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Treatment for thyroid cancer
The type of treatment your doctor recommends will depend on the type and stage of the thyroid cancer, and your age and general health.
In some cases, your doctor may recommend closely monitoring the cancer, rather than having treatment straightaway. This approach is known as active surveillance. It usually involves regular ultrasounds and physical examinations.
There is good evidence that active surveillance is safe for small papillary thyroid cancers where there is no sign that the cancer has spread from the thyroid. It may be an option when the tumour is under 10 mm, isn’t causing any symptoms and is considered to be low risk.
Some people choose to have active surveillance if the possible side effects from treatment would have more impact on their quality of life than the cancer itself. Other people find that active surveillance makes them feel anxious and prefer to have treatment straightaway. Treatment can be considered at any stage if you change your mind or if the cancer grows or spreads. If you agree to active surveillance, your doctor will talk to you about the changes to look out for.
Surgery is the most common treatment for thyroid cancer. Before the operation, a member of the surgical team and, in some hospitals, a specialist nurse will talk to you about the operation. This is your opportunity to ask questions and discuss any concerns you have.
You will be given a general anaesthetic, and the surgeon will make a small cut (5–7 cm) across your neck. How much tissue is removed will depend on how far the cancer has spread.
Types of thyroid surgery
Partial thyroidectomy – In a partial thyroidectomy (also called a hemithyroidectomy), only the affected lobe or section of the thyroid is removed. This surgery may be an option if the cancer is small and the other lobe looks normal on the ultrasound. It might also be used to diagnose thyroid cancer if a fine needle aspiration biopsy doesn’t provide a clear diagnosis. If cancer is found after a partial thyroidectomy, you may need further surgery to remove the rest of your thyroid.
Total thyroidectomy – Most people with thyroid cancer need to have a total thyroidectomy. This involves removing the whole thyroid (both lobes and the isthmus).
Lymph node removal – With either type of thyroid surgery, nearby lymph nodes may also be removed to help work out staging or if the initial scans
show that the cancer has spread to them. This is called a neck dissection. Even if the cancer doesn’t appear to have spread, the nodes behind the thyroid are occasionally removed to reduce the risk of the cancer returning.
In very rare cases, the surgeon also removes other tissue near the thyroid that has been affected by the cancer.
After the operation
You will probably stay in hospital for one or two nights to recover from surgery. Your neck wound will be closed with stitches, adhesive strips or small clips.
Your nursing team will talk to you about how to care for your surgical wound site once you go home to prevent it becoming infected. The surgeon may arrange blood tests to check on your recovery.
Further treatment after surgery
All tissue removed during the surgery is examined for cancer cells by a pathologist. The results will help confirm the type of cancer you have, and work out if the cancer has spread to any of the nearby lymph nodes and whether you need further treatment. For some people, this may mean more surgery to remove any remaining thyroid tissue. Other people may need to have thyroid hormone replacement therapy, radioactive iodine treatment
or targeted therapy.
What to expect after surgery
Most people who have thyroid surgery will feel better within 1–2 weeks, but recovery may take longer for some people.
Hoarse voice – Sometimes thyroid surgery affects the nerves to the voice box, which can make your voice sound hoarse or weak. This is often temporary and improves with time. Your singing voice may be affected. This is often temporary, but sometimes it is permanent. Most patients complain their voice gets tired after thyroid surgery, but this is usually temporary.
Sore neck – You will probably feel some pain or discomfort where the cut was made. You will be given pain medicines to manage this. The position you are placed in for surgery can sometimes give you a stiff neck and back. This is temporary, and neck massage and physiotherapy may help loosen the muscles in your neck. You can also try using a triangle-shaped pillow to support your neck after surgery and/or ask for pain medicine.
Painful swallowing – You will find it painful to swallow for a few days. Try to eat soft foods that are easy to swallow. Swallowing can feel stiff for a few months, but usually gradually improves.
Eating and drinking – Most people start eating and drinking within a few hours after the operation. To help your body recover from surgery, you need
to be well nourished. Try to eat small amounts of healthy, nutritious food.
Scarring – You will have a horizontal scar on your neck above the collarbone. In most cases, the scar is about 5–7 cm long and is often in a natural skin crease. At first, this scar will look red, but it should fade and become less noticeable with time. Your doctor may recommend using special tape on the scar to help it heal. Keep the area moisturised to help the scar fade more quickly over time. Ask your pharmacist or doctor to recommend a suitable cream.
Activity levels – Most people return to their usual activities within a week, but some people need more time to recover. You will most likely need to avoid heavy lifting, vigorous exercise (such as running) and turning your neck quickly for a couple of weeks after surgery.
