Thyroid Cancer and Quality of Life: A Literature Review

Thyroid cancer, characterized by the development of malignant tumors in the cells of the thyroid gland, impacts the quality of life and well-being of diagnosed patients. This article explores different aspects of this type of cancer, including everything from its typologies, incidence, causes, and risk factors to symptoms, diagnostic methods, and treatment options. Furthermore, the impact on Health-Related Quality of Life (HRQoL) is addressed, highlighting that, although the prognosis is generally favorable, patients can experience significant negative repercussions. Therefore, the need for further investigation into the priorities of psychological intervention with the population with this problem is emphasized.

Thyroid cancer refers to the formation of malignant tumors in the cells of the thyroid gland, an endocrine gland, located in the lower front of the neck [1,2]. It is formed by two lobes (the right and the left) joined by the isthmus. The function of the thyroid gland is to produce thyroid hormones, which help the body use energy, maintain an adequate body temperature, as well as maintain the proper functioning of some organs [1]. Furthermore, the normal thyroid gland is composed of two types of cells: follicular cells, involved in the production of thyroid hormones, and C, or particular cells, which produce the hormone calcitonin [2].

Regarding the types of thyroid cancer, these are associated with the two types of cells mentioned above, with medullary thyroid cancer being related to C cells. In contrast, the follicular, papillary, and anaplastic types are linked to follicular cells.

Therefore, the most prevalent is papillary thyroid cancer, which represents approximately 70% to 80% of thyroid cancer cases, followed by the follicular type, which represents approximately 10% to 15% of cases. This medullary type represents approximately 2%; finally, the anaplastic type constitutes less than 2% of cases [1]. When Exploring each type, it is interesting to note that the papillary type has a greater risk of spreading to the lymph nodes in the neck, while the follicular type has a greater risk of metastasizing through the blood to distant organs, such as lungs and bones; around 25% of cases of medullary thyroid cancer have a hereditary component and the anaplastic type is the most aggressive, occurring in more advanced stages of cancer, with a low probability of responding to treatment [1].

Concerning the methodology used in the present study, a search was carried out in the literature published between the years 2003 and 2023 in the databases "B-on," "PubMed," and "Google Scholar" using the keywords “ thyroid cancer," "psychotherapy," "treatment," "risk factors," "quality of life" and "epidemiology." This research was carried out with the help of the Boolean operators "AND" and "OR" and the truncators" and it took place between September 30th and November 5th, 2023. As inclusion criteria, studies would have to: (a) include the term "thyroid cancer" in its title, (b) be available in full for free and, (c) be published in English or Portuguese and (d) have a publication date between the years 2003 and 2023. They excluded studies in review format and those that did not meet the previously mentioned criteria. Therefore, 19 documents were considered for analysis (Figure 1), the main conclusions of which are presented in Table 1. Furthermore, additional records were included, selected from additional research, to make this study more complete, using 29 records (Figure 1).

Incidence and prevalence

It is three times more common in women; thyroid cancer is also more prevalent in women between 35 and 64 years and between men aged between 45 and 74 years [1,22,23].

In terms of global incidence, thyroid cancer is in ninth position in the ranking, compared to other cancers [23]. In 2020, 586202 new cases were presented, representing 3.2% of the number of cancer cases this year [23].

Regarding incidence data in Portugal, thyroid cancer is the third most common type of cancer, in terms of new cases, in women [24]. In 2010, mortality rates were 0.32/100,000 in men and 0.37/100,000 in women, with 32 and 62 cases of death recorded, respectively [25]. Furthermore, in 2018, 367 new cases were registered in men and 1275 in women [22]. Table 1.

Causes and risk factors

Most people with thyroid cancer have no obvious risk factors, and the exact reason for its development remains unknown in most cases [26]. Possible causes and risk factors may include exposure to high doses of ionizing radiation, family history, age (individuals over 40), radioactivity during natural disasters, obesity, smoking, hormonal exposures, and environmental pollution [1,27,28].

