Thyroid Cancer
In This Chapter
- Avoiding panic
- Having your thyroid cells examined
- Risks and rewards of surgery
- Understanding your cancer’s characteristics
- Obliterating cancer with precision radiation
- Surviving and thriving
One of the scariest words anyone can hear is cancer. It’s a disease that, like a malicious invader, launches an assault in one area of your body and then keeps expanding its territory, killing everything in its path.
When it comes to thyroid cancer, the good news is that it’s rarely fatal. There are around 37,000 cases of thyroid cancer diagnosed in the United States each year, and around 1,600 deaths resulting from it; so the odds for survival are over 95 percent. That’s because the most common forms of thyroid cancer grow slowly, and so can usually be stopped via surgical removal of one or both of your thyroid’s lobes before the cancer spreads to other parts of your body. If only one of your lobes needs to be removed, the other will probably be able to take on the work of producing your thyroid hormones by itself. Alternatively, if the entire thyroid has to be removed, your doctors can usually exploit the unique characteristics of thyroid cells to target any remnants of the cancer post-surgery and destroy them.
One of the most challenging aspects of thyroid cancer is dealing with the fear and stress it brings. This chapter will help you understand the process for evaluation and treatment, empowering you to ask the right questions and make the best decisions … and giving you the peace of mind of knowing that the odds are enormously in your favor.
Throat Quote
Cancer is a word, not a sentence.
—John Diamond
Noticing Nodules
There’s a saying among doctors: “If it hurts, it’s probably not cancer.” You can have thyroid cancer and not know it for years, because you’re unlikely to feel it or have it substantially affect your thyroid’s ability to function. In fact, it’s not unusual for someone to die of unrelated causes and be discovered to have thyroid cancer only upon postmortem examination.
The primary sign of thyroid cancer is one or more masses, called nodules, growing on the thyroid. They’re typically noticed when one of them grows big enough to be seen or felt through the throat. A nodule might also call attention to itself by growing large enough to give you trouble swallowing, or by pressing on your vocal nerves to make your voice hoarse.
By age 50, roughly 50 percent of us have one or more thyroid nodules; and over 95 percent of the time, these nodules are harmless. But when a nodule grows large enough to be noticed, it’s important to have a doctor check it out for safety’s sake. This is because while thyroid cancer cells typically duplicate themselves slowly, each duplication doubles the size of the mass. It can take decades for a few pioneering cancer cells to duplicate enough times to become a significant nodule; but at that point, even though the rate of duplication remains the same, the doubling effect means the cancer cells have to be dealt with because they might soon spread beyond your thyroid.
So even though the odds are against a nodule being cancerous, the possibility shouldn’t be ignored. That’s especially the case if you’re a woman, as you’re three times as likely to develop thyroid cancer as a man, and if you’re age 30 or over, as both the risk of having thyroid cancer and its severity increase as you get older.
There’s nothing you can do on your own to evaluate a nodule, so you need to see a doctor. You can start with your general practitioner, or go straight to a specialist—which in this case is an ear, nose, and throat (ENT) surgeon.
Either way, your doctor will typically perform a manual exam, take some blood to send to a lab for thyroid testing, and then prescribe an ultrasound test. You shouldn’t hesitate to agree to the latter, as it’s relatively quick and inexpensive—and it doesn’t involve radiation, so it’s entirely safe.
Checking the thyroid via ultrasound.
(Licensed from Shutterstock Images)
An ultrasound lets your doctor see what’s going on inside your throat by bouncing high-frequency sound waves off your thyroid (similar to how bats and submarines use sound to navigate). A technician will lubricate your throat with jelly to make the sound waves transmit more effectively, and then move a handheld component of the machine over your throat to take pictures of your thyroid, including its nodules.
A specialist will then examine the images, looking for such details as whether a nodule is entirely filled with fluid (in which case it might be a mere cyst), or if it’s one of a number of nodules the same size (which could mean you have a benign multi-nodule goiter), or whether it’s solid and attached to an unusually large number of veins (which is cause for suspicion as cancer is greedy for blood, making new blood vessels form just to feed itself).
Alternatively, if your doctor suspects you’re hyperthyroid, he may prescribe an iodine uptake and thyroid scan, which involves taking a tiny amount of radioactive iodine. The radiation will “light up” whatever absorbs it, and the only things in your body that absorb iodine are thyroid cells. If a nodule is causing your hyperthyroidism, it’ll show up as “hot,” meaning it absorbed the iodine and is probably responsible for your having too many thyroid hormones. If a nodule is “cold,” however—meaning it’s not absorbing the iodine and making no hormones—that’s cause for suspicion, as some types of cancer cells don’t use iodine and produce nothing except more cancer cells. About 10 percent of “cold” nodules turn out to be cancerous.