Mood changes – Changes in hormone levels may affect your mood. If you feel anxious or have panic attacks, let your doctor or nurse know as they may recommend medicines to help. Some people find meditation or relaxation techniques helpful.
Low calcium levels – You may have low blood calcium levels (hypocalcaemia) if surgery affects the parathyroid glands. This may cause headaches and tingling in your hands, feet and lips, as well as muscle cramps.
Your doctor will do blood tests to check your calcium levels, and you may be prescribed vitamin D and/or calcium supplements until your parathyroid glands recover. If the parathyroid glands don’t recover, vitamin D and/or calcium supplements need to be taken permanently. Calcium supplements should be taken at least two hours after your thyroid hormone replacement tablets.
Many people who have a partial thyroidectomy won’t need thyroid hormone replacement therapy because the remaining lobe will continue to make enough hormones.
After the whole thyroid is removed, your body will no longer produce the hormones that maintain your metabolism, and you will be prescribed a hormone tablet to replace T4 (thyroxine).
You will usually start taking hormone replacement tablets while in hospital recovering from the surgery. You will need to take a hormone tablet every day for the rest of your life.
Taking thyroid hormone tablets can have two roles:
Keeping your body’s metabolism functioning at a normal healthy rate – Without hormone replacement medicine, your metabolism will slow down and you will develop the symptoms of hypothyroidism, such as depression or weight gain.
Reducing the risk of the cancer coming back – Taking thyroid hormone tablets stops your pituitary glands from releasing too much of another hormone called thyroid-stimulating hormone (TSH). It is thought that high levels of TSH may encourage any thyroid cancer cells remaining after treatment to grow. For this reason, if the doctor thinks the cancer has a medium to high risk of recurring, they will recommend you take a high dose of T4 to reduce the level of TSH. This is known as TSH suppression.
Finding the right dose
You’ll be carefully monitored when you start thyroid hormone replacement therapy. You’ll have blood tests every 6–8 weeks to help your doctor adjust the dosage until it is right for you. Usually, the initial dose needs only small adjustments.
A small number of people may experience hypothyroidism or hyperthyroidism during the adjustment period. However, once you are taking the right dose, you should not experience side effects.
Tips for taking T4 medicines
- Take your T4 medicine at the same time every day to get into a routine. Take it on an empty stomach with a glass of water and wait 30 minutes before eating.
- Store medicines in the fridge to maintain the T4 level in the tablets. If you are travelling, the medicine will last up to 30 days without refrigeration. Some T4 medicines do not need refrigeration – check with your doctor or pharmacist.
- If you miss a dose, you should usually take it as soon as you remember. But if it’s almost time to take the next dose, skip the dose you missed.
- Wait two hours before taking calcium or iron supplements as these affect the stomach’s ability to absorb the T4.
- Check with your doctor if it’s safe to continue taking other medicines or supplements.
- Tell your doctor if you are pregnant or are planning to get pregnant, as you may need to take a higher dose.
- Don’t stop taking the T4 medicine without discussing it with your doctor.
Radioactive iodine (RAI) is also known as I131 and is a type of radioisotope treatment. Radioisotopes are radioactive substances given in a pill that you swallow. Although RAI spreads through the body, it is mainly absorbed by thyroid cells or thyroid cancer cells. RAI kills these cells while leaving other body cells relatively unharmed.
You may be given RAI to destroy tiny amounts of remaining cancer cells or healthy thyroid tissue left behind after surgery. It is usually recommended for papillary or follicular thyroid cancers that have spread to the lymph nodes or that have a higher risk of coming back after surgery. RAI doesn’t work for medullary or anaplastic thyroid cancer because these types do not take up iodine.
When to have RAI treatment
RAI is generally not given until some weeks after surgery, once any swelling has gone down. This is because swelling can affect the blood flow and stop the RAI circulating well.
It is not safe to have RAI treatment if you are pregnant or breastfeeding, so treatment may be delayed. RAI may be given up to six months after surgery. Ask your doctor for more information.
Preparing for RAI treatment
Limiting foods high in iodine – A diet high in iodine makes RAI treatment less effective. You will need to start avoiding high-iodine foods two weeks before treatment. This includes foods such as seafood, iodised table salt and sushi. Your treatment team will give you more detailed instructions.
Discussing imaging scans – CT scans and other imaging scans sometimes use an injection of a dye called contrast to make the images clearer. This contrast can interfere with how well RAI works, so it is important to tell your doctor if you have had a scan using contrast in the month before RAI treatment.
