Treating thyroid cancer

If you are diagnosed with thyroid cancer, you will be assigned a care team who will devise a treatment plan for you.

Your recommended treatment plan will depend on the type and grade of your cancer, and whether your care team thinks that a complete cure is realistically achievable (see below).

Cancer treatment team

All NHS hospitals have multidisciplinary teams (MDTs) who treat thyroid cancer. An MDT is made up of a number of different specialists and may include:

• a surgeon
• an endocrinologist (a specialist in treating hormonal conditions)
• an oncologist (a cancer treatment specialist)
• a pathologist (a specialist in diseased tissue)
• a radiotherapist or clinical oncologist (a specialist in non-surgical methods of treating cancer, such as chemotherapy and radiotherapy)
• a specialist cancer nurse, who will usually serve as your first point of contact with the rest of the team

If you have thyroid cancer, you may see some or all of these people as part of your treatment.

It can be difficult to decide on the best course of treatment for you. Your cancer team will make recommendations based on reviewing your individual case, but the final decision will be yours.

Before you go to hospital to discuss your treatment options, you may want to write a list of questions to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Questions to ask at your doctor’s appointment.

Your treatment plan

The treatment recommended for you will depend on a number of things, including:

• the type of thyroid cancer you have
• the grade of your cancer
• whether your care team thinks a complete cure is realistically achievable

Most differentiated thyroid cancers (DTCs) – papillary carcinomas and follicular carcinomas – and some cases of medullary thyroid carcinomas have a good prospect of achieving a cure.

DTCs are treated using a combination of:

• surgery to remove your thyroid gland (thyroidectomy)
• a type of radiotherapy called radioactive iodine treatment, designed to destroy any remaining cancer cells and prevent the thyroid cancer returning

Medullary thyroid carcinomas tend to spread faster than DTCs, so it may be necessary to remove your thyroid gland and any nearby lymph nodes (small glands that remove unwanted bacteria from the body). Radiotherapy iodine treatment is not used because it is ineffective in treating this type of thyroid cancer.

Stage 4 medullary thyroid carcinomas are not usually curable, but it should be possible to slow their progression and control any associated symptoms.

In most cases of anaplastic thyroid carcinoma, a cure is not usually achievable. This is because by the time the condition has been diagnosed, it has usually spread to other parts of the body, such as the windpipe and lungs.

Radiotherapy and chemotherapy can be used to slow the progression of anaplastic thyroid carcinoma and it can help control any symptoms.

Some cases of differentiated thyroid cancer, medullary thyroid carcinoma and anaplastic thyroid carcinoma may benefit from a new type of treatment known as targeted therapies.

This involves medication being used to directly target the cancerous cells (see below). However, these types of treatments are currently undergoing clinical trials and are not offered routinely on the NHS.

Thyroidectomy

In almost all cases of thyroid cancer, it will be necessary to remove some of your thyroid gland (a hemithyroidectomy) or all of your thyroid gland (a total thyroidectomy).

The decision to remove some or all of your thyroid gland will be influenced by a number of factors, including:

• the type of thyroid cancer you have
• the size of the tumour
• whether or not the cancer has spread beyond your thyroid gland

Your surgeon will explain to you the type of surgery required and why it is required, so that you can make an informed decision.

A thyroidectomy will be carried out under a general anaesthetic. The operation usually takes around two hours and will leave a small scar on your neck which will not be very noticeable.

For the first 24-48 hours after surgery, you will be connected to a series of drips to provide fluids and help speed up the healing process.

As your neck will feel sore, you will be given painkillers to help ease any discomfort. Your voice may sound hoarse, but this usually passes within a few weeks. However, in a small number of cases, the hoarseness can be permanent.

After having a thyroidectomy, swallowing food may be painful for a number of weeks. You may need to switch to a diet of soft food until your neck recovers from the surgery. A nurse or dietitian will be able to give you dietary advice.

Most people are well enough to leave hospital three to five days after having thyroid surgery. However, you will need to rest at home for two to three weeks and avoid any activities that could put a strain on your neck, such as heavy lifting.

A member of your MDT will be able to advise you about when you will be healthy and fit enough to resume normal activities and return to work.

Replacement hormone therapy

If some or all of your thyroid gland is removed, it will no longer be able to produce the hormones that regulate your metabolic system.

This means you will experience symptoms of an underactive thyroid (hypothyroidism) such as fatigue, weight gain and dry skin.

To compensate for the removal of your thyroid gland, you will need to take replacement hormone tablets for the rest of your life.

If your surgery is to be followed by radioactive iodine treatment, it is likely that initially you will be given a hormone tablet called triiodothyronine.

After radioactive iodine treatment is completed, you will be prescribed an alternative hormone tablet called thyroxine, which most people only need to take once a day.

You will need to have regular blood tests to check you are receiving the right amount of hormones, and to determine whether your dose needs to be adjusted.

It may take some time to achieve the optimum dose. Until the optimum dose is achieved, you may experience symptoms of tiredness or weight gain if your hormone levels are too low.

Alternatively, if your hormone levels are too high, you may experience symptoms such as weight loss, hyperactivity or diarrhoea. Once the right dose has been achieved, you should not experience any more side effects.

Calcium levels

Occasionally, the parathryoid glands can be affected during surgery. The parathryoid glands are located close to the thyroid gland and help regulate the levels of calcium in your blood.

If your parathryoid glands are affected during surgery, your calcium levels may decrease, which can cause a tingling sensation in your hands, fingers, lips and around your nose.

These symptoms should be reported to your MDT or GP as you may need to take calcium supplements. Most people only need to take a short course of calcium tablets because the parathryoid glands will soon start to function normally again.

Radioactive iodine treatment

After having thyroid surgery, a course of radioactive iodine treatment may be recommended. This will help destroy any remaining cancer cells in your body and prevent the cancer returning.

