The link between thyroid cancer and breast cancer

 Before I quote my two sources to back up the title of this blog, I would like to repeat the definitions of having a recurrence versus having a second primary cancer. A recurrence is when one has cancer after treatment is completed. But it is the SAME type of cancer. Having a second primary cancer is a cancer survivor developing a new unrelated ( or different) type of cancer. 

According to the American Cancer Society, " People who have or had thyroid cancer can get any type of cancer, but they have an increased risk of developing:

*Breast cancer

* Prostate cancer

*Kidney cancer

*Adrenal cancer- which is especially high in people who had the medullary type of thyroid cancer.

Patients treated with radioactive iodine also have an increased risk of acute lymphocytic leukemia ( ALL), stomach cancer and salivary gland cancer."

The second quote is from the article "The Breast-Thyroid Cancer Link: A Systematic Review and Meta-Analysis" This study is published in the Cancer Epidemiol Biomarkers Prev, 2016 Feb: 25(2): 231-238 and can be accessed from HHS Public Access. The study is authored by Sarah Nielsen, Michael White, et.al.

" Rates of thyroid cancer in women with a history of breast cancer are higher than expected. Similarly, rates of breast cancer in those with a history of thyroid cancer are increased. Explanations for these associations include detection bias, shared hormonal risk factors, treatment effect, and genetic susceptibility. With increasing numbers of breast and thyroid cancer survivors, clinicians should be particularly cognizant of this association. "

I had papillary with follicular variant thyroid cancer in 2010, then invasive lobular breast cancer in 2015. I have been interested in the relationship between these two cancers ( I think that this fact has now been established) for some time now. When I woke up from the anesthesia after my bilateral mastectomies for breast cancer, one of the first questions I asked was " were there any thyroid cancer cells present in my breast cancer tissue?" The answer to that was no, of course. At the time I did not know about the difference between having a recurrence and having a second primary cancer. I did suspect that there was some connection, I just had not been able to find one in the literature- until recently. 

I am relaying this information, not to scare anyone, but to emphasize what women with breast cancer or thyroid cancer may want to do. First, make sure that your physician is aware of the link between breast and thyroid cancer. Breast and/or thyroid cancer patients should:

* Get regular checkups and mammograms ( if this applies- in other words, if the woman has not had bilateral mastectomies)

* Eat a well balanced diet and stay at a healthy weight

* Exercise regularly

* Get plenty of sleep

* Limit alcohol consumption

* Stop smoking, and limit exposure to places where tobacco smoke is present

It is important to let your physician know of any unusual symptoms that one is having. Additional testing ( other than scheduled screening exams- colonoscopies, mammograms ( if appropriate),etc) is not recommended if patients do not present with symptoms that could indicate illness. This is a subject that patients feel differently about. On the one hand, a test that MIGHT show an early stage cancer or spread of a previous cancer would seem like a good idea. But testing anxiety, possible over-exposure to radiation from unnecessary imaging are two things that need to be considered before testing. It is important for the patient to have regular follow up by their physician(s) though. Early detection is, of course, important in the successful treatment of any cancer. 

I have seen different percentages in several articles that I have read about the thyroid-breast cancer link. The most startling one is in an article called: A Linkage Between Thyroid and Breast Cancer: A Common Etiology? This article is in Cancer Epidemiol Biomarkers Prev ( 2019) 28(4) 643-649, by Eric Bolf, Brian Sprague and Frances Carr. According to their study: 

" Women with breast cancer are 2-fold more likely to develop future thyroid cancer and women with thyroid cancer have a 67% greater chance of developing breast cancer than the general population. The etiology of these cancers and possible causative factors are at an infancy stage and just beginning to be studied. Further investigation into the genomics and epigenetics underlying both breast and thyroid cancer can yield clues...as to who are at greatest risk. "

The take away from my blog, and my own personal advice here- what I consider important and what pertains to my situation ( we are all different)  is to get regular mammograms and neck checks. And if I was able to do anything over, it would be to get 3D mammograms AND ultrasounds once or twice yearly. It might have taken me a little while to talk my physician into ordering this, and yes, I may have had to pay for some or all of the tests, but to me, it would have been worth it. I had dense breast tissue with calcifications.  I was diagnosed as having stage 2B invasive lobular breast cancer. I had bilateral mastectomies and 3 months of chemotherapy, which I feel saved my life. I would have liked to have been diagnosed  earlier, though. I was unfortunately not aware of the connection between these two cancers or I would have been a better patient advocate for myself. Please do not skip your yearly or bi-yearly mammograms! And please have your physician do a neck check, and even an ultrasound to check for nodules- especially if thyroid disorders or thyroid cancer are common in your family. This is the advice that I give to my daughter and this is the advice that I give to you. 