Raising TSH levels – For RAI treatment to work, you will need a high level of TSH in your body. There are two ways to increase your TSH levels:
- You may be prescribed a synthetic type of TSH called recombinant human thyroid-stimulating hormone (rhTSH), also known by the brand name Thyrogen. You will need two injections of Thyrogen, usually into the muscle in your buttock, with the first injection two days before RAI treatment, and then the second injection the day before. Thyrogen allows you to continue taking your thyroid hormone replacement medicine.
- You can stop taking your thyroid hormone replacement medicine for a few weeks. You will have a blood test before RAI treatment to check that the TSH levels have risen enough. In some people, stopping their hormone replacement medicine causes symptoms of hypothyroidism. These symptoms may affect your ability to concentrate, so check with your doctor whether it is safe to drive and use heavy machinery.
The option recommended for raising your TSH levels will depend on your stage of disease and what is suitable for you. For more details talk to your specialist.
Having RAI treatment
You will be admitted to hospital on the day of the RAI treatment. You may be given anti-nausea medicine before the RAI pill.
RAI treatment will make you radioactive for a few days, and you will need to stay in hospital during this time.
Once the radiation has dropped to a safe level, you will be able to go home. If you had Thyrogen injections, this usually occurs within 36–48 hours. It may be a day longer if you stopped taking your thyroid hormone replacement medicine.
A few days after treatment, you will have a full body radioisotope scan to detect if any thyroid cancer cells are left in the body. It is normal to see an area of RAI uptake in the neck on this initial scan, due to small amounts of healthy thyroid tissue remaining in your neck after surgery. The RAI will take several months to destroy this tissue.
The radioisotope scan may also show if cancer has spread to your lymph nodes or other areas of your body.
If you or your partner want to have a baby after RAI treatment, talk to your doctor. RAI may have a short-term effect on eggs and sperm, so you’ll be advised to use contraception for a time (usually 6 months for women, 3–6 months for men). Women also need to check that their thyroid hormone levels are normal before trying to get pregnant.
Safety precautions during RAI treatment
Your treatment team, family members and friends will have to take precautions to limit their exposure to radiation.
Safety precautions in hospital – Safety measures vary between hospitals, and the medical team will discuss the specific details with you before treatment starts. Safety measures usually include:
- keeping you in an isolated, shielded room
- not allowing or restricting visitors to the room – particularly children and pregnant women
- if visitors are allowed, limiting the time they can stay in the room and asking them to stay 2–3 metres away from you
- measuring your radiation levels with an instrument called a Geiger counter
- wearing gloves to clean up body fluids (e.g. urine, sweat, saliva, blood) and leftover food and drink
- washing hands thoroughly and often.
Safety precautions at home – When you go home, you may have to continue following some safety measures for a few days.
Your treatment team will discuss any safety measures with you before treatment. These precautions usually include:
- sleeping alone
- washing your clothing separately
- washing hands extra well before preparing food
- taking care with body fluids for a certain period of time
- sitting down to urinate, and putting the lid down and flushing the toilet several times after use.
Following these safety measures may make you feel frightened and lonely. Discuss any concerns you have with your doctors, nurses or a counsellor. It’s a good idea to take something to hospital to occupy your time, e.g. a book, tablet device, puzzles.
Side effects of RAI treatment
Usually, being temporarily radioactive is the only major side effect of RAI treatment. Drinking lots of water helps the RAI treatment pass out of your body faster and also reduces the bladder’s exposure to radiation.
Because the salivary glands may absorb some iodine, you might have a dry mouth as well as taste and smell changes for a few weeks after treatment. Some people will have ongoing problems with swelling and pain in their salivary glands. Ask your treatment team for medicines
(e.g. paracetamol) to relieve swelling and pain. Other side effects, such as tiredness, are often caused by thyroid hormone withdrawal, but will improve when your thyroid hormone levels return to normal.
Targeted therapy drugs attack specific features of cancer cells to stop the cancer growing and spreading. The most common targeted therapy drugs used for thyroid cancer are tyrosine kinase inhibitors (TKIs). These drugs block the chemical messengers (enzymes) that help tell cancer cells to grow, multiply and spread.
If you have advanced thyroid cancer that hasn’t responded to RAI treatment, you may be offered a TKI such as lenvatinib or sorafenib. These drugs are given as a pill, which you take daily. You will usually keep taking the pills for several years.
Other TKIs may be available on clinical trials. Talk with your doctor about the latest developments and whether you are a suitable candidate.
