Psychological Aspects of Thyroid Cancer

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Thyroid cancer is a relatively rare disease, with an incidence of 3.1 per 100000 per year [11]. Differentiated thyroid cancer, accounting for the majority of cases, is curable in 90% of patients given appropriate treatment [12]. On this basis many patients are told that thyroid cancer is a "good cancer" to have. However, medullary carcinoma, accounting for 4% of cases, has a 10-year survival rate of 75%. Undifferentiated, or anaplastic, carcinomas account for only 2% of cases, but carry a very poor prognosis, with a 3-year survival rate of only 3% [11].

There is limited published information related to the long-term physical health of survivors of thyroid cancer, and very little published material describing psychological and social outcomes [13]. However, there are a number of descriptive studies offering accounts of patients' perspectives and nursing care needs.

As part of a wider survey of adult survivors of cancer, Shultz and colleagues [13] described medical and psychosocial outcomes of 518 survivors of thyroid cancer. Interestingly, these authors found that survivors of thyroid cancer reported that their disease had affected their overall health, more frequently than did any other diagnostic group. Thyroid cancer patients who had been treated with radiation were almost twice as likely to report an overall effect on their health as those who had not received radiation. Almost a quarter of the sample described symptoms that could be associated with thyroid dysregulation, for example: dry skin; hair loss; poor concentration; sleep disturbance; fatigue; weight change; palpitations; heat/cold intolerance; diarrhea/constipation; depression; anxiety. Thyroid cancer survivors reported psychological problems, memory loss, and migraine headaches more frequently than survivors of other types of cancer. The authors conclude that the morbidity associated with a diagnosis of thyroid cancer is significantly more pronounced than generally understood [13].

An Italian study used a standardized instrument (structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders - III - Revised) to evaluate the lifetime prevalence of psychiatric disorders in 93 inpatients with different thyroid diseases. They found higher rates of several psychiatric disorders in thyroid patients than in the general population. These authors suggest that underlying biochemical abnormalities may explain the cooccurrence of psychiatric disorder and thyroid diseases [14].

A number of descriptive studies have explored patients' perspectives of undergoing treatment with radioactive iodine [15,16]. For the purpose of this treatment, patients are placed in isolation and their contact with staff and visitors is strictly limited, in order to minimize the spread of contamination from bodily fluids. Thus patients are socially as well as physically isolated, at a time when they may be in particular need of support due to distressing physical symptoms and fear of their disease. The special precautions taken with these patients, and the isolation itself, often result in increasing anxiety and fear in patients, about the nature of their disease.

Stajduhar et al. [15] elicited feedback from a small number of patients (n = 27) who had undergone treatment with radioactive iodine. Profound physical and social isolation was the greatest concern for these patients. They reported not having had adequate information or preparation prior to treatment, in order to enable them to cope effectively. They were aware of inconsistencies in staff members' understanding of the risks of radioactive iodine and the treatment process. Patients sensed a reluctance of some staff to be in contact with them. These patients also described how physical aspects of the treatment room served to compound their distress. The authors make three general recommendations on the basis of their study: (1) a program of education for patients and families prior to admission for treatment; (2) a comprehensive staff education program developed by a multidisciplinary healthcare team, in collaboration with patients; (3) modifications to the treatment room to make it more comfortable and less clinical.

Another descriptive study, using a somewhat larger population of patients (n = 190) who each completed a standardized survey, was conducted by McGrath and Fitch [16]. This study also highlighted the distressing effects of isolation and the need for careful preparation of patients prior to treatment. Patients called for written as well as verbal information. Again, they were aware that nursing staff were sometimes inexperienced and held inconsistent views about the dangers of treatment.

Both patient groups and nurses have highlighted the need for education and preparation of nursing staff who deal with thyroid cancer patients. Due to the rare nature of the disease, staff may not work with thyroid cancer patients on a regular basis [17]. Nurses who lack understanding of the relative risks of exposure to patients during treatment may avoid patients unnecessarily and therefore cause unnecessary patient distress. McGrath and Fitch sensibly suggest standard guidelines for staff and visitor contact, which are based on evidence and reflect realistic risk, as well as patients' needs, rights, and responsibilities [16].

Patients have suggested modifications to the treatment room that may improve morale, including: having a window; enough room to exercise; shower facilities; television and video player; telephone; an intercom to enable conversations with staff [15,16]. Patients have also identified a need for support groups set up specifically for people with thyroid cancer, rather than for cancer patients in general. These groups can address the particular needs and concerns of this group and provide "buddy systems" to help support patients undergoing treatment [15,18].

Following treatment for thyroid cancer, patients are required to undergo regular monitoring of their disease status for the rest of their lives. The morbidity associated with lifetime surveillance is highlighted in a number of studies [13,19,20]. Surveillance generally involves thyroid hormone withdrawal followed by body scanning. The induced hypothyroid state results in symptoms of: fatigue; sleep disturbance; impaired psychomotor skills; reduced ability to concentrate; anorexia; pain and fluid retention [19]. As is true for survivors of other types of cancer, the process of monitoring generally raises patients' concerns about the threat of recurrence.

The combination of debilitating physical symptoms and fear of recurrence can profoundly affect psychological and social wellbe-ing. In a qualitative study of a small number (n = 34) of thyroid cancer survivors, feelings of loss, anxiety, depression, and impaired concentration were reported [20]. The process of surveillance is socially very disruptive. As thyroid cancer typically affects a relatively young population, the majority of whom are of working and child-rearing age, the resulting social disruption is particularly pertinent. Thyroid cancer patients are more likely to be gainfully employed (63%) than a general population of cancer survivors (35%) [13]. However, surveillance results in time taken off work or decreased performance at work. In addition, patients' ability to carry out household tasks and engage in childcare, family and social relationships is impaired.

A disease-specific measure of quality of life (QOL - thyroid scale) was used with 34 thyroid cancer patients undergoing surveillance. Negative changes to patients' self-reported quality of life were found to be greatest between peak hormone withdrawal and thyroxine therapy. Common patient concerns included: symptoms associated with thyroid hormone withdrawal; fertility issues; distress associated with treatment; fear of cancer recurrence. However, these authors elicited some positive changes too, such as hopefulness and renewed sense of purpose in life [19]. Shultz and colleagues also reported patient perceptions that in the longer term their experiences were associated with improved family relationships [13].

It has been argued that the long-term monitoring indicated for people treated for thyroid cancer may be more difficult to endure than treatment itself [20]. A combination of physical, psychological, and social factors may give rise to emotional disturbance, for example symptoms of anxiety and depression.

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