21st Century Adult Cancer Sourcebook: Thyroid Cancer - Clinical Data for Patients, Families, and Physicians
Edition 1.0 - October 2011
National Cancer Institute
Smashwords Edition
Copyright 2011 Progressive Management
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PART ONE
Chapter 1A: Thyroid Cancer Patient Information
Chapter 2A: Thyroid Cancer Health Professional Information
Chapter 3A: Thyroid Cancer NCI Drugs
Chapter 4A: Thyroid Cancer Background Information
Chapter 5A: Thyroid Cancer Clinical Trials
PART TWO
Chapter 1B: Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (NCI)
Chapter 2B: Glossary of Clinical Trial Terms
Chapter 3B: Clinical Trials Background Information
Chapter 4B: Cancer Clinical Trials -The Basic Workbook
Chapter 5B: Cancer Clinical Trials - The In-Depth Program
Chapter 6B: Clinical Trials at NIH
Chapter 7B: How To Find A Cancer Treatment Trial: A Ten Step Guide
Chapter 8B: Taking Part in Cancer Treatment Research Studies
Chapter 9B: Cancer Clinical Trials
Chapter 10B: Access to Investigational Drugs
Chapter 12B: Taking Time: Support for People with Cancer
Chapter 13B: Facing Forward - Life After Cancer Treatment
Chapter 14B: Chemotherapy and You
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PART ONE
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Chapter 1A: Thyroid Cancer Patient Information
Patient Version
Last Modified: 07/21/2011
General Information About Thyroid Cancer
Key Points for This Section
* Thyroid cancer is a disease in which malignant (cancer) cells form in the tissues of the thyroid gland.
* Age, gender, and exposure to radiation can affect the risk of developing thyroid cancer.
* Medullary thyroid cancer is sometimes caused by a change in a gene that is passed from parent to child.
* Possible signs of thyroid cancer include a swelling or lump in the neck.
* Tests that examine the thyroid, neck, and blood are used to detect (find) and diagnose thyroid cancer.
* Certain factors affect prognosis (chance of recovery) and treatment options.
Thyroid cancer is a disease in which malignant (cancer) cells form in the tissues of the thyroid gland.
The thyroid is a gland at the base of the throat near the trachea (windpipe). It is shaped like a butterfly, with a right lobe and a left lobe. The isthmus, a thin piece of tissue, connects the two lobes. A healthy thyroid is a little larger than a quarter. It usually cannot be felt through the skin. The thyroid uses iodine, a mineral found in some foods and in iodized salt, to help make several hormones. Thyroid hormones do the following:
* Control heart rate, body temperature, and how quickly food is changed into energy (metabolism).
* Control the amount of calcium in the blood.
There are four main types of thyroid cancer:
* Papillary thyroid cancer: The most common type of thyroid cancer.
* Follicular thyroid cancer. Hürthle cell carcinoma is a form of follicular thyroid cancer and is treated the same way.
* Medullary thyroid cancer.
* Anaplastic thyroid cancer.
Age, gender, and exposure to radiation can affect the risk of developing thyroid cancer.
Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for thyroid cancer include the following:
* Being between 25 and 65 years old.
* Being female.
* Being exposed to radiation to the head and neck as a child or being exposed to atomic bomb radiation. The cancer may occur as soon as 5 years after exposure.
* Having a history of goiter (enlarged thyroid).
* Having a family history of thyroid disease or thyroid cancer.
* Having certain genetic conditions such as familial medullary thyroid cancer (FMTC), multiple endocrine neoplasia type 2A syndrome, and multiple endocrine neoplasia type 2B syndrome.
* Being Asian.
Medullary thyroid cancer is sometimes caused by a change in a gene that is passed from parent to child.
The genes in cells carry hereditary information from parent to child. A certain change in a gene that is passed from parent to child (inherited) may cause medullary thyroid cancer. A test has been developed that can find the changed gene before medullary thyroid cancer appears. The patient is tested first to see if he or she has the changed gene. If the patient has it, other family members may also be tested. Family members, including young children, who have the changed gene can decrease the chance of developing medullary thyroid cancer by having a thyroidectomy (surgery to remove the thyroid).
Possible signs of thyroid cancer include a swelling or lump in the neck.
Thyroid cancer may not cause early symptoms. It is sometimes found during a routine physical exam. Symptoms may occur as the tumor gets bigger. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:
* A lump in the neck.
* Trouble breathing.
* Trouble swallowing.
* Hoarseness.
Tests that examine the thyroid, neck, and blood are used to detect (find) and diagnose thyroid cancer.
The following tests and procedures may be used:
* Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or swelling in the neck, voice box, and lymph nodes, and anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
* Laryngoscopy: A procedure in which the doctor checks the larynx (voice box) with a mirror or with a laryngoscope. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing. A thyroid tumor may press on vocal cords. The laryngoscopy is done to see if the vocal cords are moving normally.
* Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. The blood may be checked for abnormal levels of thyroid-stimulating hormone (TSH). TSH is made by the pituitary gland in the brain. It stimulates the release of thyroid hormone and controls how fast follicular thyroid cells grow. The blood may also be checked for high levels of the hormone calcitonin.
* Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as calcium, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.
* Radioactive iodine scan (RAI scan): A procedure to find areas in the body where thyroid cancer cells may be dividing quickly. Radioactive iodine (RAI) is used because only thyroid cells take up iodine. A very small amount of RAI is swallowed, travels through the blood, and collects in thyroid tissue and thyroid cancer cells anywhere in the body. Abnormal thyroid cells take up less iodine than normal thyroid tissue. Areas that do not absorb the iodine normally (cold spots) show up lighter in the picture made by the scan. Cold spots can be either benign (not cancer) or malignant, so a biopsy is done to find out if they are cancer.
* Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later. This procedure can show the size of a thyroid tumor and whether it is solid or a fluid -filled cyst. Ultrasound may be used to guide a fine-needle aspiration biopsy.
* CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
* MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
* PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
* Fine-needle aspiration biopsy of the thyroid: The removal of thyroid tissue using a thin needle. The needle is inserted through the skin into the thyroid. Several tissue samples are removed from different parts of the thyroid. A pathologist views the tissue samples under a microscope to look for cancer cells. Because the type of thyroid cancer can be hard to diagnose, patients should ask to have biopsy samples checked by a pathologist who has experience diagnosing thyroid cancer.
* Surgical biopsy: The removal of the thyroid nodule or one lobe of the thyroid during surgery so the cells and tissues can be viewed under a microscope by a pathologist to check for signs of cancer. Because the type of thyroid cancer can be hard to diagnose, patients should ask to have biopsy samples checked by a pathologist who has experience diagnosing thyroid cancer.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment options depend on the following:
* The age of the patient.
* The type of thyroid cancer.
* The stage of the cancer.
* The patient's general health.
* Whether the patient has multiple endocrine neoplasia type 2B (MEN 2B).
* Whether the cancer has just been diagnosed or has recurred (come back).
Glossary Terms
abnormal (ab-NOR-mul)
* Not normal. An abnormal lesion or growth may be cancer, premalignant (likely to become cancer), or benign (not cancer).
anaplastic thyroid cancer (A-nuh-PLAS-tik THY-royd KAN-ser)
* A rare, aggressive type of thyroid cancer in which the malignant (cancer) cells look very different from normal thyroid cells.
benign (beh-NINE)
* Not cancerous. Benign tumors may grow larger but do not spread to other parts of the body. Also called nonmalignant.
biopsy (BY-op-see)
* The removal of cells or tissues for examination by a pathologist. The pathologist may study the tissue under a microscope or perform other tests on the cells or tissue. There are many different types of biopsy procedures. The most common types include: (1) incisional biopsy, in which only a sample of tissue is removed; (2) excisional biopsy, in which an entire lump or suspicious area is removed; and (3) needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.
biopsy specimen (BY-op-see SPEH-sih-men)
* Tissue removed from the body and examined under a microscope to determine whether disease is present.
blood (blud)
* A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.
blood chemistry study (blud KEH-mih-stree STUH-dee)
* A procedure in which a sample of blood is examined to measure the amounts of certain substances made in the body. An abnormal amount of a substance can be a sign of disease in the organ or tissue that produces it.
calcitonin (KAL-sih-TOH-nin)
* A hormone formed by the C cells of the thyroid gland. It helps maintain a healthy level of calcium in the blood. When the calcium level is too high, calcitonin lowers it.
calcium (KAL-see-um)
* A mineral needed for healthy teeth, bones, and other body tissues. It is the most common mineral in the body. A deposit of calcium in body tissues, such as breast tissue, may be a sign of disease.
cancer (KAN-ser)
* A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is a cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord. Also called malignancy.
carcinoma (KAR-sih-NOH-muh)
* Cancer that begins in the skin or in tissues that line or cover internal organs.
cell (sel)
* The individual unit that makes up the tissues of the body. All living things are made up of one or more cells.
contrast material (KON-trast muh-TEER-ee-ul)
* A dye or other substance that helps show abnormal areas inside the body. It is given by injection into a vein, by enema, or by mouth. Contrast material may be used with x-rays, CT scans, MRI, or other imaging tests.
CT scan (… skan)
* A series of detailed pictures of areas inside the body taken from different angles. The pictures are created by a computer linked to an x-ray machine. Also called CAT scan, computed tomography scan, computerized axial tomography scan, and computerized tomography.
cyst (sist)
* A sac or capsule in the body. It may be filled with fluid or other material.
diagnosis (DY-ug-NOH-sis)
* The process of identifying a disease, such as cancer, from its signs and symptoms.
familial medullary thyroid cancer (fuh-MIH-lee-ul MED-yoo-LAYR-ee THY-royd KAN-ser)
* An inherited form of medullary thyroid cancer (cancer that forms in the cells of the thyroid that make the hormone calcitonin).