Side effects of targeted therapy
The most common side effects of TKIs include diarrhoea, skin rash, bleeding and high blood pressure. In some people, TKIs can affect the way the heart and kidneys work. Some TKIs can also cause tenderness, tingling and blisters on the skin of the palms and soles.
It is important to tell your doctor about any side effects immediately. If left untreated, some side effects can become life-threatening. Your doctor will explain what to watch out for, and will monitor you throughout treatment.
External beam radiation therapy (also known as external beam radiotherapy) uses a controlled dose of radiation to kill cancer cells or damage them so they cannot grow, multiply or spread. The radiation is usually in the form of x-ray beams. Radiation is delivered precisely to the affected area, which reduces treatment time and side effects.
Most people diagnosed with thyroid cancer do not need external beam radiation therapy, but it may be recommended in particular circumstances. In a small number of cases, it may be given:
- after surgery and RAI treatment if the cancer has not been completely removed or if there is a high risk of the cancer returning (recurrence)
- as palliative treatment to relieve symptoms such as pain caused by cancer that has spread to nearby tissue or structures
- to help control medullary or anaplastic thyroid cancer (because these types do not respond to RAI).
Planning treatment – Before the treatment starts, you will have a planning session. The radiation therapist will take CT scans to work out the exact area to be treated, and may make small marks or tattoos on your skin. This ensures the same part of your body is targeted during each treatment session.
You may also be fitted for a plastic mask to wear during treatment. This will help you stay still so that the radiation is targeted at the same area of your neck during each session. You can see and breathe through the mask, but it may feel strange and uncomfortable at first. The radiation therapy team can help you manage this.
Having treatment – Radiation therapy is usually given five days a week over several weeks. Treatment sessions usually take about 10 minutes, but it will take longer to position the machine correctly.
Side effects of external beam radiation therapy
Many people develop side effects during radiation therapy. Common side effects include feeling tired, difficulty swallowing, sore throat, dry mouth, and red, dry, itchy, sore or ulcerated skin. Most of these will disappear within a few weeks or months. Your treatment team can help you prevent or manage any side effects.
Chemotherapy is the use of drugs to kill cancer cells or slow their growth. While chemotherapy is not often used to treat thyroid cancer, it may sometimes be used to treat advanced thyroid cancer that is not responding to RAI treatment or targeted therapy. It may also be used in combination with radiation therapy to treat anaplastic thyroid cancer.
The drugs are usually given by injection into a vein (intravenously) or as tablets. You will probably have several treatment sessions over a few weeks – your treatment team will work out the schedule.
Side effects of chemotherapy
The side effects of chemotherapy will vary depending on the drugs used. Common side effects include fatigue, nausea, appetite loss, diarrhoea, hair loss, mouth sores and anaemia. You may also be more likely to catch infections.
Most chemotherapy side effects are temporary and your doctor will talk to you about ways to prevent or reduce them. You could be prescribed medicines to treat the side effects or be given a different type of drug, or your doctor may recommend a break from treatment.
Most people with thyroid cancer respond well to treatment and do not need to access palliative care services. However, people at any stage of advanced thyroid cancer may benefit from palliative treatment.
Palliative treatment helps to improve people’s quality of life by managing symptoms of cancer without trying to cure the disease. The treatment you are offered will be tailored to your individual needs. It may include radiation therapy, chemotherapy, targeted therapy or other medicines.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, cultural, social and spiritual needs. Palliative care also provides support to families and carers.
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This information is reviewed by
This information was last reviewed January 2020 by the following expert content reviewers: A/Prof Diana Learoyd, Endocrinologist, Northern Cancer Institute, and Northern Clinical School, The University of Sydney, NSW; Dr Gabrielle Cehic, Nuclear Medicine Physician and Oncologist, South Australia Medical Imaging (SAMI), and Senior Staff Specialist, The Queen Elizabeth Hospital, SA; Dr Kiernan Hughes, Endocrinologist, Northern Endocrine and St Vincents Hospital, NSW; Yvonne King, 13 11 20 Consultant, Cancer Council NSW; Dr Christine Lai, Senior Consultant Surgeon, Breast and Endocrine Surgical Unit, The Queen Elizabeth Hospital, and Senior Lecturer, Discipline of Surgery, University of Adelaide, SA; A/Prof Nat Lenzo, Nuclear Physician and Specialist in Internal Medicine, Group Clinical Director, GenesisCare Theranostics, and The University of Western Australia, WA; Ilona Lillington, Clinical Nurse Consultant (Thyroid and Brachytherapy), Cancer Care Services, Royal Brisbane Women’s Hospital, QLD; Jonathan Park, Consumer.