Incidence Rates

Thyroid Factor

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Contemporary Rates

An estimated 122803 cases of thyroid cancer occurred around the world in the year 2000, causing an estimated 8570 deaths [1]. Yet thyroid cancer is relatively uncommon, striking only about 1.18 people per 100000 persons worldwide,with a somewhat higher incidence in Europe and North America [1]. Thyroid cancer accounted for only about 1.6% of all new cancer cases in the USA during 2003 [2], but it strikes at all ages. Its incidence rate in women is about threefold that in men, peaking in midlife in women and more than two decades later in men (Figure 1.1). In the first decade of life its incidence is the same in boys and girls.

The Incidence of Thyroid Cancer According to Patient Age

The Incidence of Thyroid Cancer According to Patient Age

Figure 1.1 Age at which thyroid cancer was identified in 28979 persons in the United States between 1973 and 2001.The peak age at the time of diagnosis in women is between ages 40 and 44 years and in men between 65 and 69 years. (Figures 1.1,1.2, and 1.4 are drawn from data in the Surveillance, Epidemiology, and End Results (SEER) Public Use Program [3], patients with thyroid cancer, single primary, and histologically confirmed.)

Age at diagnosis

Figure 1.1 Age at which thyroid cancer was identified in 28979 persons in the United States between 1973 and 2001.The peak age at the time of diagnosis in women is between ages 40 and 44 years and in men between 65 and 69 years. (Figures 1.1,1.2, and 1.4 are drawn from data in the Surveillance, Epidemiology, and End Results (SEER) Public Use Program [3], patients with thyroid cancer, single primary, and histologically confirmed.)

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Table 1.1 Distribution of histologic tumor types and deaths due to thyroid cancer among 53856 patients treated between 1985 and 1995 in the USAa

Type of

Percent of all

10-year relative

Cancer

Deaths due to

tumor

Patients (n)

thyroid cancers

survival

deaths (n)

tumor typeb (%)

Papillary

42686

80%

93%

2988

53%

Follicular

6764

11%

85%

1015

18%

Hürthle

1 585

3%

76%

380

7%

Medullary

1 928

4%

75%

482

9%

Anaplastic

893

2%

14%

768

14%

Total

53856

5633

a Data from Hundahl et al.[17] Percentages rounded to nearest integer. b The total number of deaths attributable to each type of thyroid cancer between 1985 and 1995.

a Data from Hundahl et al.[17] Percentages rounded to nearest integer. b The total number of deaths attributable to each type of thyroid cancer between 1985 and 1995.

Historical Changes in Mortality Rates

Despite the significant rise in the incidence of thyroid cancer, its mortality rates have declined almost 50% in the past three decades, mainly as the result of a fall in mortality rates for PTC that is most apparent in patients 40 years of age or older at the time of diagnosis, the group most likely to die of cancer (Figure 1.4A) [3]. Why this occurred is unknown, but may in part be due to earlier treatment of less advanced tumors in recent decades or other as yet unidentified factors. Declining mortality rates are mainly due to improvement in survival with PTC (Figure 1.4B).

There are striking differences in the incidence and mortality rates of thyroid cancer in men and women. While thyroid cancer is the most rapidly rising cause of cancer in women living in the USA [3], its mortality rates have declined over 30% in women (Figure 1.5), more than that of almost any cancer except those of the stomach and uterine cervix, and Hodgkin's disease [3]. In sharp contrast, mortality rates of

Regional and Distant Recurrences and Cancer Death According to Age

Figure 1.3 Thyroid cancer death rates and recurrence rates according to decade of age at the time of diagnosis in 1556 patients with PTC or FTC. (Drawn from the data of Mazzaferri and Jhiang [18,19].)

Age by Decade at the Time of Diagnosis

Figure 1.3 Thyroid cancer death rates and recurrence rates according to decade of age at the time of diagnosis in 1556 patients with PTC or FTC. (Drawn from the data of Mazzaferri and Jhiang [18,19].)

Thyroid Cancer Death Rates per 100000 Persons According to Year of Diagnosis

3 CP

o CL

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v Papillary Thyroid Cancer (n=24447) --n— Follicular Thyroid Cancer (n=4132)

v Papillary Thyroid Cancer (n=24447) --n— Follicular Thyroid Cancer (n=4132)

l—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^—i—^ 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year of Diagnosis

10-Year Cancer-Specific Survival Rates According to Years of Diagnosis

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1973-1979 n=1945 19B0-19B9 n=3753 1990-2001 n=919B

1.00

ra 0.90

ra e

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0.96

3 4 5 6 7 8 Years After Initial Therapy

Figure 1.4 A Thyroid cancer death rates per 100 000 persons in the USA according to the year of diagnosis. B Ten-year cause-specific survival rates in patients aged 40 years and older with PTC or FTC diagnosed in years 1973 to 2001 (From SEER Public Use Program [3].)

0.96

thyroid cancer in men have risen 3.9% in the past three decades (Figure 1.5) and, over time, are twice those in women (Figure 1.6), largely because men present at an older age (Figure 1.1) with more advanced tumors than those in women (Figure 1.7), making it the most rapidly rising cause of cancer death in men in the USA [3]. This is due to late diagnosis and delayed therapy, which reflects how men utilize the healthcare system. Indeed, Leenhardt et al.

Gender Differences in Incidence and Mortality 1973 to 1996

■ Males 11 Females

6G 5G 4G 3G 2G

Percent ^ Change

Mortality Rates Incidence Rates

Figure 1.5 Changes in incidence and mortality rates in males and females during years 1973 to 1996 in the USA. (From SEER Public Use Program [3].)

Cause Specific Survival of Females and Males Age 40 and Older with Papillary and Follicular Thyroid Cancer

Figure 1.6 Ten-year cause-specific survival rates in men and women aged 40 years and older with PTC or FTC.(From SEER Public Use Program [3].)

Years After Initial Therapy

Figure 1.6 Ten-year cause-specific survival rates in men and women aged 40 years and older with PTC or FTC.(From SEER Public Use Program [3].)

Figure 1.7 Changes in tumor stage of PTC and FTC in males (dark bars) and females (light bars) diagnosed in years 1973 to 1996.(From SEER Public Use Program [3].)

Gender Differences in Tumor Stage 1973 to 1996

Percent with 4 Stage 3

[14] found that the proportion of women referred for evaluation of a thyroid nodule in France has increased over the past two decades, which did not happen in men, a finding which they attributed to two factors: first, thyroid disorders are more common in women, and second, women are the main consumers of healthcare [20]. Thus there is robust evidence that the mortality rate of thyroid cancer is twice as high in men as in women because the diagnosis is delayed in men and treatment often is initiated after the tumor has spread beyond the thyroid gland.

Causes of Death from Thyroid Cancer

Because the mortality rates from thyroid cancer are low, there are few clinical descriptions of how patients die from their tumors. One study of 161 fatal cases found that respiratory insufficiency accounted for the most deaths (43%), followed by circulatory failure (15%), hemorrhage (15%), and airway obstruction (13%) [21]. Respiratory insufficiency is due to bulky pulmonary metastases that replace normal lung tissue, while massive hemorrhage and airway obstruction are due to unbridled tumor growth in the neck and mediastinum [21]. Circulatory failure is caused by compression of the vena cava by mediastinal or sternal metastases [21]. These observations provide guidance for improving survival and

Gender Differences in Tumor Stage 1973 to 1996

Distant Metastases

Regional Metastases

Localized Disease

Distant Metastases

Regional Metastases

Localized Disease

*** P < 0.001 By Fisher's exact test the quality of life for patients with advanced tumor.

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