If you are taking thyroid hormone replacement tablets, you will need to stop taking them for two to four weeks before having radioactive iodine treatment. This is because they can interfere with the effectiveness of the iodine treatment.

After you have stopped taking your thyroid hormone replacement tablets, you may feel very tired and weak, but these symptoms will pass once you begin taking the tablets again.

If it is thought that withdrawing your hormone replacement treatment could be particularly problematic, you may be given a medicine called recombinant human thyroid stimulating hormone (rhTSH). This is given as an injection on two consecutive days.

The main advantage of having rhTSH is that you will not need to interrupt your thyroid hormone replacement treatment. However, rhTSH may not be suitable for you for a number of reasons. Your MDT will be able to advise you about whether or not rhTSH is suitable for you.

The procedure

Radioactive iodine treatment involves swallowing radioactive iodine in either liquid or capsule form. The radiation contained in the iodine will travel up into your neck through your blood supply and destroy any cancerous cells.

Side effects of radioactive iodine treatment are uncommon, but a small number of people may experience tightness, pain or swelling in their neck and may feel flushed (warm). These side effects usually pass within 24 hours.

After treatment, you may have a dry mouth and notice a change in your taste. These symptoms usually disappear after a few weeks or months, although some people have an altered taste and dry mouth permanently.

Following radioactive iodine treatment, you will need to stay in hospital for three to five days because the iodine will make your body slightly radioactive. As a precaution, you will need to stay in a single room, protected by lead sheets, so that hospital staff are not exposed to radiation.

You will not be able to have visitors during this time, and pregnant women and children will not be allowed to visit you while you are in hospital because they are more vulnerable to the effects of radiation. Hospital staff will also keep their contact with you to a minimum during this time.

Your bodily fluids, such as urine, will be slightly radioactive for three to five days after your treatment, so it is important that you flush the toilet every time you use it. Your sweat will also be radioactive so you should bath or shower every day.

Once the radioactive levels in your body have subsided, you will be allowed home.

Dietary recommendations

While having radioactive iodine treatment, you will need to eat a diet low in iodine. A diet rich in iodine may reduce the effectiveness of your treatment. It is recommended that you:

• avoid all seafood
• limit the amount of dairy products you eat 
• do not eat glace and maraschino cherries because they contain colouring (E127) that is high in iodine
• do not take cough medicines or use sea salt because they both contain iodine

Eat plenty of fresh meat, fresh fruit and vegetables, and pasta and rice. They are all low in iodine.

Pregnancy and breastfeeding

You should not have radioactive iodine treatment if you are pregnant, or if there is a good chance that you may be. The treatment could damage your baby. Tell your MDT if you are unsure whether you are pregnant. Any treatment will need to be delayed until after your pregnancy.

If you are not pregnant, you will still need to use a reliable method of contraception for at least six months after having iodine treatment. This is because there is a small risk that any child conceived during this time could develop birth defects.

A similar risk applies to men, who should use a reliable method of contraception for at least four months after having iodine treatment.

Your MDT will be able to advise you about when it is safe for you to try to conceive a child.

If you are breastfeeding, you should stop for at least four weeks (but preferably eight) before starting iodine treatment, and you should not resume until after your treatment has finished. It is safe for you to breastfeed if you have another child in the future.

Fertility

Radioactive iodine treatment does not affect fertility in women. However, there is a small risk that it could affect fertility in men who need to undergo multiple treatment sessions. Your MDT will be able to advise about the level of risk in your individual circumstances.

If there is a significant risk you will become infertile after having radioactive iodine treatment, you may wish to consider having your sperm or eggs harvested and frozen so they can be used for fertility treatment at a later date.

External radiotherapy

External radiotherapy, where radioactive waves are targeted at affected parts of the body, is usually only used to treat advanced or anaplastic thyroid carcinomas.

The length of time you will need to have radiotherapy for will depend on the particular type of thyroid cancer you have and its progression.

Side effects of radiotherapy include:

• nausea (feeling sick)
• vomiting
• tiredness
• pain on swallowing
• dry mouth

These side effects should pass two to three weeks after your course of radiotherapy has finished.

Chemotherapy

Chemotherapy is usually only used to treat anaplastic thyroid carcinomas that have spread to other parts of your body.

Chemotherapy involves taking powerful medicines that kill cancerous cells. It is rarely successful in curing anaplastic cancer, but can slow its progression and help relieve symptoms.

Possible side effects of chemotherapy include:

• nausea
• vomiting
• tiredness
• loss of appetite
• hair loss 
• mouth ulcers

If you are receiving chemotherapy, you will also be more vulnerable to infection. See your GP if you suddenly feel ill or your temperature rises above 38^oC (100.4^oF).

Targeted therapies

A number of targeted therapies are being tested in clinical trials (a type of research that tests one treatment against another) to treat advanced cases of:

• medullary thyroid cancers
• differentiated thyroid cancers (DTCs) that do not respond to radioactive iodine
• anaplastic thyroid carcinomas

In targeted therapies, medication which specifically targets the biological functions that cancers need to grow and spread, is used.

As research into targeted therapies for thyroid cancer is ongoing, some medications used in this type of treatment are unlicensed. This means the medication has not been issued with a license for use in treating thyroid cancer.

In exceptional circumstances, your specialist may suggest using an unlicensed medication. They will do this if:

• they think it is likely to be effective
• there are no better alternatives
• the benefits of treatment outweigh any associated risks

If your specialist is considering prescribing an unlicensed medication, they will tell you that it is unlicensed and will discuss possible risks and benefits with you.

The decision about whether to fund treatment with medications used in targeted therapies is often made by individual Clinical Commissioning Groups (CCGs).

Find your local CCG.