Total thyroidectomy versus Partial thyroidectomy- some pros and cons

 The debate between getting a total thyroidectomy (TT) and a partial thyroidectomy ( PT) is usually a heated one. Reading posts over the years, from thyroid cancer patients on various thyroid cancer websites, it seems to me that people feel strongly one way or the other ( TT or PT). I believe that this is not a " one solution fits all" but there are several things to consider with both surgeries. I have tried my best to present the arguments for both groups in a non-biased manner, but I need to make a disclosure. For my thyroid cancer ( stage III, papillary with follicular variant) my surgeon and I decided it was best to go with a TT. Before the surgery, I did ask the surgeon for a PT and he said " No way! I have been doing this surgery for many years now, and I have seen too many people who had PTs have to come back to have the other side removed." Well, at the time I was a little upset at his remarks, but as it turned out, I did indeed have a cancerous tumor in the other side ( unknown until final biopsy ) that would have had to be removed with a second surgery. In my case, I was fortunate that my surgeon " recommended" a TT over a PT. In spite of my experience, I will present the pros and cons of both. And as I said, hopefully, in a non-biased manner.

My information for this blog comes from an article that I read on the Thyca.org website. ( wonderful website- every thyroid cancer patient can benefit from frequent visits to this site) The article is titled: ATA Thyroid nodule/DTC guidelines, by Haugen ET AL. This is a long and rather complex article, but with time and a little patience, I think it is worth the read. 

I think that a lot of us, including myself, have had a biopsy or two that came back as inconclusive ( the article refers to this as being a nodule that is " cytologically indeterminate ". ) There are two recommendations for this situation. One suggested recommendation would be a PT. Another recommendation would be the TT. The reasons given for the TT are that the nodule looked suspicious upon further analysis, the nodule looked suspicious when an ultrasound was performed, the nodule was large ( here the author defined this as greater than 4 centimeters) , the BRAF gene was present, there was a family history of thyroid cancer, or the patient had a history of radiation exposure. I really had not heard of the BRAF gene until recently. For those of you who, like me, were not familiar with this gene here is a simple definition: the BRAF gene, when mutated, can cause normal cells to become cancerous. This gene is most common in melanoma, but can also play a role in other types of cancer. 

When there are more than one nodule, every nodule ( this study recommends biopsy on nodules 1 centimeter or greater ) should be biopsied. The risk of cancer is the same as with patients who have only one nodule. The follow up with patients with multiple nodules can be: 1) wait and see- repeat FNA as prescribed by the physician 2) PT or 3) TT. 

The risks of doing a PT are fairly obvious. There may be malignancy in the other lobe that has not been detected or presents with a false negative after FNA. If there is a malignancy in the other lobe, then the patient will have to undergo a second surgery. There could also be spread of the thyroid cancer if cancerous nodes are not detected and removed. 

Now for the pros.  Having a PT, when appropriate, has less impact on the voice ( vocal cord damage). Also, the remaining thyroid lobe may produce enough thyroid hormone that supplementing with thyroid hormone will not be necessary.  When having a PT, there is less chance that the parathyroid glands will be damaged. ( there are four parathyroids; they are near proximity to the thyroid and while do not participate in thyroid hormone production, produce parathyroid hormone (PTH) which regulates the amounts of calcium, phosphorus, and magnesium in bones and blood. A person can get by with only one parathyroid, but may need calcium supplementation. If all four are removed, a person will need calcium supplementation for life.) 

After a TT, thyroid hormone replacement is mandatory. A patient cannot survive without hormone therapy. This means frequent trips to get blood work done so that TSH, free T4, T3 and other blood values remain in the correct range. I think that people who have not had to have their thyroid removed or those that are hypothyroid for other reasons, do not realize that it is not a " one and done" kind of thing. There are changes in the body (ex: weight changes, dietary changes, other medications added) as well as how one takes their medication, drug manufacturer practices - potency and consistency in strength and dosage of the thyroid hormone drugs. Many factors contribute to the necessity of consistent blood work so that thyroid patient's bodies are working correctly and the patients are feeling well. It is also very important that before a TT, a patient needs to be sure that the surgeon has experience in doing this surgery. As stated above, it is extremely important to keep as many parathyroids as possible. To explain why a skilled surgeon is vital, the parathyroid gland is the size of a grain of rice! It is also important for the surgeon to take care with the vocal cords, which are in close proximity to the thyroid gland. 

