Special considerations required to manage DTC in pregnant, elderly patients

BOSTON — Managing differentiated thyroid cancer in pregnant women and elderly patients requires special considerations, according to Steven I. Sherman, MD, chair, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas, MD Anderson Cancer Center.

Thyroid cancer, particularly papillary, is the second most common cancer diagnosed in pregnancy, followed by breast cancer. Data show that disease is most commonly diagnosed during the third trimester or in the first three to six months after (Am J Obstet Gynecol. 2003;189:1128-1135). This may be attributed to a closer degree of observation or some detection component during pregnancy and postpartum, Sherman said.

The American College of Obstetrics and Gynecology provided a recommendation in 2003 that states: “Although there are no data to support specific recommendations regarding nonobstetric surgery and anesthesia in pregnancy, it is important for nonobstetric physicians to obtain obstetric consultation before prescribing nonobstetric surgery.” ATA guidelines from 2006 recommend sonographic monitoring for malignant nodules discovered early, surgery if there is substantial growth at 24 weeks’ gestation, and surgery after pregnancy if the nodule remains stable or is diagnosed in the second half of pregnancy.

Several considerations may limit surgical options in elderly patients with thyroid cancer. One, the disease tends to be more aggressive biologically, according to Sherman. Elderly patients are at increased risk for comorbidities, such as higher rates of asthma, emphysema and congestive heart failure, among others. Notably, curative surgery is not feasible in 10% of patients older than 75 years due to presence of comorbidities, he said. This population also has a higher rate of refusal of consent, and may be less likely to want surgery. Background health should color some of the decision-making when managing thyroid cancer in elderly patients, according to Sherman. – by Katie Kalvaitis

The interesting thing for me was not necessarily about thyroid cancer per se, but the study from California on how much more cancer is diagnosed around the time of pregnancy because women are being screened more and going to the doctor more.

– David S. Cooper, MD

Director, Division of Endocrinology, Sinai Hospital of Baltimore

For more information:
Sherman SI. Special problems: managing DTC during pregnancy and in elderly patients. Presented at: American Thyroid Association Frontiers in Thyroid Cancer; July 11-12, 2008; Boston.