Thyroid Cancer: What Patients Should Know About Treatment, Surveillance and Life After

A thyroid cancer diagnosis can bring a lot of questions. Will I need surgery? Will I need radioactive iodine? What happens after treatment? And what if the cancer comes back?

For many people, thyroid cancer is highly treatable, and treatment does not necessarily mean extensive surgery or multiple rounds of therapy. Neeta Erinjeri, MD, an endocrine surgeon at Herbert Wertheim Cancer Institute, spoke with CURE about what patients should know about thyroid cancer treatment, surveillance, life after treatment and advances in personalized care.

CURE: What should someone newly diagnosed with thyroid cancer know about their treatment options?

Erinjeri: For most patients with thyroid cancer, surgery is the initial part of treatment. Meeting with a surgeon is typically one of the first steps in developing a treatment plan.

The good news is that the vast majority of thyroid cancers are not aggressive. For many patients, surgery is the only treatment they will need, and chemotherapy or other forms of treatment are rarely necessary.

The extent of surgery depends on several factors, so it is not always the same for every patient. Surgery also does not necessarily mean a large or highly invasive operation. When thyroid cancer is caught early, it can often be treated with a less extensive approach.

What determines how aggressive thyroid cancer may be?

The most important factor is the type of thyroid cancer.

Cancer is not one single disease, and even cancers that develop in the same organ can behave very differently. There are several types of thyroid cancer, and each has different levels of aggressiveness. There are also subtypes within those cancers that can provide doctors with additional information about how a tumor may behave.

Doctors also consider other factors, including a patient's individual risk factors, what the rest of the thyroid looks like, how extensive the disease is and the patient's age.

Papillary thyroid cancer is the most common type of thyroid cancer and is generally very treatable. The classic form of papillary thyroid cancer is particularly slow-growing and less aggressive.

When treating thyroid cancer, doctors are also thinking about a patient's long-term health and quality of life. For most thyroid cancer patients, the expectation is that they can go on to live a full and normal lifespan.

How do doctors decide between surgery, radioactive iodine and active surveillance?

The decision is nuanced and depends on the individual patient's cancer.

For patients with biopsy-proven thyroid cancer, surgery is generally the starting point in the United States. Whether a patient needs radioactive iodine after surgery depends on several factors, including the size of the primary tumor, what the rest of the thyroid looks like, whether lymph nodes are involved, whether the cancer has spread to surrounding structures and the specific type or subtype of thyroid cancer.

For many patients with papillary thyroid cancer, surgery is all that is needed. Radioactive iodine is generally reserved for patients whose cancer has features that indicate a higher risk.

Active surveillance is another option in certain circumstances, particularly for very small thyroid cancers. In active surveillance, the cancer is monitored closely rather than immediately treated with surgery. If the cancer shows signs of progression, treatment can then be performed.

Active surveillance is also an important part of managing patients after treatment. Once a patient has undergone surgery, whether or not they require radioactive iodine, ongoing surveillance is used to monitor for any potential recurrence.

The goal is to identify a recurrence early, when it can still be treated effectively.

What is life like after thyroid cancer treatment?

One of the most important things Dr. Erinjeri wants patients to understand is that they can generally expect to return to a normal life after the acute phase of thyroid cancer treatment.

Having thyroid cancer does mean that patients need ongoing surveillance, but it does not necessarily mean that they will have major long-term limitations or be unable to enjoy their lives as they did before their diagnosis.

Some patients will need thyroid hormone replacement after surgery, but not everyone with thyroid cancer will need it, and not everyone who has thyroid surgery will need it.

Patients who have their entire thyroid removed will require a full replacement dose of thyroid hormone. Some patients who have only part of their thyroid removed may also need supplemental hormone.

Thyroid hormone replacement is a synthetic version of the hormone naturally produced by the thyroid and is generally very well tolerated. Most of the problems patients experience occur when their hormone dose is either too low or too high.

After surgery, it can take several months to determine the appropriate dose. Doctors can monitor hormone levels with a simple blood test and adjust the medication based on how the individual patient's body is responding.

Once the appropriate dose is established, most patients remain on that dose for the long term. However, hormone requirements can change during major life events, including pregnancy and as patients get older.

Patients can also have normal pregnancies while taking thyroid hormone replacement, although the amount of medication they need may change during pregnancy.

What happens if thyroid cancer comes back?

When thyroid cancer returns, it most commonly recurs in the thyroid bed — the area where the thyroid was originally located — or in the lymph nodes on either side of the neck.

If a recurrence is suspected, doctors will typically perform a biopsy to confirm that the cancer has returned. If the recurrence is confirmed, surgery is often the first treatment, followed by radioactive iodine in appropriate patients.

Thyroid cancer can also become more advanced, although this is not common. In some cases, the cancer may invade surrounding structures or spread to other parts of the body, making it impossible to completely remove through surgery.

When that happens, patients may need additional treatments. Depending on the individual situation, options can include external beam radiation and systemic therapies.

This is also where molecular testing can become particularly important. Doctors can test individual tumors for specific mutations or molecular characteristics that may help identify targeted treatment options.

For patients with advanced thyroid cancer, a medical oncologist may become part of the care team. While medical oncologists are not typically involved in routine thyroid cancer treatment, they can provide additional expertise when disease progresses beyond what can be treated with surgery and radioactive iodine.

How is molecular testing changing thyroid cancer care?

Molecular testing is changing thyroid cancer treatment even before a patient undergoes surgery.

Some thyroid nodules produce an indeterminate biopsy result, meaning doctors cannot say with certainty whether the nodule is cancerous or benign. This uncertainty can be frustrating for both patients and physicians.

In the past, some patients with these nodules underwent surgery simply because surgery was the only way to obtain a definitive diagnosis.

Molecular testing can now provide additional information about the likelihood that an indeterminate nodule is cancerous. For some patients, the results can show that the risk of cancer is low enough that surgery may not be necessary.

This allows doctors to monitor certain patients rather than performing surgery that ultimately may reveal benign disease.

This is one of the most encouraging developments in thyroid cancer care. As researchers learn more about the molecular characteristics associated with cancer, doctors may become better able to determine before surgery which patients actually need an operation and which patients can safely be monitored.

What advances in thyroid cancer treatment could benefit patients in the future?

The growing understanding of cancer at the molecular level could lead to more personalized thyroid cancer treatment.

Researchers are identifying more mutations and molecular markers that are associated with either more aggressive or less aggressive disease. As that knowledge grows, doctors may be able to better determine which patients need surgery and which patients can be safely monitored.

Molecular discoveries are also opening new treatment options for some of the rarer and more aggressive thyroid cancers.

In some cases, medications originally developed to treat other types of cancer may also work against thyroid cancers that contain the same targetable mutation. This means patients with certain molecular characteristics may have treatment options that were not previously available.

While these advances may not change the need for surgery for every patient, they are helping physicians better tailor treatment to each individual's cancer.

For patients, that could ultimately mean more personalized care, fewer unnecessary surgeries and more treatment options for aggressive disease.

Dr. Erinjeri sees this continued progress in understanding the biology of thyroid cancer as a hopeful development for patients and their futures.

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