Management of thyroid cancer in the Northern and Yorkshire region,

Transcription

1 Management of thyroid cancer in the Northern and Yorkshire region,

2 About Public Health England Public Health England s mission is to protect and improve the nation s health and to address inequalities through working with national and local government, the NHS, industry and the voluntary and community sector. PHE is an operationally autonomous executive agency of the Department of Health. Northern and Yorkshire Knowledge and Intelligence Team (NYKIT) Public Health England Waterloo Road Wellington House London SE1 8UG Tel: Facebook: Prepared by: Sarah Lawton For queries relating to this document, please contact: sarah.lawton@phe.gov.uk Crown copyright 2014 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v2.0. To view this licence, visit OGL or psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Any enquiries regarding this publication should be sent to [insert address]. Published July 2014 This document is available in other formats on request. Please call or publications@phe.gov.uk 2

3 Contents About Public Health England 2 Executive summary 4 Introduction 5 Data and methods 6 Incidence 7 Relative survival 10 Surgical workload (malignant and non-malignant) 13 Treatment modality 22 Thyroid cancer treatment modality by pathological type 22 References 25 List of tables 26 List of figures 26 Appendix 27 Page 3 of 29

4 Executive summary Cancer of the thyroid is rare, with just over 300 new cases diagnosed each year within the Northern and Yorkshire region, 2,024 in England and 2,377 in the UK. In 2004 the Northern and Yorkshire Cancer Registry and Information Service (NYCRIS) published a thyroid audit that looked at all thyroid cancers diagnosed in 1998 and 1999 within the NYCRIS region 5 The report looked at incidence, survival and patient management as the UK had poorer five year survival than some European countries. This report is the second thyroid audit that examines the management of patients and their outcomes, to identify if there has been any improvement in the last twelve years, comparing and thyroid diagnosed cancers. The results showed that fewer patients are being operated on by a surgeon who performs fewer than five surgical procedures a year (33% to 10%) and that surgery was still the most common intervention for thyroid cancer. Long term survival is dependent on the pathological type of the cancer, with papillary, follicular and medullary, still having excellent survival rates. Thyroid cancer survival has shown a 10% improvement since the last audit, nevertheless, when comparing pathological types; anaplastic thyroid cancer still has a very poor prognosis with one-year survival being 12% for England and 15% for NYCRIS. Anaplastic thyroid cancer tends to grow much faster than other thyroid cancers and is nearly always inoperable. Page 4 of 29

5 Introduction Cancer of the thyroid is rare, with just over 300 new cases diagnosed each year within the Northern and Yorkshire region, 2,024 in England and 2,377 in the UK. Thyroid cancers account for less than 1% of all cancers diagnosed. The most common types of thyroid cancer are papillary and follicular, both of which have excellent survival rates with 5 year survival being around 95-98%. Thyroid cancer is three times more common in females than in males. Thyroid cancer risk factors include radiotherapy treatment to the neck at a young age where the cancer may develop decades later; exposure to radiation at work and family history. Patients with a family history of papillary or follicular thyroid cancer are 4-5 times more likely to develop thyroid cancer compared to those with no history; however, this is a very small risk relative to the actual number of thyroid cancers diagnosed each year 3. Early symptoms include painless swelling in the thyroid, with more advanced signs of thyroid cancer being hoarseness, difficulty swallowing or breathing, a pain in the neck or in the throat 4. Firstly, an overactive or underactive thyroid gland needs to be ruled out with a thyroid function test. If these are normal then further tests need to be carried out to confirm a cancer diagnosis such as a fine-needle aspiration, (where a small needle is inserted into the lump and a sample of cells are taken which are then examined). If differentiated thyroid cancer (DTC) is found then often a total thyroidectomy is performed sometimes followed by radio-iodine. 5