Furthermore, a Mendelian randomization study indicated an association between an increase in genetically predicted height and an increased risk of developing thyroid cancer [18,29].

Symptomatology

Generally, symptoms of thyroid cancer include the presence of a thyroid nodule or lump, but they often do not cause other symptoms [1]. Additionally, possible symptoms may include difficulty breathing, swallowing, or a "itchy throat" sensation; and hoarseness (less common, occurs if thyroid cancer targets the nerve that controls your vocal cords) [1].

Some treatments commonly lead to new symptoms, such as interruption or reduction of hormonal treatments before treatment with radioiodine or, in the case of thyrotropin (TSH, a thyroid-stimulating hormone), suppressive therapy treatments after radioiodine treatment, which can result in symptoms such as restlessness, nervousness and palpitations [7,30]. These last symptoms can persist for the rest of the patient's life [7].

Treatments can cause social, cognitive, and emotional problems, sometimes worrying these patients [7,30]. Taking into account that thyroid cancer involves hormonal disharmonies and that this can cause emotional "roller coasters" [7,31] suggests that monitoring by a psychologist can help the patient deal with these symptoms.

Diagnosis

There are several methods used in the diagnosis process and complementary exams [2]. However, it is essential to note that thyroid cancer can only be diagnosed with certainty after surgical removal of the nodule [1].

Thus, some of these methods include [2]:

• Clinical and History Examination, which aims to identify thyroid nodules through palpation and evaluate the patient's clinical history;
• Thyroid Function Tests, responsible for measuring thyroid-stimulating hormone (TSH) in the blood;
• Laryngoscopy (direct or indirect), which is essential both in the preoperative evaluation and in the initial evaluation of a thyroid nodule;
• High-resolution ultrasound, capable of detecting multiple nodules that may not be palpable, being used to perform Fine Needle Aspiration (FNA);
• Fine Needle Aspiration (FNA), a technique used to obtain samples of cells from the thyroid nodule for cytological evaluation;
• Molecular markers have been evaluated in FNA samples to improve diagnostic accuracy.

There are a variety of procedures used in diagnosis, commonly, in the case of suspected thyroid cancer, a physical examination is carried out accompanied by ultrasound/ultrasound, followed by a biopsy if previous tests show evidence of the presence of a nodule and finally, is passed on to surgical treatment if justified by the biopsy results [1].

Thyroid nodules are widespread, but less than 1 in 10 will be thyroid cancer. Ultrasound reveals thyroid nodules in 20 to 76% of cases, with only 5% - 15% associated with thyroid cancer [32].

Treatment

After a diagnosis confirms the need for treatment, methods to continue the process are considered. The most common is surgery, which can range from removing just the affected thyroid lobe to total thyroidectomy, usually followed by radioactive iodine therapy to eliminate any remaining thyroid tissue and destroy residual cancer cells [1,2]. Additionally, additional methods such as external beam radiation therapy, chemotherapy, biological therapies, and medication may be used to treat more advanced thyroid cancer that does not respond to surgery and radioactive iodine therapy [1]. However, these additional methods have a limited role in treating thyroid cancer [1]. From a healthcare system perspective, the costs associated with Basic Supportive Care (BSC) are substantial and equivalent to those found in other tumor conditions [15]. Therefore, Kreissl, et al. in 2014 [15] provided a foundation for future health economic analyses within this context.

Finally, it is important to highlight that research to develop more effective medications to treat thyroid cancer is ongoing. A recent example is the study by [11] who identified anti-miR-146b-3p as a promising potential cancer drug, especially in the treatment of differentiated thyroid cancer.

Quality of life

Health-Related Quality of Life (HRQoL) integrates the physical, psychological, emotional, and social consequences that impact the individual [33-35]. In the case of thyroid cancer, defining this construct proved to be a particularly challenging task, as its symptoms are diverse and depend on the individual's hormonal status, and can range from symptoms such as physical discomfort to emotional discomfort [7].

