NICE guideline [NG230] Published: 19 December 2022
Guidance
This guideline covers diagnosis and management of thyroid cancer in people aged 16 and over. It aims to reduce variation in practice and increase the quality of care and survival for people with thyroid cancer.
Recommendations
This guideline includes recommendations on:
• information and support for people with thyroid cancer
• assessment and diagnosis
• initial treatment of differentiated thyroid cancer
• ongoing treatment with thyroid stimulating hormone suppression for differentiated thyroid cancer
• post-thyroidectomy monitoring of differentiated thyroid cancer
• follow up of differentiated thyroid cancer
Who is it for?
• Healthcare professionals
• Commissioners and providers of thyroid cancer services
• People with thyroid cancer, their families and carers.
1.1.6 Do not refer to thyroid cancer as a 'good cancer' because many people do not find this reassuring and it can cause them to feel that their diagnosis is unimportant.
However, I would add to that, the difference between one form of thyroid cancer and another is huge. Yet I suspect some of the less well-informed might have said "good cancer" without the type even being known.
I always thought it was extremely tone deaf to refer to thyroid cancer as "a good cancer". It just seemed to be typical of the trivialisation of thyroid disease that so many thyroid patients face.
I think at least some people involved with guidance are good guys.
Might even go further and suggest that some of the bad comes about from NICE guidelines getting perverted and trashed before they get to individual patient level.
(Not always. I think we know of some specific issues with NG145 Thyroid Disease guidelines.)
I have a small element of success. I submitted the comments below to the consultation. Unfortunately I was too late to submit them via a support group - this would have got a formal response.
The objective of TSH suppression is to reduce cancer risk. Recent studies show that T4 acting at the integrin αvβ3 receptor promotes cancer growth, metastasis, and angiogenesis, inhibits apoptosis, and enhances radioresistance. Higher T4 levels have higher cancer risk and are associated with reduced life-expectancy.
The recommendations should be amended to refer to ‘TSH suppression with combination therapy, keeping free T4 levels within the lower part of the reference interval’. References to levothyroxine (monotherapy) should be replaced with ‘combination therapy’. Follow the principle ‘Do no harm’.
I can supply evidence if you wish although your team should be aware of the cancer promoting and harmful cardiac effects of high normal T4 levels.
A corollary is that we cannot assess the effectiveness of TSH suppression with levothyroxine monotherapy. The cancerous effects of high normal T4 levels counteracts the benefits of TSH suppression.
Cost effectiveness is calculated on the assumption of levothyroxine monotherapy which has marginal if any benefit. Combination therapy saves lives and cannot be compared to monotherapy on a cost basis..
Looking at the new guidelines they have removed references to 'levothyroxine' and replaced it with 'thyroid hormone'. e.g. see 1.4.2 Offer thyroid hormone at doses that will suppress TSH to below 0.1 mIU/litre ...
I suspect there was some disagreement or uncertainty but we have a small step in the right direction. I still maintain it is absurd to use a pro-cancer protocol (high or high normal fT4) in an attempt to reduce cancer risk.
One part of me wants to ask why they ever specified levothyroxine?
They should primarily state that TSH suppression is required. How that is achieved could well depend on circumstances/patient. For example, if they were already on T3-monotherapy, there seems no reason to change that. (Even if rare/unlikely.) Guidelines shouldn't lay down things which are not essential components. Though they could list options/possibilities so long as not prescriptive.
really interesting thanks for sharing. I was surprised by the lack of mention of T3 and the absence of an aftercare plan for hormone replacement. Did i miss it? 👩🌾
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My letter to NICE re- outdated guidelines and their reply
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