family history (FA-mih-lee HIH-stuh-ree)
* A record of the relationships among family members along with their medical histories. This includes current and past illnesses. A family history may show a pattern of certain diseases in a family. Also called family medical history.
fine-needle aspiration biopsy (... NEE-dul AS-pih-RAY-shun BY-op-see)
* The removal of tissue or fluid with a thin needle for examination under a microscope. Also called FNA biopsy.
fluid (FLOO-id)
* A substance that flows smoothly and takes the shape of its container. Liquids and gases are fluids.
follicular thyroid cancer (fuh-LIH-kyoo-ler THY-royd KAN-ser)
* Cancer that forms in follicular cells in the thyroid. It grows slowly and is highly treatable.
gene (jeen)
* The functional and physical unit of heredity passed from parent to offspring. Genes are pieces of DNA, and most genes contain the information for making a specific protein.
genetic (jeh-NEH-tik)
* Inherited; having to do with information that is passed from parents to offspring through genes in sperm and egg cells.
gland
* An organ that makes one or more substances, such as hormones, digestive juices, sweat, tears, saliva, or milk. Endocrine glands release the substances directly into the bloodstream. Exocrine glands release the substances into a duct or opening to the inside or outside of the body.
glucose (GLOO-kose)
* A type of sugar; the chief source of energy for living organisms.
goiter (GOY-ter)
* An enlarged thyroid. It may be caused by too little iodine in the diet or by other conditions. Most goiters are not cancer.
hereditary (huh-REH-dih-tayr-ee)
* Transmitted from parent to child by information contained in the genes.
hormone (HOR-mone)
* One of many chemicals made by glands in the body. Hormones circulate in the bloodstream and control the actions of certain cells or organs. Some hormones can also be made in the laboratory.
inherited (in-HAYR-ih-ted)
* Transmitted through genes that have been passed from parents to their offspring (children).
injection (in-JEK-shun)
* Use of a syringe and needle to push fluids or drugs into the body; often called a "shot."
iodine (I-oh-dine)
* An element that is necessary for the body to make thyroid hormone. It is found in shellfish and iodized salt.
isthmus (iz-muhs)
* A narrow part inside the body that connects two larger structures.
laryngoscope (luh-RIN-goh-SKOPE)
* A thin, tube-like instrument used to examine the larynx (voice box). A laryngoscope has a light and a lens for viewing and may have a tool to remove tissue.
laryngoscopy (LAYR-in-GOS-koh-pee)
* Examination of the larynx (voice box) with a mirror (indirect laryngoscopy) or with a laryngoscope (direct laryngoscopy).
larynx (LAYR-inx)
* The area of the throat containing the vocal cords and used for breathing, swallowing, and talking. Also called voice box.
lens (lenz)
* A clear disk that focuses light, as in a camera or microscope. In the eye, the lens is a clear, curved structure at the front of the eye behind the pupil. It focuses light rays that enter the eye through the pupil, making an image on the retina (light-sensitive layers of nerve tissue at the back of the eye).
lobe
* A portion of an organ, such as the liver, lung, breast, thyroid, or brain.
lymph node (limf node)
* A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called lymph gland.
malignant (muh-LIG-nunt)
* Cancerous. Malignant cells can invade and destroy nearby tissue and spread to other parts of the body.
medullary thyroid cancer (MED-yoo-LAYR-ee THY-royd KAN-ser)
* Cancer that develops in C cells of the thyroid. The C cells make a hormone (calcitonin) that helps maintain a healthy level of calcium in the blood.
metabolism (meh-TA-buh-lih-zum)
* The chemical changes that take place in a cell or an organism. These changes make energy and the materials cells and organisms need to grow, reproduce, and stay healthy. Metabolism also helps get rid of toxic substances.
mineral (MIH-neh-rul)
* In medicine, a mineral is a nutrient that is needed in small amounts to keep the body healthy. Mineral nutrients include the elements calcium, magnesium, and iron.
MRI
* A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or x-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints, and the inside of bones. Also called magnetic resonance imaging, NMRI, and nuclear magnetic resonance imaging.
multiple endocrine neoplasia syndrome (MUL-tih-pul EN-doh-krin NEE-oh-PLAY-zhuh SIN-drome)
* An inherited condition that may result in the development of cancers of the endocrine system. There are several types of multiple endocrine neoplasia syndrome, and patients with each type may develop different types of cancer. The altered genes that cause each type can be detected with a blood test. Also called MEN syndrome.
nodule (NAH-jool)
* A growth or lump that may be malignant (cancer) or benign (not cancer).
organ (OR-gun)
* A part of the body that performs a specific function. For example, the heart is an organ.
papillary thyroid cancer (PA-pih-LAYR-ee THY-royd KAN-ser)
* Cancer that forms in follicular cells in the thyroid and grows in small finger-like shapes. It grows slowly, is more common in women than in men, and often occurs before age 45. It is the most common type of thyroid cancer.
pathologist (puh-THAH-loh-jist)
* A doctor who identifies diseases by studying cells and tissues under a microscope.
