid (such as iodine or technetium) is injected into a vein in your arm. After about 20 minutes, you will be asked to lie under a machine called a gamma camera.

The camera measures the amount of radioactive liquid taken up by the thyroid gland. A radioisotope scan is painless and causes few side effects. After the scan, you will not be radioactive and it is safe to be with others.

If further information is needed, or if cancer cells are found elsewhere in your body, you may have a CT or PET scan.

Before follow-up tests

Usually Tg is measured when you are still on thyroid hormone replacement medication. Sometimes the doctor may want to measure stimulated Tg as the test can be more accurate when TSH is elevated.

To raise TSH to measure stimulated Tg you will need to either withdraw from thyroid hormone replacement medication or have injections of the drug recombinant human thyroid-stimulating hormone (rhTSH) or Thyrogen®.

Once your Tg is elevated, it will be measured. See below for more details.

Newer Tg tests are more sensitive, and in some cases it may not be necessary to withdraw from thyroid hormone.

"I had rhTSH injections for a recent follow-up. I didn’t experience any side effects, and I was able to continue taking my daily T4 hormone replacement." – Claire
Ways to increase accuracy of follow-up tests

Your doctor will give you instructions about what to do before your blood test or radioisotope scan.

Option 1: Stop taking T4 hormone for 2–6 weeks before appointment
  • You will be told to stop taking the T4 hormone replacements about 2–6 weeks before your follow-up appointment.
  • Without hormone replacements, your thyroid hormone levels will decrease and you may experience symptoms of hypothyroidism.
  • This can be improved by taking T3 for 10–14 days before the scan.
Option 2: Take rhTSH (Thyrogen®) to reduce side effects of stopping T4
  • rhTSH is a man-made drug that is a copy of the TSH produced by your body, and it ensures there is enough TSH in your body for accurate test results.
  • It is given as two injections, 24 hours apart.
  • You will have the radioactive iodine scan and/or blood test about 48–72 hours after your second rhTSH injection.
  • You don’t have to stop taking your thyroid hormone medication.
  • rhTSH has few side effects, but some people experience temporary headaches, nausea or weakness. Talk to your doctor for more information.

Jen’s story

"I was diagnosed with a papillary thyroid cancer 10 years ago when I was 31.

"I’d had laryngitis on and off for a while, but as I’m a receptionist I put it down to talking too much. As my husband and I were going overseas for a month, I had it checked out so I could get any prescriptions I needed here. The doctor felt a lump in my neck and sent me for an ultrasound.

"I could tell by the technician’s face that something was wrong. He called a doctor, who immediately did a fine needle biopsy. The next day, I was told I had cancer – all from a little lump I couldn’t even feel or see.

"My doctor referred me to a specialist who said that as it’s a fairly slow-growing cancer, to have my holiday and he’d operate when I returned. A couple of weeks after coming back, I had a total thyroidectomy. I had no real side effects other than a scar, which has faded. I recovered quickly and was back at work after a couple of weeks.

"Two months after the surgery, I started radioactive iodine. I was put on thyroxine to get my hormones stable and then did the radioactive iodine. I was in hospital for two nights while I was radioactive, and then for two weeks I had to follow all the precautionary safety measures, such as sleeping separately from my partner.

"I now have thyroxine once a day in the morning. I was really tired until the dose was right.

"Some people say that thyroid cancer is a good cancer to get. I know that their hearts are in the right place, and yes, it is a ‘good’ cancer because the remission rate is pretty high, but it’s still cancer. The diagnosis has reminded me to appreciate the small things in life."

Key points

  • Surgery is the most common and effective treatment for thyroid cancer.
  • There are different types of surgery for thyroid cancer. The operation you have depends on where the cancer is in the thyroid, the type and size of the cancer and whether it has spread to nearby lymph nodes.
  • You may have a total thyroidectomy (whole thyroid gland removed) or partial or hemi-thyroidectomy (part of the thyroid only). The nearby lymph nodes may also be removed (neck dissection).
  • After a total thyroidectomy, you may need to take thyroid hormone replacement medicine for the rest of your life.
  • Your doctor may recommend radioactive iodine (RAI) treatment after surgery to kill remaining thyroid tissue or cancer cells.
  • RAI treatment is taken as a capsule. You will need to stay in hospital for 2–3 days in an isolated room to safely contain the radioactivity.
  • You may prepare for RAI treatment by taking a hormone known as rhTSH or Thyrogen®. If this is unavailable, you may need to stop taking thyroid hormone replacement medicine for a few weeks before having RAI treatment.
  • External radiotherapy may be given to some people who have cancer in several lymph nodes in the neck, for locally advanced or thyroid cancer that can’t be removed by surgery, or to target cancer that has spread to the bones.
  • Targeted therapies (tyrosine kinase inhibitors) or chemotherapy may be used if the cancer no longer responds to RAI.

Reviewed by: A/Prof Julie Miller, Specialist Endocrine Surgeon, The Royal Melbourne Hospital, Epworth Freemasons and Melbourne Private Hospitals, VIC; Polly Baldwin, Cancer Council Nurse, 13 11 20, Cancer Council SA; Dr Gabrielle Cehic, Nuclear Medicine Physician, Flinders Medical Centre, Lyell McEwin Hospital and The Queen Elizabeth Hospital, SA; Dr Kiernan Hughes, Endocrinologist, San Clinic Specialist Rooms & Chatswood Rooms, Northern Endocrine Pty Ltd, NSW; Dr Chris Pyke, A/Prof of Surgery, University of Queensland, Mater Hospital, Brisbane, QLD; and Jen Young, Consumer.

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