Thyroid Cancer in the Elderly

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Citation:

Pages 32 - 37

Authors:

Ranjani Ramanathan, MD, and Henry G. Fein, MD

Author Affiliations:

Dr. Ramanathan is a first-year
Fellow in Endocrinology, Washington University, St. Louis, MO.

Dr. Fein is Clinical Director, Division of Endocrinology and Metabolism, Department of Medicine, Sinai
Hospital of Baltimore, and Assistant Professor of Medicine, Johns
Hopkins University School of
Medicine, Baltimore, MD.

This article is no longer available for CME credit.

Introduction

The highly publicized illness and subsequent death of the Chief Justice of the United States, William H. Rehnquist, from anaplastic carcinoma of the thyroid has focused attention on malignancies of this gland in older patients. The incidence of thyroid cancer has been gradually increasing over the last 50 years, with a steep increase since 1992.1 It is presently unclear whether this is a biological event or is secondary to more aggressive case finding. The female-to-male ratio of the incidence of differentiated thyroid cancer in all age groups is 2.5:1, and the peak incidence is in the fourth and fifth decades of life.

There are different forms of thyroid cancer, based on their pathology. The four principal forms are:

1. Papillary thyroid cancer: over 75% of new cases in iodine-replete areas; sometimes indolent; spreads chiefly by lymphatics.
2. Follicular thyroid cancer: over 10% of new cases; spreads chiefly by blood-borne metastases.
(The above two are classified together as differentiated thyroid carcinoma.)
3. Medullary thyroid cancer: 5% of new cases; originates from parafollicular cells and produces calcitonin; usually but not universally familial; occurs either alone or as a component of multiple endocrine neoplasia type 2.
4. Anaplastic thyroid cancer: also known as undifferentiated thyroid cancer; less than 10% of cases in patients under 50 years of age; mean age at diagnosis is 65; highly aggressive locally in the neck; disease-specific mortality approaches 100%.

How Does Age Impact Thyroid Cancer?

Several studies have shown age to be an adverse prognostic factor in thyroid cancer. Thyroid cancer mortality rates are lowest in patients younger than 40 years and increased with each subsequent decade of life.2 Furthermore, patients age 45 years or older who have lymph node recurrences are more likely subsequently to die of their disease than similar patients under age 45.2-4

Age is also associated with increased recurrence rates of thyroid cancer.3 Recurrences are most frequent at the extremes of age (< 20 and > 59 yr).2 The Union Internationale Contre le Cancer (UICC) and the American Joint Committee on Cancer (AJCC) have adopted a tumor-node-metastasis classification system in which age at diagnosis is also considered a component of stage designation.5 The National Thyroid Cancer Treatment Cooperative Study (NTCTCS) created a staging approach that was applied prospectively to a registry of patients drawn from 14 cooperating institutions. Clinical-pathologic staging was based upon patient age at diagnosis, tumor histology, tumor size, intrathyroidal multifocality, extraglandular invasion, metastases, and tumor differentiation.6

Aging patients with newly diagnosed differentiated thyroid carcinoma are at far greater risk than are younger patients. The rate of distant recurrences rises in the eighth decade of life, and the incidence of all recurrence (including those in the neck only) rises beginning in the seventh decade. Most importantly, the rate of cancer death, which rises to 5% in the fourth and fifth decades, reaches 25% in patients age 60-69 and over 30% in those over age 70.7

As patients age, there is a marked shift in the incidence of histological type of thyroid cancer. Younger patients have a high proportion of papillary cancer, while aging increases the proportion of more aggressive types such as anaplastic, Hürthle cell, and medullary thyroid cancer.3 Although anaplastic thyroid cancer accounts for only 2-5% of thyroid cancers, patients with anaplastic carcinoma are older than those with differentiated thyroid cancer. The mean age of diagnosis for anaplastic carcinoma is 65 years, and fewer than 10% of cases occur in patients younger than 50 years.3,8

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