For the pros of having a TT: well, the cancerous nodules are gone, unless they have spread into the lymph nodes or vascular tissues. A patient may decide, along with their physician, that a TT will prevent a possible second surgery. One can not discount peace of mind, when TT is appropriate. 

In conclusion, having a PT versus a TT should be based on tests ( FNA, ultrasounds, etc) recommendations from a patient's endocrinologist, physician and/or surgeon, and most importantly, what a patient prefers and feels is right for them.  This is a personal decision and there is no one choice that is right for everyone. 

Peripheral Neuropathy caused by chemotherapy medications and possible new treatment / preventative options

 When I was diagnosed with stage II-b invasive lobular breast cancer, my oncologist decided on chemotherapy after my bilateral mastectomies. I had chemotherapy treatments for three months following my surgery. Along with the five pre-treatment IV medications, I started out with Cytoxan and Taxotere ( docetaxal) as prescribed by my oncologist. Taxotere is a much used, and effective, chemotherapy drug used in treating breast, lung, stomach, prostate, head and neck cancers, among other types of cancers. Of course, as we all know, even the best medications have side effects. When I was practicing pharmacy, before I retired, I always said that it is a balancing act when starting any new  medication. One must look at the benefits versus the side effects of the drug, and decide on the appropriate action. I knew that Taxotere had some pretty bad side effects, but I felt that it was worth the risk of the possible side effects in order to kill the cancer cells. 

After my second treatment, though, I developed peripheral neuropathy in my toes, left foot, and some of my fingers. For those of you who wonder what peripheral neuropathy feels like, I think that it is somewhat different for each person. Some of my fingers were numb and tingling, and when I was barefoot, I felt that I was walking on carpet or cotton balls. In other words, my feet and toes were numb. I also experienced " pins and needles" feelings in my toes and feet at times.  My oncologist immediately stopped the Taxotere, and switched me to a regiment of Adriamycin ( doxorubicin) and Cytoxan. Adriamycin is " lovingly" referred to as the " Red Devil" by patients - probably due to it's high percentage of causing nausea and vomiting and the blood red color of the drug after it is reconstituted. It also can be very toxic to the heart, but peripheral neuropathy is not as common as it is with Taxotere.

I would love to say that my peripheral neuropathy went away, but it did not. Well, not in all locations. My fingers returned to normal, my right foot and affected toes still tingle sometimes, but not as badly. My left foot and toes are pretty much forever numb, and I still experience the "pins and needles" feeling at times.  This affects the type of shoes that I wear, among other things. I understood the risks of taking Taxotere, and for me it was at least, worth a try. I do not want a recurrence of my breast cancer or the risk of spread somewhere else, and there is the fact that the taxanes ( Taxotere is one of a class of these drugs) are very effective in killing cancer cells.

So, if cancer patients taking one these drugs develop peripheral neuropathy is there a treatment for this? The answer is no, not as yet. A more effective way is using  one or more treatments before the neuropathy starts. There are some studies that are trying to determine what type of patient might be more apt to develop neuropathy. Some possible red flags include patients who previously have had peripheral neuropathy, perhaps diabetics and older patients who might already have some nerve damage. Also, the neuropathy might be due to the number of chemotherapy cycles received. 

Some treatments that are being studied include the following: exercise, acupuncture, and cryotherapy ( or cold therapy). Exercise: a study involving aerobic exercise at home for a small group of patients for a period of six months reported significant improvement in their neuropathy. ( published in JAMA, August 1, 2023) There are no specific treatment guidelines for this in treating peripheral neuropathy. I think everyone would agree that exercise has many benefits, though. 

Acupuncture: there was a 2019 study in "Current Oncology "evaluating acupuncture in a small group of patients. The results were mixed- some benefited and some did not. This study concluded with the statement that more research is needed to determine the possible benefits of acupuncture and possible improvement of  neuropathy. There was an even smaller study conducted by researchers at Sloan Kettering Cancer Center in New York ( Jama Network Open, March 11, 2020) that concluded that after eight weeks of acupuncture, patients experienced less pain with their neuropathy. Acupuncture techniques vary, and clearly more studies are needed to determine the effectiveness of this treatment for neuropathy. 

