Anxiety, depression common at follow-up after differentiated thyroid cancer
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More than one-third of patients treated for differentiated thyroid cancer reported elevated anxiety and more than 15% reported a high level of depression at an annual follow-up, according to study findings published in Thyroid.
In an analysis of data from more than 600 survivors of differentiated thyroid cancer at a clinic in Germany, permanent hypoparathyroidism was a predictor for high anxiety and high depression. Women, adults with a higher BMI and those with permanent recurrent laryngeal nerve damage were also more likely to have a high level of anxiety, whereas elevated antithyroglobulin antibodies and the presence of digestive or genitourinary system comorbidities were predictors for a high level of depression.
“Survivors of differentiated thyroid cancer experience reduced quality of life, not only compared to the general population, but even in comparison to survivors of other cancer types that have worse survival and more invasive treatment,” Benjamin Noto, MD, nuclear medicine specialist in the clinics for radiology at University Hospital Münster in Germany, told Healio. “This is often overlooked and difficult to understand for the caring physician due to the generally excellent prognosis of the disease.”
Researchers conducted a retrospective cross-sectional study of patients with differentiated thyroid cancer attending an annual follow-up appointment at a tertiary referral hospital in Germany from 2014 to 2019. All patients were asked to complete the Hospital Anxiety and Depression Scale questionnaire prior to the appointment. Higher scores indicated higher levels of anxiety and depression, with a score of 8 of 21 defined as the cutoff for high levels of either condition. Serum thyroid hormone levels were measured at the follow-up. Participants were identified as having permanent hypoparathyroidism if parathyroid hormone levels were below the reference value in a 2021 follow-up or at any other time point more than 12 months after thyroidectomy and they had documented hypocalcemia at least 1 year after thyroidectomy. Patients were categorized as having permanent recurrent laryngeal nerve injury if vocal cord paresis after surgery persisted for more than 12 months and was confirmed by laryngoscopy.
There were 640 patients who completed the questionnaire during the study period (mean age, 50 years; 73% women). Of the study cohort, 37.6% had an anxiety score of at least 8 and 15.7% had a depression score of at least 8. Permanent hypoparathyroidism was identified in 13%, and 4.8% had recurrent laryngeal nerve damage.
Predictors for anxiety and depression after thyroid cancer
In multivariable analysis, elevated anxiety scores were more likely to be observed in women (adjusted OR = 1.9; 95% CI, 1.2-3.2; P < .01) and adults with an elevated BMI (aOR = 1; 95% CI, 1-1.1; P = .02), permanent recurrent laryngeal nerve damage (aOR = 2.6; 95% CI, 1-6.3; P = .04), permanent hypoparathyroidism (aOR = 2; 95% CI, 1.1-3.5; P = .02), or comorbidities classified in the chapter on external causes of morbidity and mortality of the ICD code (aOR = 5.5; 95% CI, 1-29.6; P < .05) or the chapter on factors influencing health status and contact with health services in the ICD code (aOR = 1.7; 95% CI, 1.1-2.6; P = .03).
Predictors for high depression scores included permanent hypoparathyroidism (aOR = 2.2; 95% CI, 1.2-4.2; P = .01), antithyroglobulin antibody titer level (aOR = 1; 95% CI, 1-1, P = .04), the presence of digestive comorbidities in the ICD code (aOR = 3; 95% CI, 1.5-6.1; P < .01) and the presence of genitourinary comorbidities in the ICD code (aOR = 2.4; 95% CI, 1-5.7; P = .04).
“Quality of life seems to be especially impaired in patients with permanent hypoparathyroidism and recurrent laryngeal nerve damage,” Noto said. “Therefore, physicians involved in the follow-up of differentiated thyroid cancer patients should pay special attention to the emotional well-being of patients with permanent hypoparathyroidism or permanent recurrent laryngeal damage.”
Depression linked to high total blood calcium
Of 130 participants with permanent hypoparathyroidism, adults with elevated depression scores had a higher total blood calcium than those with a depression score of less than 8 (2.23 vs. 2.1 mmol/L; P = .02). No difference was observed in calcium or calcitriol substitution dosing. Anxiety scores were not associated with a difference in total blood calcium.
Noto said future research could examine quality of life of patients with malignant thyroid nodules vs. those who do not have cancer. More research is also needed to explore the link between hypoparathyroidism and anxiety and depression.
“The human parathyroid hormone 2 receptor, found in the central nervous system, binds and is activated at high potency by parathyroid hormone,” Noto said. “Further studies should investigate the action of parathyroid hormone in the central nervous system and if and how parathyroid hormone deficiency can contribute to anxiety and depression.”
For more information:
Benjamin Noto, MD, can be reached at benjamin.noto@ukmuenster.de.
Perspective
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A growing body of evidence demonstrates that survivors of differentiated thyroid cancer have decreased quality of life and other adverse psychosocial outcomes. These outcomes include, but are not limited to, worry about recurrence and financial strain as severe as bankruptcy. The findings of the current cross-sectional study by Noto and colleagues add important patient-reported outcome data on depression and anxiety, which negatively influence the quality of life of thyroid cancer survivors. Because the prognosis of differentiated thyroid cancer is generally excellent and the population of survivors consistently growing, it is imperative that the field identifies factors associated with adverse psychosocial outcomes as the authors have done, so that patients at highest risk can receive appropriate care.
A key finding of this study is that patients who experience complications from surgery, such as permanent hypoparathyroidism or recurrent laryngeal nerve injury, have disproportionately higher rates of depression and anxiety. The rates of these complications are known to be higher after total thyroidectomy compared to thyroid lobectomy (or hemi-thyroidectomy) because the extent of dissection is increased. Because current guidelines endorse treatment with thyroid lobectomy for patients with low risk of recurrence and differentiated thyroid cancers under 4 cm in size, surgeons must weigh the risk of complications and possible anxiety or depression when making treatment recommendations. Efforts to recognize and treat anxiety and depression in thyroid cancer survivors is also essential to providing holistic, optimal care.
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