The study by [20] revealed that, in patients with differentiated thyroid cancer, HRQoL is significantly reduced when they are in the process of preparing for diagnostic or therapeutic procedures. The anxiety of these patients is considerably more frequent than that of the general population [20].

In this case, it has been reported that patients with thyroid cancer often face more severe psychological challenges compared to patients with poorer prognoses [7,36]. A possible explanation for this event is that this last group is focused on managing treatments and their side effects, fighting for their survival daily [7]. Additionally, thyroid cancer patients appear to experience symptoms of distress at a level similar to or greater than cancer patients in general [10].

In this sense, although the rate of thyroid cancer survivors has been increasing worldwide and its impact on HRQoL is generally considered lower compared to other cancers, such as head and neck, due to the application of less invasive treatments, patients still feel impacts on their HRQoL [33,37]. These often experience significant negative repercussions after cancer diagnosis despite generally having a more favorable prognosis [33,38] and highlighting that a favorable prognosis does not directly translate into good HRQoL for these patients [8].

Thus, highlights that the HRQoL of individuals diagnosed with thyroid cancer is often equivalent to that of the healthy population [33]. This comparison, however, is seen as an analysis that underestimates the true impact of thyroid cancer on HRQOL [33]. It may be attributed to the tendency of clinicians to neglect concerns related to HRQoL in this group, focusing on the favorable prognosis [7]. Therefore, the assessment of HRQoL in this population may not be usual since there is a misconception that the study of quality of life in this group of patients is more than in other oncological cases [7].

Therefore, it is essential to recognize the experience of being diagnosed with thyroid cancer, even in the face of a favorable medical prognosis [10,39]. This understanding seeks to contribute to a deeper integration of this situation into patients' lives [10,39].

In the case of thyroid cancer, HRQoL concerns may arise following adverse treatment outcomes [28]. Symptoms commonly associated with decreased HRQOL include insomnia, sleep disorders, memory problems, difficulty concentrating, and neuromuscular complaints [33,38].

Furthermore, apprehension regarding the possibility of cancer returning is a widespread concern for all types of cancer and is also an anxiety present in the context of thyroid cancer, again, even when the prognosis is favorable [33].

Patients must have access to information about how their quality of life can be affected by this diagnosis and the treatment that accompanies it [7,40,41]. Furthermore, this information is essential for developing intervention strategies to improve HRQoL [7].

Psychological well-being is influenced by treatment, the possibility of the emergence of another cancer or the recurrence/metastasis of the subsequent malignant disease, and future diagnostic tests [3,40,41].

Regarding the social aspect of HRQoL, [4,41,42]] explored the impact of thyroid cancer on patient-partner dynamics, as well as sexual activity. They identified that a significant portion of their sample reported perceptions of negative or mixed changes in relationships, along with a decrease in the frequency of sexual activity [4]). The results lead the authors to consider that such changes may be indicative of increased anxiety and depression, as well as a lower quality of relationships in patients with differentiated thyroid carcinoma (DTC). Another study conducted by [6] reveals that, in general, it is patients, and not their partners, who face symptoms of anxiety after thyroid cancer diagnosis and treatment. Furthermore, they highlight that patients and their partners feel overwhelmed in various ways at the time of diagnosis and treatment, which is expressed predominantly through fatigue [6]. They also identified that, when perceived as a burden, this feeling was associated with depressive symptoms, anxiety, and fatigue, especially in women. In contrast, the predominant symptom in men was just fatigue [6].

Furthermore, this social dimension can be affected by persistent restrictions on the resumption of daily life, manifesting itself in the interruption or difficulty in domestic activities, in the reduction of weekly working hours due to increased fatigue, and in the impact that cancer has on the patient's family dynamics [3,8,17]. Additionally, if adequate management of the patient's suffering is not carried out, the problem of isolation may arise [3].

