tDiviiatry

Available online 25 April 2015

Keywords:Thyroid cancerQuality of lifePatient-reported outcomesCancer managementMeeting report

hat

psychologist, and naturally from the patient him/herself. This article provides insights into each of these

ions an

toms may have a broad range (from emotional to physical discom-fort, depending on the thyroid hormone status), which can affectthe patient severely. The patient does not know what kind ofsymptoms they may be facing and is often left alone with theirdiagnosis and fears. Time pressure and the reluctance to burdenthe physician with emotional symptoms may silence the patient,and the physician often only sees the favourable prognosis of

ent andhe problem

symptoms caused by hormone withdrawal are less signIn the majority of patients, if it is considered that substherapeutic administration of radioiodine will not be reexogenous stimulation by recombinant human thyrotropin(rhTSH) is used for diagnostic purposes. In cases where radioiodinetreatment may be required, some centres still prefer endogenousstimulation for all patients. Additionally, some treatments e.g.TSH-suppressive therapy after radioiodine treatment, can lead toseveral symptoms such as palpitation, restlessness, and nervous-ness, which may last for the rest of the patients life. Since thyroid

Corresponding author.E-mail address: martha.hoffmann@meduniwien.ac.at (M. Hoffmann).

Oral Oncology 51 (2015) S1S5

Contents lists availab

nc

evbecoming an increasingly important issue but is difcult to deneand address. Particularly in the case of thyroid cancer, the symp-

this kind of preparation for radioiodine treatmusually for thyroid remnant ablation. Therefore, thttp://dx.doi.org/10.1016/j.oraloncology.2015.03.0081368-8375/ 2015 Elsevier Ltd.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).this iss withicant.equentquired,Quality of Life and Follow Up session of a physician-only meetingheld in Vienna, November 23, 2013 entitled Thyroid cancer: fromnodule to cure the controversies. The meeting was organised bythe Austrian Society of Nuclear Medicine and Molecular Imagingand the Medical University of Vienna. The session presented threedifferent perspectives on the QoL of thyroid cancer patients; thoseof the treating physician, the psychologist, and the patient. QoL is

and where the patients discomforts are and what the physiciancan do to relieve them. Some symptoms may last for a specic time(e.g. hormonal withdrawal prior to ablative radioiodine treatment),and explaining this would help the patient to understand andaccept the symptoms; or the situation could be avoided by usinga different form of treatment (e.g. by using recombinant TSH stim-ulation). However, in Austria only a minority of patients receiveIntroduction

This paper summarises presentatviews within the context of thyroid cancer where, as a consequence of increasing incidence and decreas-ing mortality rates, QoL aspects deserve close attention. Physicians often nd themselves in situationswhere they perform a balancing act between what they know is best from a somatic point of view andlearning about what is best for the individual patient. For psychologists in the eld of oncology, a mainarea of interest is the incorporation of the patients perspective into research by using patient-reportedoutcomes (PROs) which include QoL assessment. PROs can also be used in clinical practice as a way tostart a conversation about symptoms and QoL aspects that perhaps patients might not volunteer, and thisallows physicians to address QoL issues more directly. Patients usually appreciate being asked about allaspects of QoL, and need sound information about how their QoL might be affected by the disease and itstreatment. By examining and understanding the different perspectives on QoL, and how QoL differs inpatients with thyroid cancer compared with other cancers, it is hoped that the QoL can be enhanced inthis particular patient group. 2015 Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecom-

mons.org/licenses/by-nc-nd/4.0/).

d discussions from the

thyroid cancer compared with other cancer types and neglects toaddress QoL issues. A specic questionnaire may help to bridgethese two perspectives and allow both sides to understand whatReceived in revised form 10 March 2015Accepted 18 March 2015

its evaluation as well as its role in the patients overall treatment experience are under continuousscrutiny. Different perspectives on patients QoL have emerged; from the treating physician, from theQuality of life aspects in the managemen