6 Data and methods Data were extracted from PRAXIS (a local secure database that holds all cancer registrations from 1975) for three Cancer Networks in the Northern and Yorkshire Cancer Registry and Information Service (NYCRIS) region, Yorkshire Cancer Network (YCN), Humber and Yorkshire Coast Cancer Network (HYCCN) and North of England Cancer Network (NECN), for patients diagnosed with thyroid cancer (ICD-10 C73) between 2009 and All patients diagnosed with thyroid cancer (C73) were then split into separate pathological types (follicular, papillary, anaplastic, medullary and hurtle cell carcinoma). Splitting by pathological type excludes other thyroid cancer types that did not fall into one of these categories as they are more likely to be an advanced cancer type and not suitable for the types of treatment available for the above listed primary thyroid cancer types. Patients who received a hemithyroidectomy or a total thyroidectomy for malignant thyroid disease were extracted from PRAXIS; procedures extracted were OPCS B081-B086, B088, B089, and B091. For non-malignant thyroid disease data were extracted from Hospital Episodes Statistics (HES). Treatment modality describes the first of each treatment type a patient has received. Crude and age-standardised incidence rates (ASR) were calculated by sex and pathological type, as 5 year rolling averages from 2001 to 2010 and are expressed per 100,000 population. ASR rates do not directly represent incidence numbers (as larger areas and areas with elderly populations will have higher incidence), but allow comparisons between areas with different population structures as they have all been adjusted to the same standard population European standard populations were used. Crude incidence is defined as the ratio of the number of cases in each group over the relevant population at risk. Crude and relative survival rates were produced for persons diagnosed with thyroid cancer within , by pathological type. Relative survival is defined as the ratio of the observed (crude) probability of survival and the probability that would have been expected had the patients experienced the normal (background) mortality of the population in which they live, given the same distribution of factors such as age, sex and calendar year. Background mortality was calculated by Government Office Region using life tables provided by the Cancer Research UK Cancer Survival Group at the London School of Hygiene and Tropical Medicine. The estimated rates for incidence and survival have 95% confidence intervals (CI) attached. Total surgical workload has been defined as the total number of thyroidectomies a consultant performs per year. Malignant thyroid disease and non-malignant thyroid disease have been analysed separately. All information in this report is based on calendar years. Asterix denotes counts less than 5 (<5). Page 6 of 29

7 Age standardised rate (per 100,000) Management of thyroid cancer in the Northern and Yorkshire region Incidence By Pathological Type Figure 1 shows the trend of thyroid cancer incidence in NYCRIS and England, from to by pathological type. Local and national rates show that papillary incidence has increased year on year, with NYCRIS rates being slightly higher than the England rates, although not statistically significantly different. Papillary thyroid cancer has the highest incidence rates in both NYCRIS and England and has shown a statistically significant increase between and , from 1.66 (CI ) in rising to 2.58 (CI ) in Incidence trends by pathological type Anaplastic Follicular Hurtle cell Medullary Papillary Anaplastic Engl Follicular Engl Hurtle cell Engl Medullary Engl Papillary Engl Figure 1 - Incidence by pathological type Period of diagnosis Page 7 of 29

8 By pathological type and sex Figure 2 and 3 show, that during the most recent time period ( ) incidence rates for papillary cancer amongst females has increased significantly when compared to the ASR in (ASR=7.16, (CI: )) in and (ASR=11.51, (CI: )) in Additionally, papillary cancers have shown to increase amongst males, whilst this increase in males is not as high as it is amongst females the difference is significant, (ASR=2.14, (CI: )) in and (ASR=3.74, (CI: )). The incidence of follicular cancer amongst males has not increased over time but it has increased in females, however, the increase between and is not significant (ASR= 3.30, (CI: )) in and (ASR=4.40, (CI: )) in Figure 2 Incidence by pathological type males Figure 3 -Incidence by pathological type - females Page 8 of 29

9 By Cancer Network Figure 4 shows trends in incidence of thyroid cancer from to , by sex and cancer network, for all thyroid cancers combined. Thyroid cancer incidence amongst females is statistically significantly higher in compared to across all three cancer networks. Thyroid cancer incidence amongst males is also significantly higher in compared to but only in the Humber and Yorkshire Coast Cancer Network. Figure 4 - Incidence by cancer network and sex Page 9 of 29