PET scan (… skan)
* A procedure in which a small amount of radioactive glucose (sugar) is injected into a vein, and a scanner is used to make detailed, computerized pictures of areas inside the body where the glucose is used. Because cancer cells often use more glucose than normal cells, the pictures can be used to find cancer cells in the body. Also called positron emission tomography scan.
physical examination (FIH-zih-kul eg-ZA-mih-NAY-shun)
* An exam of the body to check for general signs of disease.
pituitary gland (pih-TOO-ih-TAYR-ee...)
* A pea-sized organ attached to the part of the brain called the hypothalamus. It lies at the base of the brain above the back of the nose. The hypothalamus sends signals to the pituitary gland, which then makes hormones that control other glands and many of the body’s functions, including growth.
prognosis (prog-NO-sis)
* The likely outcome or course of a disease; the chance of recovery or recurrence.
radiation (RAY-dee-AY-shun)
* Energy released in the form of particle or electromagnetic waves. Common sources of radiation include radon gas, cosmic rays from outer space, medical x-rays, and energy given off by a radioisotope (unstable form of a chemical element that releases radiation as it breaks down and becomes more stable).
radioactive (RAY-dee-oh-AK-tiv)
* Giving off radiation.
radioactive iodine (RAY-dee-oh-AK-tiv I-oh-dine)
* A radioactive form of iodine, often used for imaging tests or to treat an overactive thyroid, thyroid cancer, and certain other cancers. For imaging tests, the patient takes a small dose of radioactive iodine that collects in thyroid cells and certain kinds of tumors and can be detected by a scanner. To treat thyroid cancer, the patient takes a large dose of radioactive iodine, which kills thyroid cells. Radioactive iodine is also used in internal radiation therapy for prostate cancer, intraocular (eye) melanoma, and carcinoid tumors. Radioactive iodine is given by mouth as a liquid or in capsules, by infusion, or sealed in seeds, which are placed in or near the tumor to kill cancer cells.
recur
* To come back or to return.
risk factor (... FAK-ter)
* Something that increases the chance of developing a disease. Some examples of risk factors for cancer are age, a family history of certain cancers, use of tobacco products, being exposed to radiation or certain chemicals, infection with certain viruses or bacteria, and certain genetic changes.
scan (skan)
* A picture of structures inside the body. Scans often used in diagnosing, staging, and monitoring disease include liver scans, bone scans, and computed tomography (CT) or computerized axial tomography (CAT) scans and magnetic resonance imaging (MRI) scans. In liver scanning and bone scanning, radioactive substances that are injected into the bloodstream collect in these organs. A scanner that detects the radiation is used to create pictures. In CT scanning, an x-ray machine linked to a computer is used to produce detailed pictures of organs inside the body. MRI scans use a large magnet connected to a computer to create pictures of areas inside the body.
scanner (SKA-ner)
* In medicine, an instrument that takes pictures of the inside of the body.
sonogram (SAH-noh-gram)
* A computer picture of areas inside the body created by bouncing high-energy sound waves (ultrasound) off internal tissues or organs. Also called ultrasonogram.
stage
* The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.
surgery (SER-juh-ree)
* A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.
surgical biopsy (SER-jih-kul BY-op-see)
* The removal of tissue by a surgeon for examination by a pathologist. The pathologist may study the tissue under a microscope.
symptom (SIMP-tum)
* An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
syndrome (SIN-drome)
* A set of symptoms or conditions that occur together and suggest the presence of a certain disease or an increased chance of developing the disease.
throat (throte)
* The hollow tube inside the neck that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes to the stomach). The throat is about 5 inches long, depending on body size. Also called pharynx.
thyroid (THY-royd)
* A gland located beneath the larynx (voice box) that makes thyroid hormone and calcitonin. The thyroid helps regulate growth and metabolism. Also called thyroid gland.
thyroid cancer (THY-royd KAN-ser)
* Cancer that forms in the thyroid gland (an organ at the base of the throat that makes hormones that help control heart rate, blood pressure, body temperature, and weight). Four main types of thyroid cancer are papillary, follicular, medullary, and anaplastic thyroid cancer. The four types are based on how the cancer cells look under a microscope.
thyroid hormone (THY-royd HOR-mone)
* A hormone that affects heart rate, blood pressure, body temperature, and weight. Thyroid hormone is made by the thyroid gland and can also be made in the laboratory.
thyroid-stimulating hormone (THY-royd STIM-yoo-LAY-ting HOR-mone)
* A hormone produced by the pituitary gland. Thyroid-stimulating hormone stimulates the release of thyroid hormone from thyroglobulin. It also stimulates the growth of thyroid follicular cells. An abnormal thyroid-stimulating hormone level may mean that the thyroid hormonal regulation system is out of control, usually as a result of a benign condition (hyperthyroidism or hypothyroidism). Also called TSH.
thyroidectomy (THY-roy-DEK-toh-mee)
* Surgery to remove part or all of the thyroid.
tissue (TIH-shoo)
* A group or layer of cells that work together to perform a specific function.