H. Duan a, E. Gamper b, A. Becherer c, M. Hoffmann a,

aMedical University of Vienna, Dept. of Biomedical Imaging and Image-guided Therapy,b Innsbruck Medical University, Univ.-Clinic for Nuclear Medicine, Univ.-Clinic for PsychcAcademic Teaching Hospital Feldkirch, Dept. of Nuclear Medicine, Feldkirch, Austria

a r t i c l e i n f o

Article history:Received 19 December 2014

s u m m a r y

While there is agreement t

Oral O

journal homepage: www.elsof thyroid cancer

sion of Nuclear Medicine, Vienna, Austriaand Psychotherapy, Innsbruck, Austria

quality of life (QoL) is a central aim of medical treatment, the methods of

le at ScienceDirect

ology

ier .com/locate /ora loncology

ncolhormone disorders may lead to emotional rollercoaster rides, apsychologist may be invaluable to help the patient cope with theirsymptoms. However, until the physician knows where thepatients discomforts are, they cannot be treated or managed.

The physicians view Dr. Alexander Becherer

The physicians view of QoL in thyroid cancer patients can beexplained and explored by examining case studies.

The rst case presented was a 36 year-old female patient, with aslightly painful nodule in the anterior neck, and who had beenshowing symptoms for 1 month. Apart from a heart rate of96 bpm, she was clinically euthyroid. On palpation, the nodulewas moveable, rather dense, and likely situated in the isthmuson the left side. The physicians rst assumption based onanamnesis and clinical ndings was that this was most likely acyst, and the patient was told that most of the nodules with thishistory are benign. The patient was relieved and very happy.

However, ultrasound showed that it was not a cyst, but a17 mm hypoechogenic nodule with irregular boundaries. As noTSH level was known, scintigraphy with Tc-99 m pertechnetatedemonstrated that the lesion was cold. Thus, ne needle aspirationcytology (FNAC) was indicated. The patient was given the updatednews and was understandably very distressed.

The case illustrated that although it is better for patients (andimproves the quality of their experience) to be given a rm diagno-sis as soon as possible, particularly if the diagnosis is a benign one,this is often not possible based on statistical probabilities. Thephysician should wait for the results of the whole bundle ofdiagnostic tests because speculative diagnoses (even if statisticallyprobable) can lead to great distress once a different diagnosis ismade. However, in thyroid nodules scintigraphy can be doneimmediately and gives a result very quickly, which is much betterfor the patient than waiting for the thyrotropin result to determinewhether a nodule is hyper- or hypofunctioning.

Given the results of sonography and scintigraphy, the physi-cians view was that the nodule had a signicant chance of beinga carcinoma. The patient was told that there was a 1 in 5 chanceof the nodule being cancer (to make her aware of the possibilitythat she had a malignant disease, but without leaving her with avery pessimistic outlook). Finally, FNAC revealed papillary thyroidcarcinoma. This highlighted the importance of not telling patientstheir results in detail if there is a possibility of changing themessage. The patient underwent thyroidectomy a few days afterreceiving the FNAC result. She had a PTC pT1bN1a tumour, maxi-mum diameter of 17 mm, BRAF V600E mutated, with 6 out of 39metastatic lymph nodes. Her response to surgery and radioiodineablation with 1850 MBq 131I under rhTSH stimulation was excel-lent, with a stimulated thyroglobulin (Tg) of 0.5 ng/ml (IMMULITE

2000 XPi, Siemens Healthcare, Erlangen, Germany, analyticsensitivity, 0.2 ng/ml) two months after radioiodine ablation.

In terms of QoL issues, the patient was concerned about hersmall son, whether she would be able to see him grow up, andwhether he would lose his mother. She was also concerned abouther ability to have more children, and if the treatment for her can-cer would mean that she would lose her hair. A key learning pointfrom this interaction was the importance of remembering thatalthough physicians may tell patients You have a carcinoma withan extremely favourable prognosis, and try to make the mostmemorable words for the patient an extremely favourable prog-nosis, in fact the words that the patient mainly hears are onlyyou have a carcinoma [1].