10 Relative survival By pathological type Survival of thyroid cancer is dependent on the pathological type of the cancer. Crude and relative survival up to four years of follow-up was calculated for patients diagnosed between 2001 and 2005 and is presented in figures 5 and 6. Patients with anaplastic cell types have statistically significantly lower, one to two year survival than patients with follicular, papillary and medullary cell types. The relative survival rates represent the disease specific survival rates and show this difference more distinctly than the crude rates. The four-year relative survival rates for follicular (94%, (CI 89%-97%)), medullary (92%, (CI 69%-98%)) and papillary (97%, (CI 94%-99%)) contrast with the outcomes for anaplastic (1%, (CI 0.1%-8%)) cell types. Survival results for anaplastic were obtained for up to two years from diagnosis only; due to poor prognosis, a three or four year survival rate could not be calculated. Figure 5 - Relative survival by pathological type Figure 6 - Crude survival by pathological type Page 10 of 29

11 Relative survival (%) Management of thyroid cancer in the Northern and Yorkshire region Figure 7 shows one-year survival trends by pathological type from to in NYCRIS compared with England. Relative survival for medullary and papillary remains quite stable over time locally and nationally at around 95% to 98% respectively. Similarly, survival for anaplastic thyroid cancer does not show improvement over time, and remains low at around 15% to 12% for NYCRIS and England respectively. 120 One-year survival by pathological type Follicular Anaplastic Medullary Papillary Anaplastic Engl Follicular Engl Medullary Engl Papillary Engl Period of diagnosis Figure 7 One- year survival by pathological type Page 11 of 29

12 Relative survival (%) Relative survival (%) Relative survival (%) Relative survival (%) Management of thyroid cancer in the Northern and Yorkshire region By Cancer Network Figures 8-11 show survival by cancer network for all thyroid cancers combined (C73). Thyroid cancer survival has been improving over time for the three Cancer Networks in NYCRIS. One-year survival for cancer networks is quite high; at around 95% in , this is an improvement of 10% between and When comparing one year survival in to the baseline the improvement is statistically significant amongst all three cancer networks. Statistically significant improvements can also be seen within the YCN for two, three and four year survival year Survival by Cancer Newtork in NYCRIS for persons year Survival by Cancer Network in NYCRIS for persons N06 Yorkshire N07 Humber & Yorkshire Coast N36 North of England N06 Yorkshire N07 Humber & Yorkshire Coast N36 North of England year Survival by Cancer Network in NYCRIS for persons year Survival by Cancer Network in NYCRIS for persons N06 Yorkshire N07 Humber & Yorkshire Coast N36 North of England N06 Yorkshire N07 Humber & Yorkshire Coast N36 North of England Figure 8-One- year survival by cancer network Figure 9-Two- year survival by cancer network Figure 10-Three- year survival by cancer network Figure 11-Four-year survival by cancer network Page 12 of 29

13 Surgical workload (malignant and non-malignant) Surgical workload (malignant thyroid disease only) of surgeons treating patients with thyroidectomies. Northern and Yorkshire Cancer Registry and Information Service (NYCRIS) Surgical workload 2010 Cases treated by Surgeons < % % % % % % Total % Table 1 Surgical procedures performed by surgical workload - NYCRIS % Note: Surgeon workload represents number of surgical procedures performed on thyroid cancer patients that were diagnosed during 2010 and is not mutually exclusive; a patient could have received multiple procedures. One tenth (n=45, 10%) of surgical patients were operated on by a surgeon who performed fewer than five surgical procedures for thyroid cancer a year. Compared to 1999 where the proportion of surgical patients who were operated on by a surgeon performing fewer than five surgical procedures a year was 33%, this is a significant improvement. Guidelines for the management of thyroid cancer 1 state that all newly diagnosed cases should be seen by an Multidisciplinary Team (MDT) member, additionally the MDT will discuss and agree a patients treatment plan. A surgeon should have training and expertise in the management of thyroid cancer and be an MDT member. Guidelines for the management of thyroid cancer published in February 2014 by the British Thyroid Association 2 has stated that surgeons who operate on patients with thyroid cancer should perform a minimum of 20 thyroidectomies per year. Page 13 of 29

