Quality of Life, Thyroid Function and Type of Surgery inLow Risk Thyroid Cancer

Research Article

Annals Thyroid Res. 2021; 7(3): 335-341.

Quality of Life, Thyroid Function and Type of Surgery in Low Risk Thyroid Cancer

Cohen MV¹, Bertoni N², Nobre GM³, Tramontin MY³, Andrade FA³, Alves Jr. PA³, de Fátima Teixeira P¹, Bulzico DA³, Corbo R³, Vaisman M¹ and Vaisman F1,3*

¹Endocrinology, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Brazil

²Epidemiology Division Instituto Nacional do Cancer (INCa), Rio de Janeiro, Brazil

³Endocrinology-Instituto Nacional do Cancer (INCa), Rio de Janeiro, Brazil

*Corresponding author: Fernanda Vaisman, Praça Cruz Vermelha, 23, 8o andar-Centro, Rio de Janeiro, Brazil

Received: April 21, 2021; Accepted: May 17, 2021; Published: May 24, 2021


Background: Low risk thyroid cancer can be treated with lobectomy or total thyroidectomy. Studies have shown that the risk of recurrence does not differ between the two surgeries, although there are higher rates of complications with total thyroidectomy. Our study aimed to find if there were differences in quality of life and thyroid function in the two treatments.

Methods: Low risk DTC survivors answered three QoL questionnaires (EQ5D3L, SF36, and EORTC QLQ C30) and had their thyroid function evaluated.

Results: Twenty-six lobectomy patients and 101 total thyroidectomy were included. Hypoparathyroidism occurred more in the total thyroidectomy, and TSH was more likely to be on target (0.5-2.0) in lobectomy. There was no difference between groups regarding QoL, but there was a significant difference regarding thyroid function. In SF36 form, TSH off target led to more physical limitations, pain, less vitality, and worse social aspects. Abnormal total T3 level was associated with pain, less vitality, and worse mental health. In the EORTC QLQ C30, off target TSH led to worse role functioning, fatigue, and nausea. EQ5D form showed that worse utility index was found when TT3 was not in normal range.

Conclusion: This study showed there was a difference among thyroid function, specially TSH depending on type of surgery. When uncontrolled, TSH was associated with worse aspects of the quality of life. Therefore, lobectomy patients have a better thyroid function control and less surgical complications which might have an impact in some aspects of the quality of life when compared to total thyroidectomy.

Keywords: Thyroidectomy; Hypoparathyroidism; Differentiated thyroid carcinoma


The prevalence of Differentiated Thyroid Carcinoma (DTC) is increasing worldwide. Currently, it’s the fifth most common form of malignancy among Brazilian women [1]. Despite its low mortality, there’s a high rate of recurrence/persistence, estimated at 20- 30% [2]. Based on this, the American Thyroid Society (ATA), and other organizations (European thyroid society-ETA-and the Latin American thyroid society-LATS) classify DTCs according to this risk. Studies have shown that, in low-risk patients, 78-91 % were disease free 10 years after surgery and Radioiodine Therapy (RIT). Other studies have confirmed these results, even with no RIT, identifying 1-2% of recurrent or persistent structural disease [3].

The choice of what type of surgery should be performed on these patients has been the subject of many discussions recently. Advantages of total thyroidectomy include easier follow-up and less uncertainty regarding the therapeutic response. However, there are some disadvantages. Surgical complications (anesthetic risk, unfavorable aesthetic result, and infection), vocal changes, hypoparathyroidism, and possible respiratory failure due to bilateral recurrent laryngeal nerve injury have greater risk in this type of surgery. Also, all patients undergoing total thyroidectomy will necessarily need thyroid hormone replacement [2]. Lobectomy, however, despite the difficulties in follow-up and the possibility of needing complementary surgery, in most cases (around 80%) there is no need for hormone replacement. Additionally, complication risks are lower, and the cost is favorable [2,4]. As several studies have already shown, prognosis is similar among these patients regardless of the type of surgery [2,5]. It’s up to the medical team, together with the patient, to balance the pros and cons of each surgery when choosing the treatment. Thus, the assessment of the patient’s Health Related Quality of Life (HRQoL) is crucial for this decision.

Several studies have evaluated the HRQoL in DTC survivors, reporting a global drop in all parameters, with neuropsychometric assessments being the most relevant [6,7]. Some of these studies showed lower scores, for DTC patients compared to other neoplasms with worse prognosis and more aggressive treatments [6,7]. Factors that have been associated with a worse HRQoL include younger age, female, and lower educational level [6]. Still, there is instability in the HRQoL of patients, especially in the first 5 years after treatment6. However, there are conflicting results in the research already carried out. While some studies show a normalization of HRQoL after some time, others show that it doesn’t completely normalize [6-9].