The second case concerned a 74 year old female patient with a

S2 H. Duan et al. / Oral O14 year history of follicular thyroid carcinoma, pT4N0Mx. She had6 diagnostic scans over 6 years and was in complete remission.Then her Tg level started to rise, and the patient was treated withradioiodine therapy. Following treatment the patient received 2check-ups per year. No detectable lesions were found either bydiagnostic scanning with 131Iodine, with 18F-FDG, or with ultra-sound. However, her Tg levels continued to rise without any dis-cernible clinical symptoms.

The QoL issues in this case centred around helping the patientto accept that her Tg level was a laboratory nding which necessi-tated more frequent check-up visits, but did not inuence herwellbeing. The patient had tooth problems with softening ofadamantine, caused by xerostomia (an adverse effect of radioio-dine). Initially the patient did not want to spend any money onher teeth because she believed its not worth while investingmoney on my teeth because Im going to die soon. However, thephysician convinced her that the prognosis was good, and shehad her teeth repaired and was very proud of them. The patientis currently in very good condition, is healthy, and enjoying lifewith her husband and grandchildren.

The third case report was of a 61 year-old male patient, withpoorly differentiated follicular cancer pT4pT1Mx, that had relapsedlocally twice already in the early course of the disease. Eventuallyhe developed pulmonary metastases for which he underwent 3operations on the right lung (rst 9 years after his rst diagnosis,then again 1 year later, and nally a further year later). The patientalso underwent external radiotherapy for metastases in the leftlung. He had been treated for the last 2 years with a tyrosine kinaseinhibitor, which had slowed the progression of the cancer. Thepatient had no symptoms from the lesions, but treatment withsorafenib affected his QoL due to the development of severehand-foot-syndrome, and subsequent mild diarrhoea when heswitched his medication from sorafenib to pazopanib. However,the hand-foot-syndrome resolved and the patient controlled hisdiarrhoea during the day with other medication, and was able tocontinue to work as a travelling salesman. The patient was very,and would have not even attended his monthly check-ups if hehad not needed a new prescription for pazopanib and on the insis-tence of his wife. She said that the main reason for her husbandmissing the check-ups was his fear of receiving bad news. His maincomplaints were diarrhoea, his hair becoming white, and a lack ofcompliance with his antihypertension medicine.

In summary, although this patient had a severe, progressivedisease, he had an acceptable QoL. This is because he had differentcoping strategies than those of the patient in case study 2 illus-trated by the fact that he had bought a new sports car, showingthat he saw his prognosis in a different way.

In general, it is important to remember that thyroid cancer is adisease with rising incidence but decreasing mortality in Austriaand throughout the whole world [2,3], and this gap often leadsus to believe that a patient should not be worried by their thyroidcancer [1]. However, this is not very helpful, and physicians shouldavoid telling patients it could have been worse because thepatient is occupied with their own fate, asking why this happenedspecically to them, even when they appear to be trying to makethe best out of their situation.

Hypocalcaemia is an issue in QoL (even more than laryngealnerve palsy, when it occurs unilaterally), and the side effects ofradioiodine should be considered, although there is no risk of infer-tility or genetic changes [4,5]. Most patients live long enough toexperience side effects and they can adversely affect QoL. Forexample, xerostomia occurs in 1020% of patients [6,7]. There isa low risk of induction of a second malignant tumour by radioio-dine, however, discussions centreing around this are controversial.Data on this issue are heterogeneous but there is a probable hazardratio of 1.2 and females are more at risk than men.

ogy 51 (2015) S1S5Therefore, in summary, physicians should not give positivediagnoses too readily, even if the statistics are in favour of goodnews. It is easier to turn indifferent news into good news than vice

ncolversa. Patients fear every check-up visit. Therefore, it is wise toschedule them as infrequently as possible. New drugs for treatingiodine-refractory tumours open new elds of possibilities and alsobring new side effects and new issues in medical training (if man-agement is not done by oncologists). Physicians should be madeaware of all side effects; it is crucial to realise that an informedpatient tolerates much more than an uninformed patient.