If your ultrasound or uptake scan provides enough information to consider your nodule(s) benign, then you can stop exploring the possibility of cancer for now. However, you should see your doctor at least once a year so she can monitor your thyroid and note whether there’s any further growth.
On the other hand, if the testing leaves room for suspicion, this is the time to start looking for an ENT surgeon who has long experience and a great reputation for diagnosing and, if necessary, dealing with thyroid cancer.
Getting a Biopsy
The next step in checking your nodule(s) is a fine needle aspiration biopsy. This involves your ENT doctor taking a very thin—and relatively painless—needle attached to a syringe and sticking it into your throat, aiming for every major nodule on your thyroid (usually based on his feeling its location, or sometimes with the aid of an ultrasound machine).
For each insertion, you’ll be asked to hold your breath so your doctor can gently rock the needle back and forth to gather as much tissue as possible. Your doctor will then retract the syringe to capture small bits of tissue from the nodule. He’ll repeat this procedure 2-6 times for each large nodule. This is a quick procedure that’s usually performed in your doctor’s office, and when done properly isn’t much more of a bother than getting an injection.
The samples from your biopsy will be sent to a cytopathologist, who’s an expert at evaluating minute clues about cells. The cytopathologist will carefully examine your samples under a microscope, and will then reach one of four conclusions:
- You don’t have thyroid cancer and your nodule’s cells show no signs of cancer. This happens about 70 percent of the time.
- You do have thyroid cancer and your doctor’s needle captured cells that are clearly cancerous. This happens about 5-10 percent of the time.
- Not enough thyroid tissue was gathered to make an analysis. This happens about 10 percent of the time.
- No cells were found that are definitively cancerous, but there are cells with suspicious characteristics. This happens about 10-15 percent of the time.
The first three situations are relatively straightforward. If the cytopathologist finds no significant signs of cancer, the chances are over 95 percent that you’re fine. Simply be sure to visit your general practitioner every six months to check on whether there’s been any nodule growth.
Alternatively, if the cytopathologist determines you have cancer, the chances she’s right are also over 95 percent (and if she’s highly experienced, closer to 100 percent). This isn’t a cause for panic, as most thyroid cancer is as treatable as cancer gets; but it does mean you’ll need surgery. (More on this shortly.)
If not enough useable tissue was gathered, then the biopsy has to be repeated. This isn’t unheard of. However, you might want to have a discussion with your ENT about what went wrong; and at the same time casually ask how many thyroid biopsies he’s performed. If your doctor hasn’t already handled hundreds of thyroid cancer cases, consider finding one who has.
The most complicated situation is when the cytopathologist has enough tissue to work with, but still can’t make a definitive judgment. This can happen for a number of reasons. For example, you might have thyroid cancer, but your doctor didn’t happen to capture cancer cells during any of his needle insertions (a nodule can contain both cancerous and benign cells). However, he captured nearby cells that hint at the presence of cancer. Or your sample might consist of follicular cells. Follicular cancer comprises around 12 percent of all thyroid cancers, but a biopsy is incapable of providing enough information to distinguish between cancerous and noncancerous follicular cells.
When faced with this gray area, the only way to find out for certain whether a nodule is cancerous is to surgically remove it and place it under a microscope. However, the surgery carries significant risks (described below). And in over 75 percent of these cases, the nodule turns out to be benign.
At the same time, there’s also a risk in letting a nodule that might be cancerous con-tinue to grow … and potentially spread beyond your thyroid. This is a situation in which you want a deeply experienced ENT doctor to advise you. You should ask for a copy of the cytopathologist’s report and have your doctor explain the details behind the finding of “indeterminate.”
Thyroidian Tip
Another pre-surgery test worth asking about is a coarse needle biopsy, which allows for the removal of a greater amount of thyroid tissue than fine needle aspiration for nodules three quarters of an inch or larger. Not all doctors are qualified to perform this procedure; but when used as a follow-up for certain types of indeterminate results, coarse needle biopsies have been found to significantly reduce unnecessary thyroid surgeries.
You might also want to get a second opinion. Surgery on your throat isn’t something to take lightly, and neither is cancer; so don’t hesitate to gather more information before making a decision.
Selecting Surgery
If your biopsy showed you have thyroid cancer, or if the results were sufficiently suspicious to justify pursuing a definitive answer, your next step is to have surgery.