14 Specialty of Clinician First hospital visit n % Dermatology * * Ear, Nose & Throat Surgery % Endocrinology * * Gastroenterology * * General Medicine * * General Surgery % Haematology * * Medical Oncology * * Neurosurgery * * Oral Surgery * * Paediatrics * * Paediatric Surgery * * Respiratory medicine * * Trauma & Orthopaedic Surgery * * Radiotherapy/Clinical Oncology * * Unknown/Unspecified Specialty 72 23% Total 332 Table 2 - Speciality of clinician seen during first hospital visit - NYCRIS Within NYCRIS during 2010, 36% of patients diagnosed with thyroid cancer were first seen by an ENT surgeon followed by 33% of patients being seen by a general surgeon. Specialty of Clinician First surgical procedure n % Ear, Nose & Throat Surgery % Gastroenterology * * General Surgery % Paediatric Surgery * * Unknown/Unspecified Specialty 12 4% Total 304 Table 3 Speciality of clinician undertaking a thyroid cancer patient s first procedure - NYCRIS Note: Speciality of clinician first procedure represents the clinician s main speciality that performed a patient s first surgical procedure, the results are mutually exclusive. 95% of patients diagnosed in 2010 were first treated by either an ENT or general surgeon (n=288). Page 14 of 29

15 Surgical workload for non-malignant thyroid disease only within the Northern and Yorkshire Cancer Registry and Information Service Surgical Cases treated by % workload 2010 Surgeons <5 79 7% % % % % % % > % Total % Table 4 Surgical workload, non-malignant disease During 2010, 7% of patients were operated on by a surgeon who performed fewer than five non-malignant thyroidectomies, with the largest number of non-malignant procedures being carried out by surgeons who performed between procedures a year. 75% of nonmalignant thyroid proceudres were undertaken by as surgeon who performed over 20 procedures a year. Page 15 of 29

16 Humber and Yorkshire Coast Cancer Network (HYCCN) Surgical workload (malignant thyroid disease only) of surgeons treating patients with thyroidectomies. Surgical workload 2010 Cases treated by Surgeons <5 6 13% % * * % Total Table 5 Surgical procedures performed by surgical workload HYCCN % Data from the Humber and Yorkshire Coast Cancer Network shows that 13% of patients diagnosed during 2010 were operated on by a surgeon who performed fewer than five surgical procedures for thyroid cancer a year. Cancer network level analysis was not presented in the 2004 audit but when re-producing the results for 1999 this figure has gone from 53% to 13%. Specialty of n % Clinician First hospital visit Ear Nose & Throat Surgery 17 40% General Surgery 11 26% Respiratory medicine * * Unknown/Unspecified Specialty 13 31% Total Table 6- Speciality of clinician seen during first hospital visit HYCCN During 2010, within the Humber and Yorkshire Coast Cancer Network, 40% of patients diagnosed with thyroid cancer were first seen by an ENT surgeon followed by 26% of patients being seen by a general surgeon. Page 16 of 29

17 Specialty of Clinician First surgical procedure n % Ear Nose & Throat Surgery 24 69% General Surgery 8 23% Unknown/Unspecified Specialty * * Total Table 7 Speciality of clinician undertaking a thyroid cancer patient s first procedure - HYCCN 91% of patients diagnosed in 2010 were first treated by either an ENT or general surgeon (n=32). Surgical workload for non-malignant thyroid disease only within the Humber and Yorkshire Coast Cancer Network Surgical workload 2010 Cases treated by Surgeons <5 14 6% % % % > % Total % Table 8 - Surgical workload, non-malignant disease % During 2010, 6% of patients were operated on by a surgeon who performed fewer than five non-malignant thyroidectomies each year with the largest number of non-malignant procedures being carried out by a surgeon who performed >100 procedures a year. Page 17 of 29

18 North of England Cancer Network (NECN) Surgical workload (malignant thyroid disease only) of surgeons treating patients with thyroidectomies Surgical workload 2010 Cases treated by Surgeons <5 13 6% % % % % Total % Table 9 - Surgical procedures performed by surgical workload NECN % The North of England Cancer Network data shows that 6% of patients who were diagnosed during 2010 were operated on by a surgeon who performed fewer than five surgical procedures for thyroid cancer a year. When re-producing the results for 1999 this figure has gone from 41% to 6%. Specialty of n % Clinician First hospital visit Ear Nose & Throat Surgery 38 25% Endocrinology * * Gastroenterology * * General Medicine * * General Surgery 60 40% Haematology * * Neurosurgery * * Oral Surgery * * Paediatric * * Paediatric Surgery * * Trauma & Orthopaedic Surgery * * Unknown/Unspecified Specialty 35 23% Total 150 Table 10- Speciality of clinician seen during first hospital visit NECN During 2010, within the North of England Cancer Network, 40% of patients diagnosed with thyroid cancer were first seen by a general surgeon followed by 25% of patients being seen by an ENT surgeon. Page 18 of 29