The psychologists view Dr. Eva Gamper

QoL encompasses a range of different concepts that are verydifcult to put into practice. In health care, for many years thesolution to this was to restrict the measurement of QoL to someof the symptoms, side-effects, and functioning, and to have theseitems rated by physicians. However, it was realised that theseproxy ratings had limitations, such as a low inter-rater reliability[8,9], a moderate agreement between proxy and patient reports[10,11], and loss of information through interpretation and transla-tion into medical terms [12]. Therefore, the use of patient reportedoutcomes (PROs) as an additional source of information is increas-ing in importance. According to the FDA, the denition of a PRO isthe report of a patients health condition coming directly from thepatient without any interpretation of the patients response by aclinician or anyone else [13].

The core concept of PRO research is health-related QoL (HRQoL),which comprises QoL domains that are inuenced by the diseaseand its treatment, i.e. HRQoL provides a measure that assesses apatients psychological, social and somatic status [14] and isexpected to predict the effect of therapy. In thyroid cancer researchHRQoL measurement is still uncommon. This could be becauseincident rates are small and it is very hard to collect sufcient data.However, it could also be due to a general opinion that QoL assess-ment is less important in this patient group because, comparedwith other cancer patients, they feel quite well. In addition, theprognosis is good, so there is no trade-off to be made betweensurvival and QoL when developing the treatment plan. However,does a good prognosis coupled with favourable treatment options(which might be the predominant features of thyroid cancer froma physicians point of view) really directly correlate with a goodpatient-reported HRQoL? The information found in the literatureshows that patients that have to go through thyroid withdrawal(i.e. endogenous TSH stimulation) clearly have an impairedHRQoL, in physical as well as in psychosocial domains [1517].Furthermore, this patient group reports worse HRQoL than patientswith exogenous TSH stimulation [1820]. There are conictingresults concerning the inuence of age and gender, and on if andwhen patients in recurrence reach general population levels ofQoL [17,2123]. Usually patients HRQoL decreases with age,except for anxiety and depression which might be more pro-nounced in younger patients. Furthermore, women report moreimpairments than men, especially in the emotional dimensions.The question of whether these age and gender patterns are thyroidcancer specic or if they only reect general response patterns(which can also be found in the general population) has beeninvestigated by Singer et al. [24]. They found that after controllingfor the effects of age and gender, thyroid cancer patients stillreported signicantly more impairment than the German generalpopulation in all but two domains (constipation and diarrhoea)of the Quality of Life Questionnaire Core-30 (QLQ-C30: function-ing: physical, role, emotional, social, cognitive; symptoms: fatigue,nausea/vomiting, pain, dyspnea, sleep, appetite, constipation,diarrhoea, nancial impact, and global QoL). In line with previousndings, patients reported not only physical but severe psychoso-

H. Duan et al. / Oral Ocial problems, especially in role functioning. The QoL impairmentsreported by thyroid cancer patients therefore cannot be attributedto the fact that the majority of the patients are female and thatfemales generally tend to self-report more problems inquestionnaires.

In summary, there are two very different perspectives on thy-roid cancer to be kept in mind. There is the medical expert, whocompares thyroid cancer with other cancers and might focus onits good prognosis and favourable treatment options (with few sideeffects and little social stigma). The expert may not even realise ifthe patient is under-reporting symptoms, as a low level of impair-ment would t the picture of the disease. Then there is the patientwho, although they need to know about the favourable prognosisand treatment options, still has to deal with a cancer diagnosisfor the rest of their life. Additionally, the patient may also havephysical impairments never experienced before, and which mayerode their QoL. In the case of radioiodine treatment, s/he has todeal with an unusual treatment including isolation for radioprotec-tion, which might augment the feeling of being socially marginal-ized as well. A range of emotional, social, and cognitive issues canbecome very burdensome and sometimes patients even worryabout the appropriateness of these problems and may feel guiltyfor taking psychological counselling help as they are expected tobe alright.

