Thyroid Cancer Cases Rise with Increased Detection but Challenges Persist

     Over-diagnosis, shortage of radioactive iodine facilities, and limited number of endocrine surgeons and trained cytopathologists  may adversely impact thyroid cancer treatment in the future

·         Tata Memorial Hospital witness increase in thyroid cancer cases

Mumbai, 22 September, 2016 - The health outcome for thyroid cancer patients in the state may be severely impacted in the coming years if the problem of over diagnosis and shortage of well-trained endocrine surgeons, cytopathologists, and limited number of radioactive iodine facilities and endocrine surgeons is not addressed on an urgent basis. As per thyroid cancer experts, there has been a significant increase in the incidence of thyroid cancer with more number of cases being registered at leading hospitals over last few decades. Without restrain, increased screening could be responsible for the rise in thyroid cancer misdiagnosis.

According to Dr Anil D'Cruz, Director, Tata Memorial Hospital, “The trend of thyroid cancer is increasing globally. 20 years back, the number of patients seen at the Tatamemorial Hospital was less than 100 per year. But now the numbers have increased many folds. Increased detection has been attributed to the global rise in thyroid cancer incidence as witnessed in South Korea and most of the developed world. It is important to know that many of these thyroid cancers are indolent (harmless) and would not have caused problems to the patients in their lifetime. Over detection may therefore result in unnecessary treatment.”

Finding tiny harmless tumors that really do not need treatment is known as over-diagnosis. Removing harmless tumors, as a result of over- diagnosis can lead to a slew of cascading health problems such as need to take thyroid hormones for lifetime, inappropriate hormone function, chronic hormone deficiency, depression, and other symptoms of low thyroid function. Surgical removal of the thyroid, which is the mainstay of thyroid cancer treatment, can also result in accidental damage to vocal cords and/or parathyroid glands.

Thyroid cancer patients already face numerous difficulties in treatment and management as follow- ups after initial treatment can be a tedious process, and many may have to be under observation for a long time, in some cases upto 20 years or more. The main treatment and follow up which is done with radioactive iodine scans is available only in a very few centers. Availability of limited number of  nuclear medicine physicians trained in radioactive iodine ablation treatment and follow up diagnostic scans is another major challenge.

Dr Vikram Lele, Head, Nuclear Medicine, Jaslok Hospital & Research Centre said, “In Jaslok, we see almost 12 thyroid cancer patients per month. In terms of treatment, there is a lack of specialist surgeons and cytopathologists. Facilities providing radioactive iodine treatment are scarce. In Maharashtra, there are only 8 facilities providing radioactive treatment. In Mumbai it is only available at the Radiation Medicine Centre behind Tata memorial hospital, Jaslok Hospital, Saifee Hospital and KDA hospital. Only Dhruva reactor provides radioactive iodine. When the reactor is working, the radioactive iodine provided helps in reducing the overall cost of treatment. When the reactor is not working, we need to import it from other countries, which in turn, increases the cost of treatment.”

Thyroid cancer diagnosis requires experienced thyroid cytopathologist who can study and diagnose thyroid diseases at the cellular level, differentiate tumorous cells from non-tumour cells and help the surgeon decide for surgery. Fine needle aspiration (FNA) cytology and fine needle capillary sampling are the two most widely used diagnostic techniques for assessing the cytopathology of thyroid nodules to identify those patients who have nodules that should be removed. These procedures are seldom interpreted accurately by inexperienced technicians as risk classification is based on probability factor.

Enumerating on the clinical challenges, Dr D'Cruz said,“Firstly, thyroid cancer is detected by Ultra Sonography and Fine Needle Aspiration Cytology (done by pathologists). Both these procedures are highly operator dependent and therefore doctors diagnosing thyroid cancer must have adequate expertise to accurately reach a diagnosis. Secondly, the main treatment of thyroid cancer is surgery. However, surgery not performed by experienced surgeons can result in significant morbidity to the patients. Surgery on the thyroid gland may damage the nerves supplying the voice box of the patient or the parathyroid glands which are closely related to the thyroid. Both these structures are very delicate and need special attention during surgery. (The parathyroids control the calcium metabolism of the body). As a result, patients may have a hoarse voice or may need to take calcium supplements for life (10-12 tablets per day). Thirdly, for high risk patients, radionuclide treatment with iodine is recommended as an adjuvant following good surgery. Unfortunately, the numbers of treating centers are few and far between.”

Thyroid cancer is the most common cancer of the endocrine system and occurs in all age groups. Diagnosis plays a crucial role in identifying cancerous tumours from harmless ones. The primary management for most patients with thyroid cancer is surgical removal of the entire thyroid gland. Following surgery, the patients are required to undergo radioactive iodine scans.

Addressing the challenges, Dr D'Cruz said, “Unnecessary screening for thyroid cancer should be discouraged. Recently, IARC (International Agency for Research on Cancer) has also given a similar advisory.  Surgeons should be trained in thyroid surgery as complications are directly related to the volumes operated on. Thyroid surgery must be performed only in centers with this expertise.”

Thyroid cancer starts in the thyroid gland that produces thyroid hormones which are important in the normal regulation of the metabolism of the body. The exact cause of thyroid cancer remains unknown and the common symptoms include a lump or thyroid nodule in the neck, trouble with swallowing, throat or neck pain, swollen lymph nodes in the neck, persistent cough and vocal changes. Early detection is critical because thyroid cancer has a good prognosis and high cure rate, and less treatment is required if the cancer is detected at an early stage.

Highlighting the need for early diagnosis and accessibility of radioactive iodine therapy to all patients, Dr Lele said, “If there is a lump in the neck, patients should not ignore but get it checked. Thyroid cancer is mostly curable when detected early. Patients should keep in mind that the center they are going should be fully equipped for diagnosis and treatment of thyroid cancer”

USA is expected to have the highest number of thyroid cases by 2020 in the world, closely followed by India at the third position. The number of endocrinologist surgeons and cytopathologist entering the work force would probably not meet that demand.

According to official statistics, the number of thyroid patients in India is one-tenth of 80,000 Americans who are suffering from thyroid cancer. Thyroid cancer is much more common in women than in men. About three women are diagnosed for every man and can happen at any stage of adult life. The cure rate for most thyroid cancers is around 97-98 percent if detected and treated timely.