19 Specialty of n % Clinician First surgical procedure Ear Nose & Throat Surgery 54 38% Gastroenterology * * General Surgery 82 57% Paediatric Surgery * * Unknown/Unspecified Specialty 5 3% Total 143 Table 11 - Speciality of clinician undertaking a thyroid cancer patient s first procedure - NECN 95% of patients who were diagnosed during 2010 were first treated by either an ENT or general surgeon (n=136). Surgical workload for non-malignant thyroid disease only within the North of England Cancer Network Surgical workload 2010 Cases treated by Surgeons <5 41 8% % % % % % Total % Table 12- Surgical workload, non-malignant disease % During 2010, 8% of patients were operated on by a surgeon who performed fewer than five non-malignant thyroidectomies each year with larger numbers of non-malignant procedures being carried out by surgeons who performed between procedures a year. Page 19 of 29

20 Yorkshire Cancer Network (YCN) Surgical workload (malignant thyroid disease only) of surgeons treating patients with thyroidectomies Surgical workload 2010 Cases treated by Surgeons < % % % % % % Total % Table 13- Surgical procedures performed by surgical workload YCN % The Yorkshire Cancer Network data shows that 13% of patients who were diagnosed during 2010 were operated on by a surgeon who performed fewer than five surgical procedures for thyroid cancer a year. When re-producing the results for 1999 this figure has gone from 53% to 13%. Specialty of Clinician First visit n % Dermatology * * Ear Nose & Throat Surgery 65 46% Endocrinology * * General Medicine * * General Surgery 41 29% Haematology * * Medical Oncology * * Oral Surgery * * Paediatric Surgery * * Radiotherapy/Clinical Oncology * * Unknown/Unspecified Specialty 24 17% Total 140 Table 14 Speciality of clinician seen during first hospital visit YCN Within the Yorkshire Cancer Network During 2010, 46% of patients diagnosed with thyroid cancer were first seen by an ENT surgeon followed by 29% of patients being seen by a general surgeon. Page 20 of 29

21 Specialty of n % Clinician First surgical procedure Ear Nose & Throat Surgery 81 64% General Surgery 39 31% Paediatric Surgery * * Unknown/Unspecified Specialty * * Total 126 Table 15- Speciality of clinician undertaking a thyroid cancer patient s first procedure - YCN 95% of patients diagnosed during 2010 were first treated by either an ENT or general surgeon (n=120). Surgical workload for non-malignant thyroid disease only within the Yorkshire Cancer Network Surgical workload 2010 Cases treated by Surgeons <5 24 5% % % % % % % Total % Table 16 - Surgical workload, non-malignant disease % During 2010, 5% of patients were operated on by a surgeon who performed fewer than five non-malignant thyroidectomies each year with the largest number of non-malignant procedures being carried out by surgeons who performed between procedures a year. Page 21 of 29