HRQoL assessment can contribute a great deal to bridging thegap between these 2 perspectives. It adds value by incorporatingthe patient perspective into both thyroid cancer research andclinical practice. Patients are very willing to provide informationon many aspects of their QoL and this can help the physician tounderstand patients concerns. Patients can be told what otherpatients have perceived, and this can improve patient-centred careand patientphysician communication. HRQoL assessment shouldbe encouraged; it is easy to perform and provides a lot of valuableinformation.

The patients view Dr. Heying Duan

Dr. Duan is a nuclear medicine expert, and has also been athyroid cancer patient, and therefore offered a unique perspectiveon the disease. In October 2002, Dr. Duan found a lump in her neck.She presented to her physician in January 2003 and was referred tothe nuclear medicine department. Two nodules in her thyroid werediscovered, which were classied as cold nodules by scintigraphyand surgery was performed 2 weeks later. Histology revealed apapillary thyroid carcinoma (pT2 without lymph node metastases).The diagnosis and treatment inuenced Dr. Duan to become anuclear medicine physician, and although she uses her personalexperience to reassure patients, she tries hard to maintain herobjective perspective.

In terms of QoL, when Dr. Duan had her rst appointment herTSH was slightly above 4.0 lU/L, which would not normally betreated, but she had severe fatigue. After surgery, the symptomswere even worse: constant tiredness and feeling cold, even anxietyattacks, and a range of other symptoms from total apathy to rest-lessness. When diagnosed, one of the rst questions she had waswill I die soon? but Dr. Duan then rationalised the diagnosis andtried not to blame herself or anyone else for the situation. Shewas also afraid for her fertility, especially after radioiodine therapy.Currently, Dr. Duan has no symptoms and her QoL is not affected atall by her thyroid cancer.

In retrospect, Dr. Duan would have liked more informationabout hypothyroidism and its related symptoms; at the time, shedid not understand if the symptoms were because of her diagnosis,if they were permanent, or if they would change her personality.Thankfully, the symptoms vanished following T4 substitution.

Dr. Duan felt that if the physicians had asked her more in depth

ogy 51 (2015) S1S5 S3questions about her QoL when she was experiencing thesymptoms, she would have understood more clearly that herexperiences were related to the hypothyroidism as a result of her

ncolthyroid carcinoma. In addition these symptoms would eventuallydisappear.

Dr. Gamper added that even carrying out a QoL assessment hasthe potential to improve patients QoL. Computer-assisted assess-ments allow real-time feedback of the patients QoL prole andenable the physician to very quickly get an overall picture of thepatients health status and to structure the consultation accord-ingly. QoL assessment can also help to overcome white coatsilence patients are often reluctant to discuss all of their symp-toms with their physician because of time pressures and a desire tonot burden the physician with emotional, social, or minor healthproblems. Thus, the questionnaire can be an effective and time-saving communication tool, allowing the physician to quicklyappraise if a patient needs symptom management, more medicalinformation, or referral to psycho-oncologists or social workers.

It is very difcult for patients to differentiate in HRQoL betweendisease-related QoL issues and other general stresses. Dr. Duanbelieves that the patients attitude to their diagnosis is paramount.If the patient deals with the diagnosis in a positive way, they cancope with the stresses and strains caused both by their diseaseand by their everyday life much more easily.

Still, every person has a different way of coping and counter-intuitively, thyroid cancer patients often have more severe psycho-logical problems than patients with a poor prognosis, who are occu-pied by juggling their treatment and side effects and are confrontedwith trying to survive every day. Singer et al. [24] reported that thy-roid cancer patients asked for psychological counselling support,but there are no published outcome data. Psychologists with train-ing in psychooncology do not need extra training to counsel thyroidcancer patients because many of the issues that arise are commonto all cancer patients. They certainly need background knowledgeof thyroid cancer including treatment options and sequelae. In par-ticular, the symptoms of hypo/hyperthyroidism as these mighteasily be misinterpreted as psychiatric symptoms.