There are very few studies that evaluate patients with lobectomy, and even less that correlate the type of surgery with HRQoL. Since lobectomy is increasingly seen as a sufficient treatment for lowrisk DTCs, it is necessary to assess whether this surgery is better regarding HRQoL than total thyroidectomy. Furthermore, there are no studies that correlate thyroid function and HRQoL in patients treated for DTC specially when comparing the extent of surgery. With this, our study has the objective of evaluating HRQoL as well as thyroid function in patients with low-risk DTC treated with total thyroidectomy compared with the ones treated with less than total thyroidectomy.


This was an observational study, conducted in the National Institute of Cancer (INCa) in Rio de Janeiro. It included patients with low and low-intermediate risk DTC, over 18 years, with total or less than total thyroidectomy, no adjuvant therapy, and in active follow-up in this institution between August 2018 and August 2019. Exclusion criteria included: pregnancy; RIT; other primary cancers; and patients who couldn’t answer the questionnaires due to cognitive impairment. After applying inclusion and exclusion criteria, the study population consisted of 127 patients, 101 with total, and 26 with partial thyroidectomy.

The patients were called for their routine consult, and before this, a trained physician applied 3 certified HRQoL questionnaires. The first, was the EQ-5D-3L, a generic questionnaire with 5 questions that give a utility index and a visual analogue scale ranging from 0 (worst) to 100 (best) [10]. Second, the SF-36, also a generic questionnaire, with 36 questions that assess 8 parameters: functional capacity; physical limitations; perception of pain; global health; vitality; social aspects; emotional aspects; and mental health [11]. Lastly, the EORTCQLQC30. It evaluates the HRQoL specifically in cancer patients assessing 4 aspects: quality and global health; functional status; symptoms; and financial difficulties regarding their disease [12]. All three questionnaires were validated in Portuguese and authorized to be used in this research by their creators.

After the questionnaires were applied, TSH, Free T4 (FT4), Total T3 (TT3), antiperoxidase, and antithyroglobulin were drawn. These parameters were measured by electrochemiluminescence. Reference value of TSH was 0.27 to 4.2μUI/mL, FT4 0.93 to 1.7ng/mL, TT3 70 to 120ng/mL. TPOantibody was normal if less than 34U/mL, and antithyroglobulin if less than 115U/mL.

We also asked about medications used, physical activity (in which less than 150 minutes per week was considered as sedentary), comorbidities, marital status, level of education, income (divided as A-more than 20 minimal wages/month, B-between 10-20 minimal wages/month, C-between 4-10 minimal wages/month, D-between 2-4 minimal wages/month, and E-less than 2 minimal wages/month), ethnicity, and menopausal status. In addition, a retrospective analysis of the patients’ medical records was conducted regarding the tumor (histology, size, TNM stage and risk classification), the surgery (type, size of remnants if present based on the last ultrasound, and date of the surgery), and surgery complications, in which hypoparathyroidism was considered permanent when lasting more than six months and transitory when less than that.

Descriptive analysis of the sample characteristics was performed, and we compared sociodemographic and clinical characteristics of patients who underwent partial thyroidectomy and those who underwent total thyroidectomy, using Chi-squared and Fisher test.

The proportion of problem levels reported for each dimension of the EQ5D was compared between both groups of patients using Chi-squared/Fisher test. Descriptive analysis of VAS and utility score (calculated based on the valuation of the Brazilian population) 12129} [13] were calculated and we compared the mean value of each patient group using t-Student test.

The EORTC raw scores of each scale were transformed to a score ranging from 0-100, with higher scores representing either better functioning/QoL or more symptom/item burden according to the evaluated scale in the sample. EORTC and SF-36 scales means of patients with partial and total thyroidectomy were compared with t-Student test.

Also, we compared the HRQoL index/scores of patients considering TSH, total T3 and free T4 results, independently of surgery type.

The significance level alpha of 5% was considered to test differences. All analyses were performed using the software R version 3.5.1.

This study was approved by the science and ethics committee of INCa and all patients involved signed a consent form before entering the study.


After applying inclusion and exclusion criteria, as well as active recruitment of patients that met all the norms of the study in our database, 127 patients with DTC entered the research, 26 with partial thyroidectomy (seen as lobectomy in the tables presented in this article) and 101 with total thyroidectomy (Figure 1). Table 1 describes the characteristics of the population of this study. Most patients were women (88.46% with lobectomy and 91.09% with total thyroidectomy) and 40-59 years old with no difference between the groups. At the time of surgery, the population was also preferentially in the 40-59 age groups (51.2%). However, when analyzing the groups separately, it was seen that out of the patients with lobectomy, 65.38% were under 40 years old, while the patients with total thyroidectomy were mainly 40-59 years old (58,42%). Other characteristics such as race, educational level, marital status, income, physical activity, medications, and menopause didn’t have any difference as well. However, the BMI analysis reached statistical differences when comparing the two groups. The group submitted to lobectomy had mostly a normal BMI (36%), while total thyroidectomy group were predominantly obese (51.55%).