If you choose this route, you’ll first be placed under anesthesia. Your ENT surgeon will then open your neck and very carefully work on your thyroid. This is a delicate procedure because there are some critical body parts nearby. Specifically, the nerves for your vocal chords are right next to your thyroid. If these nerves are pulled too hard or otherwise injured, it will impair your ability to speak. The results can be a hoarse or whispery voice, with reduced power and/or range. In most cases the condition is temporary, but there are rare instances when the damage is permanent. This is a major reason to choose an ENT who has performed many previous thyroid surgeries.
Also at risk are your parathyroids, which are small glands residing behind your thyroid that regulate the amount of calcium in your blood and bones (see Chapter 15). The precise location, number, and size of these glands varies from person to person, increasing the odds of accidentally damaging one or more of them. Thyroid surgeons focus heavily on protecting the parathyroids, so the likelihood of permanent harm is small, but temporary injury is a real possibility, happening to around 8 percent of patients. (A telltale sign is tingling or numbness in your fingers, toes, or lips within the first few days following surgery.) Even if you feel no symptoms, you’ll be told to take calcium supplements for a month following the surgery to lighten the strain on your parathyroids in case they need time to recover.
During surgery, your doctor first explores your thyroid to spot all nodules and anything else suspicious. If this inspection makes it apparent that you have cancer on both lobes, then he’ll remove the entire thyroid.
Otherwise, first the lobe with the largest (or only) nodule is removed. If you’re in a top facility with both a cytopathologist and cytology lab available for the operation—which is ideal—the lobe’s cells are examined while you’re still under anesthesia, providing your surgeon with definitive information about whether there’s cancer present and, if so, what type of cancer. Your surgeon can then decide whether to remove the rest of your thyroid or to allow the second lobe to remain. In the latter case you’ll probably still have a fully functioning thyroid (with the remaining lobe simply doing twice the amount of the work as before).
If your hospital doesn’t have the resources to check your thyroid’s cells during the operation, though, then your doctor may remove one lobe, end the operation, and wait until a cytopathologist examines the lobe to decide if you need a second operation to take out the rest of your thyroid.
Alternatively, if the results of your biopsy strongly indicate cancer, you and your doctor may decide pre-surgery that he’ll remove the entire thyroid. This spares you from undergoing a second operation and provides peace of mind that the cancer won’t spread—but at the cost of a functioning thyroid that might never become cancerous. The pros and cons of this decision vary depending on such factors as the type of cancer involved (some are more aggressive than others) and your age (thyroid cancer becomes more dangerous as you get older).
Types of Thyroid Cancer
After you’ve had surgery, sections of your removed nodule(s) will be studied by a cytopathologist to determine precisely what sort of thyroid cancer caused them. This is important information because it’ll help determine what additional steps need to be taken.
The primary possibilities are no cancer, papillary, follicular, and medullary. (There are other types, but they collectively account for less than 5 percent of thyroid cancer cases.)
No Cancer
After removing half your thyroid, your doctor may find the nodule(s) growing on it to be benign. As mentioned previously, this happens over 75 percent of the time. You may feel bad about losing a healthy thyroid lobe, as well as risking your vocal chords and parathyroids; but you may also feel glad about having the peace of mind of knowing you’re cancer-free.
Either way, you still have half of a functioning thyroid, and there’s a good chance it’ll make all the thyroid hormone you need. For safety’s sake, however, keep a lookout for hypothyroid symptoms (see Chapter 6). Also take care to get your thyroid hormone levels tested after six months, and then annually, in case you eventually become hypothyroid as a result of your remaining lobe doing twice as much work as it was designed for.
Papillary Cancer
Papillary is by far the most common form of thyroid cancer, accounting for about 80 percent of cases. It typically stems from exposure to radiation. It’s slow growing, taking 10-20 years to develop to the point where it’s noticeable.
It’s also well differentiated, meaning it closely resembles normal thyroid cells. For example, papillary cancer absorbs iodine like a normal thyroid cell—which means it’s ideally suited for destruction by radioactive iodine (see the next section, “Getting Radioactive”).
Papillary cancer tends to stay in the neck—for instance, invading the lymph nodes. However, around 5-10 percent of patients eventually develop papillary cancer in other areas of their body, particularly the lungs and bones. So even though it’s slow growing, this cancer has to be taken seriously and destroyed before it spreads.
Follicular Cancer
Follicular is the second most common form of thyroid cancer, accounting for around 12 percent of cases. Its causes are believed to include radiation, genetics, and low iodine consumption.
