Thyroid Cancer: Overview And Peculiar Aspects In Philippines Nemencio A. Nicodemus Jr., MD

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1 16 April 2016, Manila, Philippines Thyroid Cancer: Overview And Peculiar Aspects In Philippines Nemencio A. Nicodemus Jr., MD IMPROVING THE PATIENT S LIFE THROUGH MEDICAL EDUCATION

2 Learning Objectives Describe the burden of differentiated thyroid carcinoma in the population Report data on epidemiology of thyroid carcinoma in Philippines Describe the peculiar clinical features of differentiated thyroid carcinoma in Philippines respect to other countries Describe the impact of thyroid carcinoma on health system in Philippines

3 Prevalence of Goiter in the Philippines is Increasing! ,9 6,7 3, National Nutrition Survey, DOST-FNRI, 1987, 1993 RaboccaJC, et al. for the PSEM PhilTiDesWorking Group. JAFES; 27(1): 27-33, May 2012

4 PhilTiDeS: Prevalence of Goiter in the Philippines 44%of goiters are nodular RaboccaJC, et al. for the PSEM PhilTiDesWorking Group. JAFES; 27(1): 27-33, May 2012

5 Iodine Status and Thyroid Nodules To determine the association of iodine deficiency with thyroid carcinoma among adult Filipinos Cross sectional study of 164 Filipinos 18 years old and above with nodular goiters who underwent thyroidectomy Prevalence of iodine deficiency among patients with thyroid nodules: 63.4% It may be a risk factorfor nodular thyroid disease Ejercito-De Jesus RE, et al Phil J Internal Medicine.46:27-34, Jan-Feb 2008

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8 5-Year Data on Prevalence of Thyroid Malignancies in a Tertiary Government Hospital Cross-sectional study of the of patients who underwent thyroid surgery (primary surgery, repeat surgery) between January 2006 and December 2010 Total cases: 1, (29.7%) were malignant 1204 (86.3%) were females Holgado JWA and Gloria JDLS, Philippine General Hospital Department of Otorhinolaryngology, unpublished

9 Overall distribution of thyroid lesions, 2006 to 2010 Holgado JWA and Gloria JDLS, unpublished

10 Distribution of thyroid malignancies, 2006 to 2010 Holgado JWA and Gloria JDLS, unpublished

11 Frequency of thyroid malignancies by age group, 2006 to 2010 Mean age = 44.8 years [13 87 years] Holgado JWA and Gloria JDLS, unpublished

12 Frequency of thyroid malignancies by sex, 2006 to 2010 Holgado JWA and Gloria JDLS, unpublished

13 Comparison of the frequencies of the three most common thyroid malignancies by sex, 2006 to 2010 Holgado JWA and Gloria JDLS, unpublished

14 Ten Most Common Cancer Sites in Metro Manila & Rizal For The Period , Both Sexes Proportion Of Cases NHL Prostate Ovary Retum Thyroid Colon Cervix, uteri Liver Bronchus, lung Breast 3,1 3,5 3,5 3,5 4,3 5,4 6,1 6,5 12,9 16, Redaniel MTM, et al. Cancer in the Philippines Vol , 2008

15 Ten Most Common Cancer Sites in Metro Manila & Rizal For The Period , Females Proportion Of Cases NHL Rectum Liver Corpus uteri Colon Bronchus, lung Thyroid Ovary Cervix, uteri Breast 2,5 2,8 3,1 4,2 4,6 6 6,1 6,2 10, Redaniel MTM, et al. Cancer in the Philippines Vol , 2008

16 The Incidence Of Thyroid Cancer In Males Has Been Almost Stable, Metro Manila and Rizal Province, Medina VM, et al. Cancer in the Philippines Vol part 2, 2011

17 In females, the incidence of thyroid cancer has been increasing, Metro Manila and Rizal Province, Medina VM, et al. Cancer in the Philippines Vol part 2, 2011

18 Trend of the frequency of benign and malignant thyroid lesions, 2006 to 2010 Holgado JWA and Gloria JDLS, unpublished

19 Trend of the frequency of papillary thyroid carcinoma cases, 2006 to 2010 Holgado JWA and Gloria JDLS, unpublished

20 Features of Malignant Thyroid Nodules Among Filipinos To determine the clinicopathological, biochemical, and sonographicfeatures of thyroid nodules predictive of malignancy among adult Filipino patients 837 Filipino patients 19 years of age who underwent thyroid surgery from 2008 to benign and 420 malignant tumors Canete EJ, et al. Endocrinol Metab 2014;29:

21 Factors Predictive of Malignancy in Thyroid Nodules Factor Odds Ratio P value Hard nodule 58.8 <0.001 Firm nodule 12.8 <0.001 Presence of microcalcifications 11.1 <0.001 Irregular margins on ultrasound 4.5 <0.001 Absence of associated symptoms 2.3 <0.002 Canete EJ, et al. Endocrinol Metab 2014;29:

22 Thyroid Cancer Outcomes in Filipino Patients 499 patients with thyroid cancer (36 Filipino and 463 non-filipino) treated at mount sinai hospital Minimum 5-year follow-up period Minimum 1.0-cm tumor size Outcomes measured: thyroidcancer recurrence, rate of death from disease and time to recurrence Kus LH, et al. Arch Otolaryngol Head Neck Surg. 2010;136(2):

23 Filipino patients are significantly more likely to develop thyroid cancer recurrence Filipino patients (n=36) Non-Filipino patients (n=463) Adjusted OR Recurrence 9 (25.0%) 44(9.5%) 6.99* (95% CI, ) Death 2 (5.6%) 9 (1.9%) 2.96 (95% CI, ) *Controlled for sex, age group, history of head and neck radiation therapy, family history of thyroid cancer, tumor size, tumor pathologic findings, stage of primary disease, use radioactive iodine therapy, use of external beam radiation therapy, and type of thyroid surgery Kus LH, et al. Arch Otolaryngol Head Neck Surg. 2010;136(2):

24 Difference in the time to recurrence between the groups is not significant The mean times to recurrence were 52.6 months (range, months) for Filipino patients and 53.1 months (range, months) for non-filipino patients Kus LH, et al. Arch Otolaryngol Head Neck Surg. 2010;136(2):

25 Risk Factors for Recurrence with Well-Differentiated Thyroid Cancer 649 patients with papillary thyroid cancer (PTC) and 79 patients with follicular thyroid cancer (FTC) Mean follow-up: 53±12 (PTC) and 83±23 (FTC) months Tumor recurrence was assessed only after thyroidectomy: Elevated stimulated (>2 μg/l) or unstimulated(>1 μg/l) serum thyroglobulin after thyroidectomy and radioactive ablation Recurrent or new-onset lymphadenopathies proven to be thyroid cancer by biopsy or radioiodine scan Recurrent or new-onset distant metastases proven to be thyroid cancer by biopsy or radioiodine scan. Lo TEN, et al. Endocrinol Metab 2015;30:

26 Risk Factors for Recurrence in Filipinos with Well-Differentiated Thyroid Cancer Papillary thyroid cancer Risk factor Odds ratio (95% CI) Age >45 yr 1.44 ( ) Lymph node metastases at presentation (N1) 4.00 ( ) Distant metastases at presentation (M1) 2.78 ( ) Multifocality 1.43 ( ) Follicular variant histology 0.60 ( ) Postsurgical radioactive ablation 0.31 ( ) Follicular thyroid cancer Distant metastases at presentation (M1) 19.4( ) Postsurgical radioactive ablation 0.41 ( ) Lo TEN, et al. Endocrinol Metab 2015;30:

27 Lymph node metastases at presentation is the strongest predictor of recurrence in PTC Lo TEN, et al. Endocrinol Metab 2015;30:

28 Distant metastases at presentation is the strongest predictor for FTC recurrence Lo TEN, et al. Endocrinol Metab 2015;30:

29 Implication Stratification of WDTC based on recurrence risk factors will be helpful in guiding the intensity of treatment strategies and long-term thyroid cancer surveillance Lo TEN, et al. Endocrinol Metab 2015;30:

30 Five-year relative survival (%) of cancer patients adjusted to the World Standard Cancer Patient Population, Site Philippine residents Filipino-Americans Caucasians Period Estimate SE Period Estimate SE Period Estimate Stomach Colorectal Liver Lung Leukemia Breast Cervix Ovary Thyroid SE Laudico AV, et al. Jpn J Clin Oncol 2010;40(7)

31 Thyroid Cancer In The Philippines Less than a third of thyroid nodules are malignant The prevalence of thyroid malignancies is slowly increasing, particularly in women and in the productive age group (21 to 60 years old) Well-differentiated thyroid carcinomas (Papillary, Follicular) with good prognoses are the most predominant types Filipino patients are at higher risk for recurrence Lymph node and distant metastases are the strongest predictors for recurrence

32 Impact on Philippine Health System After diagnosis and initial management of thyroid cancer, surveillance and monitoring is life-long Loss of productivity due to illness and expense of surveillance and monitoring greatly impact on the cost for the patient At present, patients pay out-of-pocket for their health maintenance Given that prognosis is good and treatment is costeffective, the government must increase its coverage for thyroid cancer management and monitoring

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