The Difficult Problem of Timely Diagnosis
“The diseases of young men are more acute and curable, of old men longer and hard to cure…”—Sir Francis Bacon When people initially heard last autumn that Chief Justice William Rehnquist had undergone surgery for thyroid cancer, they hoped for the best and assumed that he would make a speedy recovery as most people do with thyroid cancer. Physicians are used to diagnosing follicular or papillary cancer of the thyroid and have been ingrained to think that if one had the power to “choose” a specific cancer, thyroid cancer would be one to consider, as few die of this illness.
There are four major types of thyroid cancer. Papillary cancer is the most common cancer affecting the thyroid gland. It accounts for approximately 80% of all thyroid cancers and affects individuals mostly in their 40s. It has a 70:30 preponderance for women and is responsible for only a few percent of the deaths due to thyroid cancer. This form of thyroid cancer rarely metastasizes beyond neighboring lymph nodes. Follicular cancer is the next most common cancer of the thyroid gland responsible for approximately 12% of thyroid cancers. It usually affects individuals between the ages of 20 and 60 years and once again most commonly affects women. It accounts for only a small portion of the deaths from thyroid cancer but has a greater tendency to invade neighboring blood vessels and distant sites. Although less common than either of the aforementioned cancers, medullary cancer of the thyroid gland most commonly affects individuals in their 50s and is also slightly more common in women. It accounts for approximately 3-4% of thyroid cancers and has an 80% 5-year survival rate. It has received a great deal of attention, however, due to its association with other endocrine disorders such as hyperparathyroidism and pheochromocytoma.
Anaplastic carcinoma of the thyroid is a much more serious form of thyroid cancer. It largely affects the elderly, women only slightly more than men, and is responsible for over 90% of deaths from thyroid cancer. It has a dismal 1-year survival rate of approximately 10% and a 5-year survival rate of only 5%. It is a rapidly growing, difficult-to-treat cancer with distant metastases a reality. When I heard the early reports on the Chief Justice state “thyroid cancer” and “tracheostomy” in the same sentence, I knew just what form of thyroid cancer Justice Rehnquist most likely had: anaplastic. I realized then that the prognosis would not be what many had originally hoped.
As is the case with so many other illnesses that affect the elderly, they are often recognized only late in their course and often in a manner or form different from that seen earlier in life. One must consider a different list of differential diagnoses when evaluating the older individual. I hope you will join me in wishing Chief Justice Rehnquist the very best as he continues to tackle what is certainly the most difficult “case” of his long and illustrious career. I welcome your comments. Send comments to Dr. Gambert at firstname.lastname@example.org.