Like papillary, follicular cancer is well differentiated, absorbing iodine like normal thyroid cells—which means it’s also ideally suited for destruction by radioactive iodine.
Follicular cancer doesn’t tend to spread in the neck, but around 20 percent of patients eventually develop it in the lungs and bones.
Medullary Cancer
Medullary is the third most common form of thyroid cancer, accounting for around 5 percent of cases. Its causes are unknown beyond genetics; about 25 percent of people struck by it have a family history of the disease.
Medullary cancer is not well differentiated, so it doesn’t absorb iodine like a normal thyroid cell and won’t be affected by radioactive iodine. It’s also not affected by chemotherapy.
Medullary cancer is substantially more aggressive than papillary and follicular, invading lymph nodes over 50 percent of the time.
The best method for eliminating medullary cancer is surgery—removing the entire thyroid, possibly the lymph nodes, and anywhere else it appears to have invaded. Follow-up visits to check for any recurrence is mandatory. If the cancer comes back, the best option is usually more surgery. However, sometimes radiation can also be effective.
Getting Radioactive
One of the advantages of getting your entire thyroid removed is it makes you a candidate for radioactive iodine treatment. This is a clever way to destroy papillary and follicular cancer (making up about 92 percent of thyroid cancer cases) by taking advantage of one of the unique properties of the thyroid.
Specifically, the thyroid is the only gland in your body that absorbs iodine. And although your thyroid was removed, many of its cells are still in your throat … including cancerous ones. To deal with this, after surgery you won’t be allowed thyroid medication for 4-6 weeks. This will put you into a severe hypothyroid state—and make your thyroid cells starved for iodine.
You’ll then be given a single dose of radioactive iodine (usually via a small pill encased in an impressively large and heavy lead container). Although the pill looks ordinary, it’s so radioactive that you’ll be told to avoid living things—people and pets—for 48 hours after taking it. You’ll also be told to suck on sour candies, which will prevent the radiation from doing damage to your salivary glands. (Don’t spit on anything, though, as your saliva—and, for that matter, your clothes—will be radioactive for the next 30 days.)
The iodine from the pill will be ignored by the rest of your body and travel straight to your throat, where it’ll be eagerly absorbed by whatever thyroid cells remain. If you have papillary or follicular cancer, its cells absorb the iodine … and the radiation will obliterate them. (It’ll also kill whatever benign thyroid cells remain; but since your thyroid is now gone, that doesn’t matter.)
Thyroidian Tip
Thyroid cancer cells will typically be confined to your throat. If they’ve spread to other parts of your body, though, they’ll attract and absorb their share of the radioactive iodine and it’ll annihilate them as well.
If all goes well, this treatment will make you cancer-free, eliminating the possibility of stray thyroid cancer cells eventually spreading to other parts of your body. The only downside is the same as that carried by any radiation treatment—long-term, it poses the risk of initiating cancer itself. But in this case, the positive outcome of annihilating cancer that exists here and now more than makes up for the remote possibility of developing cancer years later from the radiation.
Treatment for Life
If your entire thyroid is removed, you’ve effectively become hypothyroid. You’ll therefore need to take thyroid medication—typically, a pill or two every morning—for the rest of your life.
You can find information about medication options in Chapters 8 and 9. In your case, your first choice should be desiccated thyroid, or a mix of desiccated and synthetic thyroid. Synthetic medications (e.g., Synthroid and Cytomel) can be fine if your thyroid is still partially functioning, but since it’s not, desiccated thyroid is the only way for your body to obtain not only T4 and T3, but also a normal amount of T2 (which has been found to be significant for metabolism and weight loss) and T1 (which so far has no known use, but is being studied).
You should also make a point of seeing your doctor every 6-12 months for follow-up visits. That’s especially true if you’ve had radioactive iodine therapy, as there’s a special test you can take a year following the treatment to check on whether it’s been successful. Meanwhile, feel comforted in knowing the chances are around 97 percent that it has, and that you’re entirely healthy again.
Julie’s Story
If you’d like a down-to-earth example of what going through the diagnostic and treatment process is like, the experience of my patient Julie is fairly typical.
While curling her hair shortly after her 38th birthday, Julie noticed a lump the size of a marble protruding from her neck. She thought it was quite prominent and was surprised she hadn’t spotted it before. Then it occurred to Julie that it might have grown quickly. She realized it could be serious and needed to be checked out.
Julie’s family doctor saw her the following week. After feeling her throat, he told her it was probably just a swollen lymph node. “These things happen all the time,” he said. “Don’t worry about it; but come back next month if it’s still there.”