22 Treatment modality Thyroid cancer treatment modality by pathological type Note: Treatments delivered to thyroid cancer patients that were diagnosed during 2009 and 2010 are not mutually exclusive; a patient could have received multiple treatment types, only the first of each type has been used in this analysis. In 2009 and 2010, the oncologists (who prescribe radio-iodine) followed the 2007 edition of the British Thyroid Association Guidelines on the management of thyroid cancer. They commonly recommended radio-iodine to most patients with DTC larger than 1 cm in diameter. Radioiodine is not recommended for anaplastic or medullary tumours. External beam radiotherapy is rarely used for DTC. It is reserved for patients with advanced locoregional disease (for both DTC and medullary cancers) usually when the tumour is incompletely resected (and radioiodine resistant in the case of DTC). Palliative radiotherapy is offered to anaplastic thyroid cancer patients, without extensive disease, who are considered, fit enough to benefit. NYCRIS Anaplastic Follicular Medullary Hurtle cell carcinoma Papillary Total Total number of cases Surgery % 32% 94% 92% 98% 95% 93% Radio-iodine Ablation % 0% 53% 0% 64% 57% 54% External beam radiotherapy 9 6 * * % 47% 5% * * 4% 6% Table 17 NYCRIS Treatment Modality During 2009 and 2010 within NYCRIS, 57% of patients diagnosed with papillary cancer, 53% of patients diagnosed with follicular cancer and 64% of patients diagnosed with hurtle cell carcinoma received radio-iodine therapy and in total 93% of patients received surgery. Papillary and follicular thyroid cancer types are the most common and account for 68% and 19% of cases within NYCRIS respectively, with 5 year relative survival being over 90%. Medullary cancer accounts for 2% of thyroid cancers in NYCRIS; the main treatment for this cancer during 2009 and 2010 was surgery (92%). Anaplastic thyroid cancer, although rare, is an aggressive thyroid cancer type. External beam radiotherapy may be used in patients who are not suitable for surgery or where surgery cannot remove the tumour completely, and tends to be more of a palliative treatment than a curative one. Within NYCRIS, 47% of patients diagnosed with anaplastic thyroid cancer received external beam radiotherapy. 5 year relative survival for patients diagnosed with anaplastic cancer is very low with most patients dying within a few months of diagnosis. Anaplastic cancer accounts for 3% of thyroid cancers in NYCRIS. Page 22 of 29

23 Within NYCRIS, 94% of patients diagnosed with follicular thyroid cancer received surgery (surgical procedures are listed the in appendix), however, within the Yorkshire Cancer Network 100% of patients diagnosed with follicular cancer received surgery. The proportion of patients diagnosed with papillary thyroid cancer that then went on to have surgery varies little by cancer network (95% YCN, 92% HYC, 96% NECN). The proportion who received radio-iodine therapy also varies (67% YCN, 49% HYC, 49% NECN). YCN Anaplastic Follicular Medullary Hurtle cell carcinoma Papillary Total Total number of cases Surgery 0 33 * % 0% 100% * 100% 95% Radio-iodine Ablation % 0% 48% 0% 75% 67% 62% External beam radiotherapy * * * * 9 14 % * * * * 5% 6% Table 18 Yorkshire Cancer Network - Treatment Modality HYCCN /2010 Anaplastic Follicular Medullary Hurtle cell carcinoma Papillary Total Total number of cases 5 17 * 5 49 Surgery * 16 * 5 45 % * 94% * 100% 92% Radio-iodine Ablation * 24 % 0% 71% 0% * 49% External beam radiotherapy * 0 0 * * 7 % * 0% 0% * 8% 9% Table 19 Humber & Yorkshire Coast Cancer Network - Treatment Modality NECN /2010 Anaplastic Follicular Medullary Hurtle cell carcinoma Papillary Total Total number of cases Surgery * % * 91% 100% 96% 96% Radio-iodine Ablation % 0% 52% 0% 52% 49% 48% External beam radiotherapy * * 15 % 75% 8% 0% * * 5% Table 20 North of England Cancer Network -Treatment Modality Page 23 of 29

24 Conclusion The incidence of thyroid cancer has increased since 1999 when there were around 150 new cases per year to over 300 per year in This reflects thyroid cancer incidence throughout the developed world. Since the last audit published in 2004, there has been increased surgical site specialisation and in the YCN many more ENT surgeons operate on thyroid cancer than general surgeons. Fewer surgeons operate on small numbers of patients. The pathologists diagnosed a higher proportion of papillary thyroid cancer in (68%) than in (56%) probably due to a new classification system. The proportion of differentiated thyroid cancer patients who received some type of surgery, radio-iodine and radiotherapy was similar in to that in Fewer ATC patients received radiotherapy in (47%) compared with in (72%) with surgical procedures increasing from (17%) in to (32%) in However, the survival of anaplastic thyroid cancer remains unchanged. The palliative effect of radiotherapy in ATC is poor. It often causes more side effects than benefits and there has been a move away from radiotherapy for the majority of ATC patients, offering best supportive care instead. Thyroid cancer survival has been improving over time for the whole region probably reflecting better site specialisation of all the doctors involved in the management of thyroid cancer, MDT working and the development of guidelines. When combining all thyroid cancers one year survival has improved for each cancer network, however, the Yorkshire Cancer Network has shown to have improved in one, two, three and four year survival. Page 24 of 29

