‘Watch and wait’, a new strategy to treat thyroid cancer

“I have been diagnosed with cancer and they propose to do nothing.” This is a phrase that makes you dizzy: how come you don’t do anything? Nevertheless, watch and wait it’s a new way of treat cancer.

Of English watch and wait either active surveillance, consists of intensively monitoring the evolution of the tumor in each patient, without performing any surgical intervention or providing any treatment. It is currently being used with patients with thyroid, prostate, and lymphoma cancer.

The case of papillary cancer

Naturally, this option is not valid for any type of cancer. With regard to thyroid cancer, it can only be applied to so-called low-risk papillary carcinoma or microcarcinoma. But what are its characteristics? And why can only watch and wait with this type of disease?

Papillary cancer is the most frequent of those that affect the thyroid gland, and the number of diagnosed increases every year. It is not yet known why. One explanation is the improvement of imaging techniques, capable of locating small tumors (less than 1 cm), which are called microcarcinomas. And where does papillary come from?

In general, thyroid cancer is divided into two groups, depending on its state of cell differentiation, or what is the same, how disorganized and uncontrolled the cells that form it are. There are, then, differentiated tumors, such as papillary or follicular carcinoma; and undifferentiated, such as poorly differentiated or anaplastic. The latter are very aggressive, with low survival and without effective treatment.

In a healthy thyroid, the cells are organized into spheres. Inside, thyroglobulin accumulates, a protein necessary to generate thyroid hormones (T3 and T4), which help control the metabolism and growth of the organism. Papillary carcinoma cells form papillae, like elongated fingers, hence their name.

In general, papillary carcinoma has a good prognosis, although in some cases it can progress and become aggressive. It is treated by surgery, removing part or all of the thyroid, and/or with radioactive iodine.

In the second assumption, the therapy works as follows. Thyroid cells need to take up iodine in order to produce thyroglobulin and thyroid hormones. By maintaining a certain cellular structure, the papillary carcinoma still has the capacity to capture this mineral, and if it is radioactive, the tumor cells die by integrating it.

Small and non-aggressive tumors

Previously, microcarcinomas went unnoticed due to their small size – some were discovered postmortem – and because they do not present symptoms. This suggested that the disease was not actually progressing and that the person was living normally. Although more microcarcinomas are now being diagnosed, mortality has not increased.

With this in mind, follow-up studies of papillary microcarcinoma patients were conducted, first in Japan and Korea and in recent years in the US. In the vast majority of patients, the tumor did not change in size over time. Sometimes it even got smaller and disappeared on its own. It only grew in a small percentage of individuals, but it did so slowly.

In other words, the vast majority of people diagnosed with papillary microcarcinoma are receiving possibly unnecessary treatment. Keep in mind that surgery always involves risk, and in this case the laryngeal nerve or the vocal cords may be damaged. Afterwards, a hormonal supplement is needed for life.

And when it comes to radioactive iodine therapy, it’s not just tumor cells that die, but healthy ones as well. The watch-and-wait option doesn’t seem like such a bad idea. But what does it consist of?

So watch and wait

First, candidates must have a papillary tumor of less than 1.5 cm, without invasion of the lymph nodes in the neck. They cannot have other types of diseases and preferably be over 60 years of age. The young, it seems, tend not to be consistent during follow-up, and tumors in patients older than six decades tend to show slow growth.

Follow-up consists of performing an ultrasound test every 6 months for the first two years and then annually. Decisions are made as the tumor evolves.

But patients need to balance feelings of concern about letting cancer run its course against the risk of side effects and complications from treatment. Once the patient is diagnosed and considered low risk, they are given the option of undergoing surgery or watch and wait.

There are three types of patients: those who prefer to treat and undergo surgery immediately, those who start by monitoring and then, even without changes in the tumor, prefer to treat it, and those who endure. Having cancer carries a great psychological burden, and not everyone experiences it the same way.

The US is several years ahead of us: the watch-and-wait option is still being explored in Europe. But are we prepared?

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