trachea (TRAY-kee-uh)
* The airway that leads from the larynx (voice box) to the bronchi (large airways that lead to the lungs). Also called windpipe.
tumor (TOO-mer)
* An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). Also called neoplasm.
ultrasound (UL-truh-SOWND)
* A procedure in which high-energy sound waves are bounced off internal tissues or organs and make echoes. The echo patterns are shown on the screen of an ultrasound machine, forming a picture of body tissues called a sonogram. Also called ultrasonography.
vein (vayn)
* A blood vessel that carries blood to the heart from tissues and organs in the body.
vocal cord (VOH-kul kord)
* One of two small bands of muscle within the larynx that vibrates to produce the voice.
voice box (voys …)
* The area of the throat containing the vocal cords and used for breathing, swallowing, and talking. Also called larynx.
x-ray (EX-ray)
* A type of radiation used in the diagnosis and treatment of cancer and other diseases. In low doses, x-rays are used to diagnose diseases by making pictures of the inside of the body. In high doses, x-rays are used to treat cancer.
Table of Links
1 http://www.cancer.gov/cancertopics/pdq/treatment/unusual-cancers-childhood/Patient/Page3#Section 92
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Stages of Thyroid Cancer
Key Points for This Section
* After thyroid cancer has been diagnosed, tests are done to find out if cancer cells have spread within the thyroid or to other parts of the body.
* There are three ways that cancer spreads in the body.
* The following stages are used for papillary and follicular thyroid cancer in patients younger than 45 years:
* Stage I
* Stage II
* The following stages are used for papillary and follicular thyroid cancer in patients 45 years and older:
* Stage I
* Stage II
* Stage III
* Stage IV
* The following stages are used for medullary thyroid cancer:
* Stage 0
* Stage I
* Stage II
* Stage III
* Stage IV
* Anaplastic thyroid cancer is considered stage IV thyroid cancer.
After thyroid cancer has been diagnosed, tests are done to find out if cancer cells have spread within the thyroid or to other parts of the body.
The process used to find out if cancer has spread within the thyroid or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
* CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
* MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
* Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
* Radioactive iodine scan (RAI scan): A procedure to find areas in the body where thyroid cancer cells may be dividing quickly. Radioactive iodine (RAI) is used because only thyroid cells take up iodine. A very small amount of RAI is swallowed, travels through the blood, and collects in thyroid tissue and thyroid cancer cells anywhere in the body. Abnormal thyroid cells take up less iodine than normal thyroid cells. Areas that do not absorb the iodine normally (cold spots) show up lighter in the picture made by the scan. Cold spots can be either benign (not cancer) or malignant, so more tests are needed to find out if they are cancer. A scan of the whole body may be done to find out the stage of the cancer.
* Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells.
* Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
* Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
There are three ways that cancer spreads in the body.
The three ways that cancer spreads in the body are:
* Through tissue. Cancer invades the surrounding normal tissue.
* Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
* Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
The following stages are used for papillary and follicular thyroid cancer in patients younger than 45 years:
Stage I
In stage I papillary and follicular thyroid cancer, the tumor is any size, may be in the thyroid, or may have spread to nearby tissues and lymph nodes. Cancer has not spread to other parts of the body.
Stage II
In stage II papillary and follicular thyroid cancer, the tumor is any size and cancer has spread from the thyroid to other parts of the body, such as the lungs or bone, and may have spread to lymph nodes.
The following stages are used for papillary and follicular thyroid cancer in
Stage I
In stage I papillary and follicular thyroid cancer, cancer is found only in the thyroid and the tumor is 2 centimeters or smaller.
Stage II
In stage II papillary and follicular thyroid cancer, cancer is only in the thyroid and the tumor is larger than 2 centimeters but not larger than 4 centimeters.
Stage III
In stage III papillary and follicular thyroid cancer, either of the following is found:
* the tumor is larger than 4 centimeters and only in the thyroid or the tumor is any size and cancer has spread to tissues just outside the thyroid, but not to lymph nodes; or
* the tumor is any size and cancer may have spread to tissues just outside the thyroid and has spread to lymph nodes near the trachea or the larynx (voice box).
Stage IV
Stage IV papillary and follicular thyroid cancer is divided into stages IVA, IVB, and IVC.
* In stage IVA, either of the following is found:
* the tumor is any size and cancer has spread outside the thyroid to tissues under the skin, the trachea, the esophagus, the larynx (voice box), and/or the recurrent laryngeal nerve (a nerve with two branches that go to the larynx); cancer may have spread to nearby lymph nodes; or
* the tumor is any size and cancer may have spread to tissues just outside the thyroid. Cancer has spread to lymph nodes on one or both sides of the neck or between the lungs.
* In stage IVB, cancer has spread to tissue in front of the spinal column or has surrounded the carotid artery or the blood vessels in the area between the lungs; cancer may have spread to lymph nodes.
* In stage IVC, the tumor is any size and cancer has spread to other parts of the body, such as the lungs and bones, and may have spread to lymph nodes.