A week later Julie’s lump had clearly grown larger, so she made another appointment with her doctor. When he examined her neck again, he found the lump was now over 1 centimeter. “I’m sending you to get an ultrasound,” he said. “That’ll help us know what’s going on.”
The ultrasound was arranged for the following week. While waiting for it, Julie could think of little else. During her test Julie tried to get some information from the face of the technician, but he was unreadable. After it was done she asked him what he thought. “All I can do is take the images,” he said. “I’m not qualified to evaluate. But your doctor will receive the results within a few days.”
In fact, Julie’s doctor called her the next day. “It’s not a lymph node,” he said. “It’s a thyroid nodule. I’m referring you to an ENT.”
The next week Julie was seen by an ear, nose, and throat surgeon. After a manual exam, he conducted a fine needle aspiration biopsy, taking six tiny samples of Julie’s nodule with a needle and syringe. Although Julie pressed, the doctor was unwilling to make any guesses about her condition. “I’ll probably have the results tomorrow, though,” he said. “I’ll call you when they come in.”
The next day Julie was unable to concentrate on anything as she waited anxiously for the call. She hoped it would happen in the morning, but it didn’t. She stayed by her desk during lunch, just in case. When 4 P.M. rolled by, Julie stopped waiting and called the doctor’s office. “I’m glad you got in touch,” the receptionist said. “The doctor had tried to call you, but it looks like two digits of your phone number accidentally got transposed. Let me put you through now.” After a moment, Julie was on the line with the ENT.
Julie first thought from his calm tone of voice that the results came back negative. Then he told her, “You tested positive for papillary cancer of the thyroid. However, the cells don’t appear to be very aggressive.” All Julie really heard at that moment was “You have cancer.”
The following day Julie met with the ENT, and he calmly assured her that her odds were excellent. “The surgery alone will probably cure you,” he said. “But we’ll give you a dose of radiation afterward to be extra safe. With your permission, I’ll make the arrangements.”
Given the schedule of the ENT and the anesthesiologist, plus Julie needing prior authorization from her insurance provider, the operation was scheduled to take place in three weeks. Julie began to feel everyone was taking this far too casually. During the three weeks she did little other than fixate on the lump of foreign poison she felt was going to end her life.
When the ENT performed the surgery, he found two nodules—the one that had already been noticed, which had since grown to over 2 centimeters, and another one that was 1.5 centimeters. They were both on the left lobe;, but based on a discussion with Julie before the operation, the ENT removed her entire thyroid so Julie could feel certain the cancer wouldn’t spread.
When Julie woke up afterward, the ENT told her the operation was a success. He also told her that she wouldn’t be given thyroid hormones for six weeks “so when you take the radioactive iodine, any remaining cancer cells will suck it up like a vacuum cleaner.”
Six weeks later, in a hypothyroid state that had made her thoroughly fatigued and 10 pounds heavier, Julie was given 130 millicuries of radioactive iodine. She stayed away from people and other living things for two days. During this time there was some swelling under her jaw, but sucking on sour candies made it go away.
Afterward Julie made an appointment with an endocrinologist and was overjoyed to finally be allowed to take thyroid medication.
Over the next couple of months Julie was relieved that the surgery, the radiation, and most importantly the cancer were behind her. However, she noticed clear continuing symptoms of fatigue; plus her hair started thinning, and she was starting to feel inexplicably depressed. Her endocrinologist told her that according to the blood tests her thyroid dosage was fine, so nothing else needed to be done.
After a few more months, Julie’s hair started falling out. No longer trusting her endocrinologist, Julie sought me out. I found she was actually still hypothyroid due to her medication dosage being too low, and also being exclusively T4 (i.e., with no T3 or T2).
I switched Julie to desiccated thyroid and a higher dosage. Within two months Julie felt entirely healthy again.
The Least You Need to Know
- Thyroid cancer is about as treatable as cancer gets, with a survival rate of over 95 percent.
- Ultrasound and fine needle aspiration biopsy are the best ways to explore a thyroid nodule.
- If you need surgery, get the most experienced ear, nose, and throat (ENT) surgeon you can find.
- If you have your entire thyroid removed, don’t hesitate to obliterate remaining cancer cells with radioactive cancer treatment.
- For the two most common types of thyroid cancer, papillary and follicular, the cure rate is 97 percent.
- If your entire thyroid is removed, choose desiccated thyroid medication to fully replace its hormones (T4, T3, T2, and T1).