Whatever perspective is examined, it is key to understand thatQoL and emotional burden is not directly related to the severity ofthe disease and that more research is needed to learn about thyroidcancer patients needs. However, the three cases presented high-light some fundamental points to be considered regarding thetreatment of thyroid cancer patients and their QoL:

A rm diagnosis improves the quality of patients experi-ences because speculative diagnosis can cause distress.

Despite the physician giving a favourable prognosis atdiagnosis, the patient is likely to focus on the negative ele-ments of the cancer diagnosis.

QoL can be improved by explaining that the frequency oflaboratory tests and check-ups do not necessarily relateto prognosis.

Patients have very different coping strategies which havean impact on their QoL.

Even though there is decreasing mortality associated withthyroid cancer, telling patients it could have been worseshould be avoided.

Hypocalcaemia and the side effects of radioiodine canadversely affect QoL.

It is easier to turn indifferent news into good news thanvice versa.

A patient, who is informed, and aware of all of the sideeffects of treatment, is likely to be more tolerant of treat-ment than an uniformed patient.

The use of PROs as an additional source of information is ofincreasing importance.

S4 H. Duan et al. / Oral O HRQoL measurement in thyroid cancer maybe uncommonbecause of the misconception that QoL is less importantin this group of patients than in other cancer patients. HRQoL assessment can contribute to bridging the gapbetween physicians and patients; improving communica-tion between them and potentially improving patientsQoL.

Conict of interest

None declared.

Acknowledgements

Genzyme sponsored this meeting. Lisa Chamberlain James, PhDof Trilogy Writing & Consulting Ltd. provided writing and editorialassistance. No competing interests have been declared.

References

[1] Easley J, Miedema B, Robinson L. Its the Good cancer, so who cares? Perceivedlack of support among young thyroid cancer survivors. Oncol Nurs Forum2013;40(6):596600.

[2] STATISTIK AUSTRIA. Krebsinzidenz (Neuerkrankungen pro Jahr)/Krebsmortalitt (Sterbeflle pro Jahr), [accessed 02.01.14].

[3] La Vecchia C, Malvezzi M, Bosetti C, Garavello W, Bertuccio P, Levi F, et al.Thyroid cancer mortality and incidence: a global overview. Int J Cancer 2014.http://dx.doi.org/10.1002/ijc.26251. October 4. [Epub ahead of print].

[4] Bal C, Kumar A, Tripathi M, Chandrashekar N, Phom H, Murali NR, et al. High-dose radioiodine treatment for differentiated thyroid carcinoma is notassociated with change in female fertility or any genetic risk to the offspring.Int J Radiat Oncol Biol Phys 2005;63:44955.

[5] Hyer S, Vini L, OConnell M, Pratt B, Harmer C. Testicular dose and fertility inmen following I(131) therapy for thyroid cancer. Clin Endocrinol (Oxf)2002;56:7558.

[6] Klubo-Gwiezdzinska J, Burman KD, Van Nostrand D, Mete M, Jonklaas J,Wartofsky L. Radioiodine treatment of metastatic thyroid cancer: relativeefcacy and side effect prole of preparation by thyroid hormone withdrawalversus recombinant human thyrotropin. Thyroid 2012;22:3107.

[7] Hyer S, Kong A, Pratt B, Harmer C. Salivary gland toxicity after radioiodinetherapy for thyroid cancer. Clin Oncol (R Coll Radiol) 2007;19:836.

[8] Brundage MD, Pater JL, Zee B. Assessing the reliability of two toxicity scales:implications for interpreting toxicity data. J Natl Cancer Inst1993;85(14):113848.

[9] Myers J, Gardiner K, Harris K, Lilien T, Bennett M, Chow E, et al. Evaluatingcorrelation and interrater reliability for four performance scales in thepalliative care setting. J. Pain Symptom Manage 2010;39(2):2508.

[10] Basch E, Jia X, Heller G, Barz A, Sit L, Fruscione M, et al. Adverse symptom eventreporting by patients vs clinicians: relationships with clinical outcomes. J NatlCancer Inst 2009;101(23):162432.