25 References 1) British Thyroid Association. Guidelines for the management of thyroid cancer [Internet]. 2 nd ed. London: Royal College of Physicians; 2007 [cited 2014 June 12]. Available from: 2) British Thyroid Association. Guidelines for the management of thyroid cancer [Internet]. 3 rd ed. London: Royal College of Physicians; 2014 [cited 2014 June 12]. Available from: 3) Cancer Research UK. Thyroid cancer statistics 2012 [Internet]. London: Cancer Research UK: 2012 [cited 2014 June 12]. Available from: 4) NHS Choices. Thyroid cancer 2012 [Internet]. Leeds: NHS Cchoices; 2012 [cited 2014 June 12]. Available from: 5) NYCRIS. Management of thyroid cancer in the Northern and Yorkshire region. Leeds:NYCRIS; Page 25 of 29

26 List of tables Table 1 Surgical procedures performed by surgical workload - NYCRIS Table 2 - Speciality of clinician seen during first hospital visit - NYCRIS Table 3 Speciality of clinician undertaking a thyroid cancer patient s Table 4 Surgical workload, non-malignant disease Table 5 Surgical procedures performed by surgical workload HYCCN Table 6- Speciality of clinician seen during first hospital visit HYCCN Table 7 Speciality of clinician undertaking a thyroid cancer patient s Table 8 - Surgical workload, non-malignant disease Table 9 - Surgical procedures performed by surgical workload NECN Table 10- Speciality of clinician seen during first hospital visit NECN Table 11 - Speciality of clinician undertaking a thyroid cancer patient s Table 12- Surgical workload, non-malignant disease Table 13- Surgical procedures performed by surgical workload YCN Table 14 Speciality of clinician seen during first hospital visit YCN Table 15- Speciality of clinician undertaking a thyroid cancer patient s Table 16 - Surgical workload, non-malignant disease Table 17 NYCRIS Treatment Modality Table 18 Yorkshire Cancer Network - Treatment Modality Table 19 Humber & Yorkshire Coast Cancer Network - Treatment Modality Table 20 North of England Cancer Network -Treatment Modality List of figures Figure 1 - Incidence by pathological type... 7 Figure 2 Incidence by pathological type males... 8 Figure 3 -Incidence by pathological type - females... 8 Figure 4 - Incidence by cancer network and sex... 9 Figure 5 - Relative survival by pathological type Figure 6 - Crude survival by pathological type Figure 7 One- year survival by pathological type Figure 8-One- year survival by cancer network Figure 9-Two- year survival by cancer network Figure 10-Three- year survival by cancer network Figure 11-Four-year survival by cancer network Page 26 of 29

27 Appendix Grouping Grouping Term Morphology Code Morphology Term ATC Anaplastic M80123 Large cell carcinoma unspecified M80203 Carcinoma undifferentiated unspecified M80213 Carcinoma anaplastic unspecified M80223 Pleomorphic carcinoma M80323 Spindle cell carcinoma M80703 Squamous cell carcinoma M80713 Squamous cell carcinoma keratinising M85603 Adenosquamous carcinoma FTC Follicular M83303 Follicular (adeno)carcinoma M83313 Follicular (adeno)carcinoma well differentiated (m.i.) FTC Follicular carcinoma - M83353 Follicular carcinoma minimally invasive minimally invasive HTC Hurtle cell carcinoma M82903 Oxyphilic adenocarcinoma MTC Medullary M82463 Neuroendocrine carcinoma M83453 Medullary carcinoma with amyloid stroma M85103 Medullary carcinoma nos PTC Papillary M80523 Papillary squamous cell carcinoma M80525 Microinvasive papillary squamous cell carcinoma M82603 Papillary adenocarcinoma unspecified M83403 Papillary (adeno)carcinoma follicular variant M83413 Papillary microcarcinoma M83423 Papillary carcinoma oxyphilic cell M83443 Papillary carcinoma columnar cell Poorly Differentiated Poorly differentiated M83373 Insular carcinoma Page 27 of 29

28 Thyroidectomy OPCS-4 Codes B081 B082 B083 B084 B085 B086 B088 B089 B091 Thyroidectomy procedure codes Page 28 of 29

29 Page 29 of 29