The following stages are used for medullary thyroid cancer:
Stage 0
Stage 0 medullary thyroid cancer is found only with a special screening test. No tumor can be found in the thyroid.
Stage I
Stage I medullary thyroid cancer is found only in the thyroid and is 2 centimeters or smaller.
Stage II
In stage II medullary thyroid cancer, either of the following is found:
* the tumor is larger than 2 centimeters and only in the thyroid; or
* the tumor is any size and has spread to tissues just outside the thyroid, but not to lymph nodes.
Stage III
In stage III medullary thyroid cancer, the tumor is any size, has spread to lymph nodes near the trachea and the larynx (voice box), and may have spread to tissues just outside the thyroid.
Stage IV
Stage IV medullary thyroid cancer is divided into stages IVA, IVB, and IVC.
* In stage IVA, either of the following is found:
* the tumor is any size and cancer has spread outside the thyroid to tissues under the skin, the trachea, the esophagus, the larynx (voice box), and/or the recurrent laryngeal nerve (a nerve with 2 branches that go to the larynx); cancer may have spread to lymph nodes near the trachea or the larynx; or
* the tumor is any size and cancer may have spread to tissues just outside the thyroid. Cancer has spread to lymph nodes on one or both sides of the neck or between the lungs.
* In stage IVB, cancer has spread to tissue in front of the spinal column or has surrounded the carotid artery or the blood vessels in the area between the lungs. Cancer may have spread to lymph nodes.
* In stage IVC, the tumor is any size and cancer has spread to other parts of the body, such as the lungs and bones, and may have spread to lymph nodes.
Anaplastic thyroid cancer is considered stage IV thyroid cancer.
Anaplastic thyroid cancer grows quickly and has usually spread within the neck when it is found. Stage IV anaplastic thyroid cancer is divided into stages IVA, IVB, and IVC.
* In stage IVA, cancer is found in the thyroid and may have spread to lymph nodes.
* In stage IVB, cancer has spread to tissue just outside the thyroid and may have spread to lymph nodes.
* In stage IVC, cancer has spread to other parts of the body, such as the lungs and bones, and may have spread to lymph nodes.
Glossary Terms
abnormal (ab-NOR-mul)
* Not normal. An abnormal lesion or growth may be cancer, premalignant (likely to become cancer), or benign (not cancer).
anaplastic thyroid cancer (A-nuh-PLAS-tik THY-royd KAN-ser)
* A rare, aggressive type of thyroid cancer in which the malignant (cancer) cells look very different from normal thyroid cells.
benign (beh-NINE)
* Not cancerous. Benign tumors may grow larger but do not spread to other parts of the body. Also called nonmalignant.
biopsy (BY-op-see)
* The removal of cells or tissues for examination by a pathologist. The pathologist may study the tissue under a microscope or perform other tests on the cells or tissue. There are many different types of biopsy procedures. The most common types include: (1) incisional biopsy, in which only a sample of tissue is removed; (2) excisional biopsy, in which an entire lump or suspicious area is removed; and (3) needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.
blood (blud)
* A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.
blood vessel (blud VEH-sel)
* A tube through which the blood circulates in the body. Blood vessels include a network of arteries, arterioles, capillaries, venules, and veins.
bone cancer (bone KAN-ser)
* Primary bone cancer is cancer that forms in cells of the bone. Some types of primary bone cancer are osteosarcoma, Ewing sarcoma, malignant fibrous histiocytoma, and chondrosarcoma. Secondary bone cancer is cancer that spreads to the bone from another part of the body (such as the prostate, breast, or lung).
bone scan (bone skan)
* A technique to create images of bones on a computer screen or on film. A small amount of radioactive material is injected into a blood vessel and travels through the bloodstream; it collects in the bones and is detected by a scanner.
breast cancer (brest KAN-ser)
* Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare.
cancer (KAN-ser)
* A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is a cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord. Also called malignancy.
capillary (KA-pih-layr-ee)
* The smallest type of blood vessel. A capillary connects an arteriole (small artery) to a venule (small vein) to form a network of blood vessels in almost all parts of the body. The wall of a capillary is thin and leaky, and capillaries are involved in the exchange of fluids and gases between tissues and the blood.
carotid artery (kuh-RAH-tid AR-tuh-ree)
* A major artery that carries blood from the heart to the head. There is a carotid artery on each side of the neck, and each one splits into two branches. The interior branch carries blood to the brain and eyes, and the exterior branch carries blood to the face, tongue, and outside parts of the head.
cell (sel)
* The individual unit that makes up the tissues of the body. All living things are made up of one or more cells.
centimeter (SEN-tih-MEE-ter)
* A measure of length in the metric system. There are 100 centimeters in a meter and 2½ centimeters in an inch.
chest x-ray (chest EX-ray)
* An x-ray of the structures inside the chest. An x-ray is a type of high-energy radiation that can go through the body and onto film, making pictures of areas inside the chest, which can be used to diagnose disease.
contrast material (KON-trast muh-TEER-ee-ul)
* A dye or other substance that helps show abnormal areas inside the body. It is given by injection into a vein, by enema, or by mouth. Contrast material may be used with x-rays, CT scans, MRI, or other imaging tests.