[11] Efcace F, Rosti G, Aaronson N, Cottone F, Angelucci E, Molica S, et al. Patientversus physician symptom and health status reporting in chronic myeloidleukemia. Haematologica 2013. November 15. [Epub ahead of print].

[12] Trotti A, Colevas AD, Setser A, Basch E. Patient-reported outcomes and theevolution of adverse event reporting in oncology. J Clin Oncol2007;25(32):51217.

[13] FDA: Guidance for Industry. Patient-reported outcome measures: use inmedical product development to support labeling claims. December 2009, [accessed 02.01.14].

[14] Velikova G, Stark D, Selby P. Quality of life instruments in oncology. Eur JCancer 1999;35(11):157180.

[15] Dow KH, Ferrell BR, Anello C. Quality-of-life changes in patients with thyroidcancer after withdrawal of thyroid hormone therapy. Thyroid 1997;7(4):6139.

[16] Luster M, Felbinger R, Dietlein M, Reiners C. Thyroid hormone withdrawal inpatients with differentiated thyroid carcinoma: a one hundred thirty-patientpilot survey on consequences of hypothyroidism and a pharmacoeconomiccomparison to recombinant thyrotropin administration. Thyroid 2005;15(10):114755.

[17] Tagay S, Herpertz S, Langkafel M, Erim Y, Freudenberg L, Schpper N, et al.Health-related quality of life, anxiety and depression in thyroid cancerpatients under short-term hypothyroidism and TSH-suppressivelevothyroxine treatment. Eur J Endocrinol 2005;153(6):75563.

[18] Schroeder PR, Haugen BR, Pacini F, Reiners C, Schlumberger M, Sherman SI,et al. A comparison of short-term changes in health-related quality of life inthyroid carcinoma patients undergoing diagnostic evaluation withrecombinant human thyrotropin compared with thyroid hormonewithdrawal. J Clin Endocrinol Metab 2006;91(3):87884.

ogy 51 (2015) S1S5[19] Taeb D, Sebag F, Cherenko M, Baumstarck-Barrau K, Fortanier C, Farman-AraB, et al. Quality of life changes and clinical outcomes in thyroid cancer patientsundergoing radioiodine remnant ablation (RRA) with recombinant human TSH

(rhTSH): a randomized controlled study. Clin Endocrinol (Oxf)2009;71(1):11523.

[20] Lee J, Yun MJ, Nam KH, Chung WY, Soh EY, Park CS. Quality of life andeffectiveness comparisons of thyroxine withdrawal, triiodothyroninewithdrawal, and recombinant thyroid-stimulating hormone administrationfor low-dose radioiodine remnant ablation of differentiated thyroidcarcinoma. Thyroid 2010;20(2):1739.

[21] Crevenna R, Zettinig G, Keilani M, Posch M, Schmidinger M, Pirich C, et al.Quality of life in patients with non-metastatic differentiated thyroid cancerunder thyroxine supplementation therapy. Support Care Cancer2003;11(9):597603.

[22] Pelttari H, Sintonen H, Schalin-Jntti C, Vlimki MJ. Health-related quality oflife in long-term follow-up of patients with cured TNM Stage I or IIdifferentiated thyroid carcinoma. Clin Endocrinol (Oxf) 2009;70(3):4937.

[23] Tan LG, Nan L, Thumboo J, Sundram F, Tan LK. Health-related quality of life inthyroid cancer survivors. Laryngoscope 2007;117(3):50710.

[24] Singer S, Lincke T, Gamper E, Bhaskaran K, Schreiber S, Hinz A, et al. Quality oflife in patients with thyroid cancer compared with the general population.Thyroid 2012;22(2):11724.

H. Duan et al. / Oral Oncology 51 (2015) S1S5 S5

Quality of life aspects in the management of thyroid cancerIntroductionThe physicians view Dr. Alexander BechererThe psychologists view Dr. Eva GamperThe patients view Dr. Heying Duan

Conflict of interestAcknowledgementsReferences