A very interesting feature today. I have copied and pasted the transcript or, if you prefer, listen to the feature.
As cancers go, cancer of the thyroid gland in the neck is comparatively rare, but it’s on the increase. Last year there were just over 3,000 cases diagnosed across the UK – two thirds of whom were women over the age of 30. But there is growing concern that increased use of imaging techniques like CT scans are picking up small, slow growing tumours that would otherwise have gone undetected and never posed a threat to life. And that, in some cases, the resulting over treatment may be doing more harm than good. But which cases?
Kate Newbold is Consultant Clinical Oncologist at the Royal Marsden Hospital in London.
Newbold
Well the incidence of thyroid cancer’s really increasing and what we’re noticing is that from the 1970s we’d see about five cases per 100,000, in 2009-2010 we were seeing almost 15 cases per 100,000.
Porter
Take me back to the ‘70s, how would a typical case of thyroid cancer have presented?
Newbold
So at that stage it would probably be a patient would have noticed a lump in the neck and the most common for men is if when they’re shaving they suddenly realise that they’ve noticed a lump in the neck, for ladies maybe looking at photographs or when they’re applying their makeup. The nature of thyroid cancer is it’s incredibly slow growing and when you get the diagnosis they’ll look back at family photographs and say actually the lump was there but because it has grown so slowly it’s not been noticed.
Porter
Who gets thyroid cancer and do we know why?
Newbold
We don’t know all the causes for thyroid cancer yet. One definite cause is exposure to radiation, so we know that patients who have been treated, for example, for childhood cancers with radiotherapy are at risk of developing thyroid cancer. We know that patients who have been exposed to nuclear accidents. But in the majority we don’t know what the cause is.
Porter
So what’s a typical presentation today then, somebody that you might see in your clinic, how is it first picked up?
Newbold
So still lumps in neck are the most common way of presenting but increasingly now, compared to my colleagues sort of 10-20 years ago, we’ll have patients sent to us from other doctors who have done a scan of the neck. So, for example, a lot of the stroke investigations where patients have their carotid arteries in the neck ultra-sounded they will also say oh and actually we’ve seen a nodule in the thyroid, please could you see and investigate. So we’re seeing a lot more of what we call incidental findings. So the whole sort of picture of thyroid cancer’s changing to the degree that we’ve got a lot of early stage tumours which probably are not going to affect a person’s life expectancy but they’ve been detected.
Porter
Is there a concern amongst specialist, like yourselves, and surgeons, your colleagues that you work with, that we are over-treating some thyroid cancers?
Newbold
I think that has definitely been the concern amongst the thyroid cancer doctors’ community.
Balasubramanian
My name is Saba Balasubramanian, I’m a consultant endocrine surgeon and I work in Sheffield. There are no increases in exposure to any of the risk factors that cause thyroid cancer, that we know of, and therefore there has been speculation for quite some time on whether we’re simply picking up more and more cancers, including these very slow growing dormant cancers that patients would have otherwise lived with.
Porter
In the last 18 months or so I can think of at least two of my patients who’ve been in having investigations, one for a stroke, one for something else where they’ve picked up and said oh by the way can you please refer this patient because he’s got nodules…
Balasubramanian
They found a lump yeah.
Porter
And you must see quite a few of those in your clinic?
Balasubramanian
Lots and lots of patients, it’s becoming a regular feature, in every clinic there’s one or two patients where a lump has been picked up entirely incidentally.
Porter
Well listeners now will say well that’s good isn’t it, I mean picking these cancers up early makes them easier for people like you to treat?
Balasubramanian
Yeah that is the obvious response from many of our patients. The problem is that with thyroid tumours a lot of us have thyroid tumours, so there has been a very recent review of autopsy studies, studies which have looked at the thyroid gland in patients who have died of other reasons and surprisingly these studies have shown that around 10% of us in the population have a focus of thyroid cancer within the thyroid gland that we’ve not had any problem from, not had any symptoms and people have died of other reasons and these autopsy studies have picked that up. And that particular number, the 10% or so, has not changed over the last 60, 70 years. So we know from these autopsy studies that the true incidence hasn’t changed over the last how many decades that there’s been data but the clinically detected cancer has sky rocketed, we now think that that is primarily due to the increased use of scanning.
Porter
But can you, as a surgeon, or your oncologist colleagues not look at the scan, do a biopsy and decide which of these cancers need treatment or not?
Balasubramanian
It is difficult. Scans alone it is difficult to say which of these lumps that have been detected incidentally have potential to grow. Biopsies also in thyroid disease are quite difficult, so when we do a biopsy of the thyroid gland we usually do not get a straightforward black and white yes or no answer as to whether this is thyroid cancer or not.
Newbold
We are getting better at trying to work out the character or how a particular thyroid nodule is going to behave. Increasingly we’re going to be using molecular markers, so looking at mutations within the DNA of these cells that we might take out on a needle aspiration from the nodule. So we’re moving towards improving that but we haven’t got definitive answers straightaway, so we have to use a combinations of things. And actually the only thing at the moment that will definitely tell us is if we remove that nodule from the thyroid gland which often means removing half of the thyroid gland initially to get that answer.
