Thyroid cancer cases rise but challenges persist

The health outcome for thyroid cancer patients may be severely impacted in the coming years if the shortage of cytopathologists, standard diagnostic labs and endocrine surgeons is not addressed on an urgent basis. Currently the twin states of Telangana and Andhra Pradesh has only three to four cytopathologists and two to three endocrine surgeons.

The reason behind the shortage in cytopathologists and endocrine surgeons is limited scope for these experts and low awareness amongst the medical fraternity. There is less demand from the hospitals for these specialists and therefore very few students come forward to choose such fields as career option.

As per Dr A Zakir Ali, Consultant and Head, Dept. of Nuclear Medicine, Basavatarakam Indo-American Cancer Hospital & Research Institute, “We are treating 400 new patients every year as compared to 150 patients 8 years ago. As we do not have the concept of cytopathologists, it is the general pathologists who might be practicing cytopathology along with general pathology.

There are very few centers which offer fellowship courses in cytopathology and moreover this narrow specialty doesn’t offer many job opportunities and remuneration.” Like cytopathologist, endocrine surgeons are also a very rare entity. The reason for this is that this super specialization is not commonly available in all institutions. There is also very low awareness among the doctors itself about this specialization. Moreover, surgeries like for thyroid carcinoma or parathyroid adenoma are being performed in many cases by surgical oncologists themselves.

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.

Highlighting the challenges in finding a standard lab in the state, Dr Ali said, “There are many small ill-equipped labs cropping all over the city providing diagnosis at a low cost. A standard lab requires a lot of investments on the infrastructure, equipment, pathologists and technicians along with NABL accreditation. Finding good pathologists for running these labs is equally difficult. “

Thyroid cancer diagnosis requires experienced thyroid cytopathologist who study and diagnose thyroid diseases at the cellular level, differentiate tumorous cells from non tumour cells and advice for surgery. For a simple thyroid nodule patients need to go undertake preliminary tests such as thyroid function test, neck ultrasound neck and fine needle aspiration cytology (FNAC) etc.

Fine needle aspiration (FNA) biopsy 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 it requires in-depth knowledge, understanding and practice.

To address the challenges, Dr Ali said, “We need to introduce cytopathology and endocrinology surgery courses as a super specialization at more institutes, more awareness amongst the physicians & the public and provide more job opportunities for such specialists. In order to standardise diagnostic labs, the government should make NABL accreditation mandatory or any other equivalent certificates to run all labs.”

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

Delay in patient referral by general physician, general surgeons and ENT surgeons to the oncosurgeons and endocrine surgeons also poses a great challenge in terms of getting timely treatment. Sometimes incomplete surgery and delay in referring patients for radioiodine therapy also put patient life in danger.

Highlighting the need for early diagnosis to all patients, Dr Ali said, “If there is a lump in the neck, patients should not ignore but get it checked. There is only 5 per cent chance that the nodule in the neck is likely to be cancerous. If a thyroid cancer is detected at an early stage, it can be almost completely treated. Even if a patient has a terminal stage thyroid cancer, his survival can be prolonged with a good quality of life for at least 3 years by means of palliative care (radioiodine therapy).”

A significant number of thyroid cancer patients can be treated if they get a proper treatment under the supervision of a thyroid cancer specialist. 57 year old from Hyderabad Mr GVR was diagnosed to have thyroid cancer with spread to other parts of the body. He had a big wound in the backbone because of which the patient developed paralysis.

The doctors told him that he had an end-stage cancer and his survival is less than 6 months and hence he did not require any treatment. In 2012 the patient came to Indo-American Cancer Hospital with a backache and complete paralysis of both legs. After the initial examination, the patient underwent total thyroidectomy (complete removal of thyroid gland) followed by radioiodine therapy.

He had an excellent response after the surgery when he revisited the hospital after few months. “Though his cancer in the bones was still persisting, it was less intense and reduced in size. With timely and proper treatment, he could fulfill all his duties and take care of his family properly,” said Dr Ali.

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.

The US 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 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 thyroid cancer is around 97-98 per cent.