Cryotherapy: where exercise and acupuncture are more treatments, cryotherapy is more of a preventative measure. I think a lot of people know about the " cold caps" that help prevent hair loss on the head 

 during chemotherapy. This is a similar technique, but instead of a cap, this involves frozen gloves and booties for the hands and feet. Again, more studies are needed to determine if this is an effective treatment to prevent peripheral neuropathy. 

I think an important take away from this and my personal story, is that patients need to be sure to tell their oncologists about ANY unusual symptoms that they may be experiencing during chemotherapy. Establishing a good relationship between patient and their oncologist is key in getting good treatment and having a good outcome. Quality of life after chemotherapy treatment is extremely important for the patient as well as the patient's family. 

Here are a few things that everyone needs to know about skin cancer.

 Everyone who reads by blogs, thank you- by the way!- knows that I am a thyroid cancer survivor as well as a breast cancer survivor. What I have not talked about is that I also am a skin cancer survivor. I had thyroid cancer in 2010, and breast cancer in 2015. In between those two cancers, I had squamous cell carcinoma on my leg, and basal cell carcinoma on my face. The treatment for both cancers was surgery; no other treatment was required, because they were detected early and had not spread to any of my lymph nodes. Early detection and treatment is KEY so I decided to provide some skin cancer facts, as well as suggested ways to prevent skin cancer. 

First of all, skin cancer is the MOST common cancer in the United States, according to the American Academy of Dermatology ( AAD). Listed below are some more facts about skin cancer from the AAD:

* It is estimated that one out of five Americans will develop skin cancer in their lifetimes.

*Approximately 9,500 people EVERY DAY in the U.S. are diagnosed with skin cancer.

*Non-melanoma skin cancers ( basal and squamous cell) affect more than 3 million Americans per year.

* Women have a greater increase of having basal and squamous cell cancer compared to men.

* Melanoma ( the most serious and deadly type of skin cancer) is said to be the fifth most commonly diagnosed cancer in men and women.

*Melanoma rates in the U.S. have doubled over the past 30 years.

* The good news is that melanoma incidence has begun to decline in adolescents and adults 30 years of age and younger.

* Skin cancer can affect anyone- regardless of skin color.

* Skin cancer rates are higher in women than in men before age 50, but are higher in men after age 50.

* It is estimated than melanoma will affect 1 in 27 men and 1 in 40 women during their lifetimes.

* Basal cell and squamous cell carcinomas, which are the two most common types of skin cancers, are highly treatable if detected early and treated appropriately.

The AAD encourages everyone to use sunscreen, wear protective clothing ( long sleeve shirts, pants, and a wide brimmed hat) as well as avoiding indoor tanning beds. The best, most protective outdoor clothing has ultraviolet protection factor ( UPF) on the label. Severe sunburns as a child increase the likelihood of skin cancer as an adult, so children need to be protected appropriately. 

* Risk factors for ALL types of skin cancer include people with skin that burns easily; blonde or red hair ( I have red hair!); a history of excessive sun exposure; frequent sunburns- especially as a child; tanning bed use; a weakened immune system; and a history of skin cancer.

I could not find, in the articles that I read, a consensus on how often a person should see a dermatologist for a skin check. Just from personal experience, I would recommend sooner rather than later, especially for cancer patients who have weakened immune systems. It is important to self check one's skin and pay attention to any moles or spots that change, darken or bleed, as well as irregularly shaped places that may be crusty and red in color. 

Personally, I go once a year to see my dermatologist ( I went more often right after my basal and squamous cell carcinomas were diagnosed) for a full body skin check. I can go more often if I need something checked out. Right before Christmas, I had a pre-cancerous lesion removed from my scalp. First, my dermatologist did a biopsy ( we cancer patients sure are familiar with THOSE) and in the abundance of caution, the lesion was removed. I had had this " spot" for quite some time, and my dermatologist felt that it was wise to remove it before it became cancerous. Yes, I had stitches in my head for Christmas...I did get two cute hats, though!

Seriously, skin cancer is , as the AAD said, the most common cancer in the United States. Survival rates for basal and squamous are very good if detected and treated early. Even with melanoma, according to AAD statistics, the five year survival rate for people whose melanoma is detected early with no spread to lymph nodes is 99%. That is compared to 68% if the melanoma has spread to the lymph nodes and 30% if the melanoma has spread to distant lymph nodes and other organs in the body. 

The take away from my blog would be this: use sun protection regularly, avoid tanning beds at all costs,  and get a full body skin check once a year or as often as your dermatologist recommends. The National Institutes of Health describes our skin as " the largest organ in the body, and covers the body's entire external surface." If we take care of our skin, it will take care of us.