CT scan (… skan)
* A series of detailed pictures of areas inside the body taken from different angles. The pictures are created by a computer linked to an x-ray machine. Also called CAT scan, computed tomography scan, computerized axial tomography scan, and computerized tomography.
esophagus (ee-SAH-fuh-gus)
* The muscular tube through which food passes from the throat to the stomach.
follicular thyroid cancer (fuh-LIH-kyoo-ler THY-royd KAN-ser)
* Cancer that forms in follicular cells in the thyroid. It grows slowly and is highly treatable.
injection (in-JEK-shun)
* Use of a syringe and needle to push fluids or drugs into the body; often called a "shot."
invasive cancer (in-VAY-siv KAN-ser)
* Cancer that has spread beyond the layer of tissue in which it developed and is growing into surrounding, healthy tissues. Also called infiltrating cancer.
iodine (I-oh-dine)
* An element that is necessary for the body to make thyroid hormone. It is found in shellfish and iodized salt.
laryngeal (luh-RIN-jee-ul)
* Having to do with the larynx.
larynx (LAYR-inx)
* The area of the throat containing the vocal cords and used for breathing, swallowing, and talking. Also called voice box.
lung
* One of a pair of organs in the chest that supplies the body with oxygen, and removes carbon dioxide from the body.
lymph (limf)
* The clear fluid that travels through the lymphatic system and carries cells that help fight infections and other diseases. Also called lymphatic fluid.
lymph node (limf node)
* A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called lymph gland.
lymph vessel (limf ...)
* A thin tube that carries lymph (lymphatic fluid) and white blood cells through the lymphatic system. Also called lymphatic vessel.
lymphatic system (lim-FA-tik SIS-tem)
* The tissues and organs that produce, store, and carry white blood cells that fight infections and other diseases. This system includes the bone marrow, spleen, thymus, lymph nodes, and lymphatic vessels (a network of thin tubes that carry lymph and white blood cells). Lymphatic vessels branch, like blood vessels, into all the tissues of the body.
malignant (muh-LIG-nunt)
* Cancerous. Malignant cells can invade and destroy nearby tissue and spread to other parts of the body.
medullary thyroid cancer (MED-yoo-LAYR-ee THY-royd KAN-ser)
* Cancer that develops in C cells of the thyroid. The C cells make a hormone (calcitonin) that helps maintain a healthy level of calcium in the blood.
metastasis (meh-TAS-tuh-sis)
* The spread of cancer from one part of the body to another. A tumor formed by cells that have spread is called a “metastatic tumor” or a “metastasis.” The metastatic tumor contains cells that are like those in the original (primary) tumor. The plural form of metastasis is metastases (meh-TAS-tuh-SEEZ).
MRI
* A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or x-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints, and the inside of bones. Also called magnetic resonance imaging, NMRI, and nuclear magnetic resonance imaging.
nerve (nerv)
* A bundle of fibers that receives and sends messages between the body and the brain. The messages are sent by chemical and electrical changes in the cells that make up the nerves.
organ (OR-gun)
* A part of the body that performs a specific function. For example, the heart is an organ.
papillary thyroid cancer (PA-pih-LAYR-ee THY-royd KAN-ser)
* Cancer that forms in follicular cells in the thyroid and grows in small finger-like shapes. It grows slowly, is more common in women than in men, and often occurs before age 45. It is the most common type of thyroid cancer.
pathologist (puh-THAH-loh-jist)
* A doctor who identifies diseases by studying cells and tissues under a microscope.
primary tumor (PRY-mayr-ee TOO-mer)
* The original tumor.
radioactive (RAY-dee-oh-AK-tiv)
* Giving off radiation.
radioactive iodine (RAY-dee-oh-AK-tiv I-oh-dine)
* A radioactive form of iodine, often used for imaging tests or to treat an overactive thyroid, thyroid cancer, and certain other cancers. For imaging tests, the patient takes a small dose of radioactive iodine that collects in thyroid cells and certain kinds of tumors and can be detected by a scanner. To treat thyroid cancer, the patient takes a large dose of radioactive iodine, which kills thyroid cells. Radioactive iodine is also used in internal radiation therapy for prostate cancer, intraocular (eye) melanoma, and carcinoid tumors. Radioactive iodine is given by mouth as a liquid or in capsules, by infusion, or sealed in seeds, which are placed in or near the tumor to kill cancer cells.
scan (skan)
* A picture of structures inside the body. Scans often used in diagnosing, staging, and monitoring disease include liver scans, bone scans, and computed tomography (CT) or computerized axial tomography (CAT) scans and magnetic resonance imaging (MRI) scans. In liver scanning and bone scanning, radioactive substances that are injected into the bloodstream collect in these organs. A scanner that detects the radiation is used to create pictures. In CT scanning, an x-ray machine linked to a computer is used to produce detailed pictures of organs inside the body. MRI scans use a large magnet connected to a computer to create pictures of areas inside the body.