Porter
And looking at those incidental findings – a nodule that’s picked up, or a number of nodules that are picked up – when they come to a clinic like you what are the chances that that’s something serious?
Newbold
It’s still much more likely that it is a non-cancerous or benign nodule than it is a cancer.
Balasubramanian
What we get from the pathologist is an estimate of cancer risk with these lumps. And as you know if you say to a patient that there is a 5%, 10%, or 25% risk of cancer the usual response is going to be I’d rather have it out. So that leads to a lot more surgery and it leads to complications from surgery. And when you in hindsight think that this was done for a lump that probably would not have caused the patient any harm then you get the idea of how much overtreatment is a problem.
Porter
Where are the patient groups in this? I mean what’s their attitude been?
Balasubramanian
So the patient groups are a little bit concerned about the reporting of over-diagnosis in the medical literature, that this could lead them down into a scenario where we dismiss patients with thyroid lumps, some of them potentially cancerous, and not take them seriously.
Farnell
I’m Kate Farnell, I’m the CEO of the Butterfly Thyroid Cancer Trust in Newcastle-upon-Tyne. I’m also the thyroid cancer patient advisor at the Freeman Hospital in Newcastle. Perhaps more importantly I’m a thyroid cancer survivor of 17 years now. When patients are hearing that their cancer perhaps is being tagged with a label of over-diagnosis they’re not happy about it. They feel that alright, okay, it may have been an incidental finding, I may have been having a scan for something else, what they always say is how would you feel, would you care that it was incidental? No you wouldn’t. You would be pleased that it had been found at a stage where it could be successfully treated and hopefully you could get a cure. Now that said, there are people who will have the most common types of this cancer and they won’t survive it. Patients also hear that if we lived to a grand old age and we had to undergo an examination after death a lot of patients would, a lot of us, would have had a thyroid cancer that hasn’t done us any harm, we didn’t know it was there and it didn’t progress. But do you as a person want to take that risk? And is over-diagnosis such a terrible thing? If you ask any of my patients, they knew I was doing this today and they said – Kate, please get the patient perspective over – and that is if we know we’ve got a cancer we want it dealt with.
Balasubramanian
If it is cancer the primary treatment is surgery. It is a very commonly performed operation, it is tricky because there are a number of very important structures around the thyroid gland that the surgeon would try actively to avoid bruising or damage to but despite the best efforts a significant proportion of people do have complications. The operation could affect their voice because of bruising or damage to the nerves that are on the back of the thyroid up towards the voice box. Another complication is damage to the parathyroid glands, these are small glands, most of us have four of them, two on either side of the thyroid gland, and they are usually stuck to the back of the thyroid and have to be separated from the thyroid gland, so these parathyroid glands get bruised or damaged then your blood calcium levels will drop and you get a number of symptoms from a low calcium problem. Usually this is temporary but between 5 and 10% of patients who have all of their thyroid gland removed have a long term low calcium problem. So surgery is the mainstay of treatment, surgery is the primary treatment and some patients after surgery need radioactive iodine to reduce the risk of the tumour coming back.
Porter
So the patient has a cancer, sees the surgeon – you – you remove the entire gland, the idea of giving the radioactive iodine is to pick up any thyroid tissue that might be left behind?
Balasubramanian
Correct, so after the entire gland has been removed, or in other words a total thyroidectomy has been performed, the radioactive iodine, when given orally, gets preferentially taken up the thyroid gland along with the thyroid cancer and it helps to mop up any microscopic tiny remnants of thyroid or thyroid cancer that is left behind either in the neck or if there is cancer that has spread to other parts of the body, which I must say is very uncommon in thyroid cancer, then the iodine will be effective against those cancer cells that have spread outside. Some radioiodine is also taken up by the salivary glands, the glands around your face and below your jaw, that produce saliva and that is why some patients get a dry mouth or sometimes some discomfort and hot feeling around the neck but these effects are only transient, only for a few days if that.
Porter
It sounds a bit scary, the concept of having radioactive stuff concentrated in your neck, it’s a kind of smart bomb that picks cells, kills them and hopefully doesn’t cause any collateral damage while it’s doing it.
Balasubramanian
That is correct, that is correct which is why radioiodine is considered to be a very safe and effective treatment. It is very different to radiotherapy, which is used in the treatment of lots of other cancers, which is associated with lots of side effects.
Newbold
And the third treatment is the treatment with the thyroxine replacement, which we tend to give at a slightly higher dose in patients with thyroid cancer and that can cause increased risk of osteoporosis – thinning of the bones – or irregular heartbeats.
Porter
If a patient does have thyroid cancer generally, as an overview, what’s the prognosis like these days?
Newbold
So the prognosis is very good. So in the majority of thyroid cancers this will be a treatable and a curable cancer with cure rates in the high 90s.
Porter
Clinical oncologist Kate Newbold. And if you’d like more information on thyroid cancer and the Butterfly Thyroid Cancer Trust there are links on the Inside Health page of the Radio 4 website.
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