Additionally, the treatment of differentiated thyroid cancer has significant emotional repercussions for the patient [14]. As previously mentioned, radioactive iodine therapy requires isolation, making this period challenging for the physician [9]. Thus, the prevalence of distress in patients is high even before this therapy [9]. [10] highlight that although medical care for patients with thyroid cancer is well-established in medicine, the patient experience does not reflect this simplicity. Medical care alone is insufficient to meet the needs for monitoring and social support they perceive.

The study by [5] analyzed correlations between Benefit Found (BF) and psychological adjustment in thyroid cancer with demographic variables. They found that older age is associated with greater self-acceptance and spiritual well-being. However, female sex is related to less positive change in substance use and higher levels of stress linked to cancer. Furthermore, having a partner or a higher income was associated with a greater purpose in life. In summary, this study revealed that age and gender play crucial roles in the experiences and adjustment of cancer patients, impacting aspects ranging from psychological well-being to quality of life and the impact on professional life [5].

It is positive to realize that studies have been carried out to understand the influence of treatments on the quality of life of these patients. For example, the study by [21] sought to understand whether different types of surgery affect a patient's quality of life by comparing the effects of hemorrhoidectomy and complete thyroidectomy in patients with differentiated thyroid cancer. It was concluded that the type of surgery does not appear to have a distinct influence on quality of life in general [21].

In summary, psychological care and rehabilitation play an essential role in the management of thyroid cancer, ensuring adequate emotional and social support for patients during and after the completion of cancer therapy to achieve complete recovery in terms of psychosocial [12,41]. In this sense, the development of psychological intervention programs is encouraged, aiming at rehabilitation and a complete return to patients' social roles before treatment [13,41]. Each phase in the treatment of patients with thyroid cancer can impact different facets of the overall quality of life. As healthcare professionals, we must recognize that we are responsible for providing an accurate diagnosis, appropriate treatment, and care to restore balance in our patient's quality of life [3].

Psychological intervention

Implementing an effective psychological intervention that is well received by patients requires an essential understanding of the priorities they attribute to quality of life. In the study by [19], fatigue emerged as a central concern for several groups analyzed, highlighting the quality of sleep and sudden episodes of tiredness. Additionally, the issue of employment was identified as a priority by patients, indicating a reluctance to abandon work as they seek to remain professionally active for as long as possible [19]. Lastly, fear of progression was noted as the third predominant concern among most patients [19]. [16] emphasize the advantages of individualized communication in intervention to alleviate psychological suffering. They describe how psychological intervention has the potential to significantly improve the suffering of patients undergoing radioactive iodine treatment for differentiated thyroid cancer [16,39]. This intervention demonstrated effectiveness in reducing anxiety, depression, and fatigue associated with cancer, contributing to improving the mood of these patients.

Furthermore, the psycho-oncological approach, focused on counseling on depression, quality of life, anxiety, and well-being in patients with differentiated thyroid cancer, was highlighted by [14] as capable of significantly improving these factors.

Thyroid cancer is a complex condition affecting the thyroid gland, classified into papillary, follicular, medullary, and anaplastic. The global incidence, especially in women aged 35 to 64, highlights its relevance. In addition to physical challenges, thyroid cancer impacts patients' Quality of Life (QOL), addressed by Health-Related Quality of Life (HRQoL), considering physical, psychological, and social implications. A significant reduction in HRQOL is recognized in literature, during diagnostic and therapeutic procedures with high levels of anxiety. Patients with less favorable prognoses may cope better with the psychological impact, suggesting emotional complexity. Recognizing the experience of diagnosis, even with a positive prognosis, is crucial, and highlights the importance of psychological support to deal with emotional challenges. Psychological intervention is essential in reducing anxiety, depression, and fatigue associated with treatment. Therefore, thyroid cancer management goes beyond medical treatment, integrating approaches to ensure complete recovery and resumption of daily activities. Therefore, we emphasize the need for further investigations into intervention priorities for this population and the publication of updated incidence and mortality data for the Portuguese population.

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