scanner (SKA-ner)
* In medicine, an instrument that takes pictures of the inside of the body.
sonogram (SAH-noh-gram)
* A computer picture of areas inside the body created by bouncing high-energy sound waves (ultrasound) off internal tissues or organs. Also called ultrasonogram.
spinal column (SPY-nul KAH-lum)
* The bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone. The spinal column encloses the spinal cord and the fluid surrounding the spinal cord. Also called backbone, spine, and vertebral column.
stage
* The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.
stage 0 medullary thyroid carcinoma in situ (... MED-yoo-LAYR-ee THY-royd KAR-sih-NOH-muh in SY-too)
* No tumor is found in the thyroid but abnormal cells are found by screening tests. These abnormal cells may become cancer and spread into nearby normal tissue.
staging (STAY-jing)
* Performing exams and tests to learn the extent of the cancer within the body, especially whether the disease has spread from the original site to other parts of the body. It is important to know the stage of the disease in order to plan the best treatment.
thyroid (THY-royd)
* A gland located beneath the larynx (voice box) that makes thyroid hormone and calcitonin. The thyroid helps regulate growth and metabolism. Also called thyroid gland.
thyroid cancer (THY-royd KAN-ser)
* Cancer that forms in the thyroid gland (an organ at the base of the throat that makes hormones that help control heart rate, blood pressure, body temperature, and weight). Four main types of thyroid cancer are papillary, follicular, medullary, and anaplastic thyroid cancer. The four types are based on how the cancer cells look under a microscope.
tissue (TIH-shoo)
* A group or layer of cells that work together to perform a specific function.
trachea (TRAY-kee-uh)
* The airway that leads from the larynx (voice box) to the bronchi (large airways that lead to the lungs). Also called windpipe.
tumor (TOO-mer)
* An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). Also called neoplasm.
ultrasound (UL-truh-SOWND)
* A procedure in which high-energy sound waves are bounced off internal tissues or organs and make echoes. The echo patterns are shown on the screen of an ultrasound machine, forming a picture of body tissues called a sonogram. Also called ultrasonography.
vein (vayn)
* A blood vessel that carries blood to the heart from tissues and organs in the body.
x-ray (EX-ray)
* A type of radiation used in the diagnosis and treatment of cancer and other diseases. In low doses, x-rays are used to diagnose diseases by making pictures of the inside of the body. In high doses, x-rays are used to treat cancer.
Recurrent Thyroid Cancer
Recurrent thyroid cancer is cancer that has recurred (come back) after it has been treated. Thyroid cancer may come back in the thyroid or in other parts of the body.
* * * * * * * * * * * *
Treatment Option Overview
Key Points for This Section
* There are different types of treatment for patients with thyroid cancer.
* Four types of standard treatment are used:
* Surgery
* Radiation therapy, including radioactive iodine therapy
* Chemotherapy
* Thyroid hormone therapy
* New types of treatment are being tested in clinical trials.
* Targeted therapy
* Patients may want to think about taking part in a clinical trial.
* Patients can enter clinical trials before, during, or after starting their cancer treatment.
* Follow-up tests may be needed.
There are different types of treatment for patients with thyroid cancer.
Different types of treatment are available for patients with thyroid cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Four types of standard treatment are used:
Surgery
Surgery is the most common treatment of thyroid cancer. One of the following procedures may be used:
* Lobectomy: Removal of the lobe in which thyroid cancer is found. Biopsies of lymph nodes in the area may be done to see if they contain cancer.
* Near-total thyroidectomy: Removal of all but a very small part of the thyroid.
* Total thyroidectomy: Removal of the whole thyroid.
* Lymphadenectomy: Removal of lymph nodes in the neck that contain cancer.
Radiation therapy, including radioactive iodine therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Radiation therapy may be given after surgery to kill any thyroid cancer cells that were not removed. Follicular and papillary thyroid cancers are sometimes treated with radioactive iodine (RAI) therapy. Higher doses than the amounts used to diagnose thyroid cancer are used. RAI is taken by mouth and collects in any remaining thyroid tissue, including thyroid cancer cells that have spread to other places in the body. Since only thyroid tissue takes up iodine, the RAI destroys thyroid tissue and thyroid cancer cells without harming other tissue. Before a full treatment dose of RAI is given, a small test-dose is given to see if the tumor takes up the iodine.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Thyroid hormone therapy
Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. In the treatment of thyroid cancer, drugs may be given to prevent the body from making thyroid-stimulating hormone (TSH), a hormone that can increase the chance that thyroid cancer will grow or recur.
Also, because thyroid cancer treatment kills thyroid cells, the thyroid is not able to make enough thyroid hormone. Patients are given thyroid hormone replacement pills.
New types of treatment are being tested in clinical trials.
Information about clinical trials is available from the NCI Web site 2.
Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.
Tyrosine kinase inhibitor therapy is a type of targeted therapy being studied in the treatment of thyroid cancer. Tyrosine kinase inhibitors block signals needed for tumors to grow.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.