The Laryngoscope

Lippincott Williams & Wilkins, Inc.

2007 The American Laryngological,
Rhinological and Otological Society, Inc.

Health-Related Quality of Life in Thyroid

Cancer Survivors
Lincoln G. L. Tan, MBBS, MRCS, MMed; Luo Nan, PhD;
Julian Thumboo, MBBS, MRCP, MMed, FAMS, FRCP; Felix Sundram, MBBCh, MSc DMRT;
Luke K. S. Tan, MBBS, FRCS, MMedSci, FAMS(ORL)

Objective: The study objective was to study the

impact of the diagnosis, treatment, and follow-up
of differentiated thyroid cancer (DTC) on the
quality of life and related issues in an urban
multi-ethnic Asian population. Design: A selfadministered questionnaire containing the Short
Form 36 Health Survey (SF-36) and assessing sociodemographic, disease, and treatment-related
status was mailed to patients with DTC. Main Outcomes: One hundred fifty-two (52.4%) of 290 patients answered the questionnaire. There was a
statistically significant decrease in SF-36 scores
between thyroid cancer survivors and the general
population in all domains except for social functioning (SF). Physical functioning (PF) was worse
in those survivors who were aged 50 years or
older. Mental health (MH) scores were better in
those who had more than 12 years of formal education. Being employed had a positive influence
on role physical (RP) and role emotional (RE)
scores. Being of Malay/Indian ethnicity strongly
correlated with lower scores in bodily pain (BP),
SF, RE and MH domains. Conclusion: Although
most patients with well-differentiated thyroid
cancer have near normal life expectancy, our
study has shown that there is a significant decrease in their quality of life, especially in the
elderly and poorer educated. Returning to work
should be encouraged to improve the quality of
From the Department of OtolaryngologyHead and Neck Surgery
(L.G.L.T., L.K.S.T.), National University Hospital, Singapore, Yong Loo Lin
School of Medicine, National University of Singapore, Singapore; the Centre for Health Services Research (L.N.), Yong Loo Lin School of Medicine,
National University of Singapore, Singapore; the Department of Rheumatology and Immunology (J.T.), Singapore General Hospital, Singapore; the
Department of Medicine (J.T.), Yong Loo Lin School of Medicine, National
University of Singapore, Singapore; and the Department of Nuclear Medicine (F.S.), Singapore General Hospital, Singapore.
Editors Note: This Manuscript was accepted for publication November 7, 2006.
Institution where work was performed: Department of Otolaryngology
Head and Neck Surgery, National University Hospital, Singapore, Yong
Loo Lin School of Medicine, National University of Singapore, Singapore.
Send correspondence to Dr Luke Tan, Department of OtolaryngologyHead and Neck Surgery, National University Hospital, Singapore, 5 Lower Kent Ridge Road, Singapore 119074. E-mail: drluketan@
hotmail.com
DOI: 10.1097/MLG.0b013e31802e3739

Laryngoscope 117: March 2007

life in DTC survivors. Key Words: Quality of life,

health surveys, thyroid neoplasm, thyroid carcinoma, survivors.
Laryngoscope, 117:507510, 2007

INTRODUCTION
Differentiated thyroid cancers (DTC) in general have
very good prognosis, and the overall long-term survival
rate of patients with DTC is more than 90%, with variations among subsets of patients.1 Traditionally, the measure of primary outcome in cancer has been survival time.
But it is increasingly recognized that the diagnosis and
management of cancer can have a major impact on every
aspect of a patients quality of life (QOL) and that measuring these changes is important. In addition to mortality, cancer can cause significant morbidity not only from
the disease but also from the treatment. We believe this is
especially so in DTC, which tends to affect young patients
in the prime of their lives.
There have been relatively few health-related
(HR)QOL studies looking specifically into thyroid cancer
and none in an urban multi-ethnic Asian population. We
sought to address this gap in the literature, and therefore
the aim of this study was to determine QOL in DTC
survivors in Singapore and compare this with national
norms of QOL using the Short Form 36 Health Survey
(SF-36).

MATERIALS AND METHODS

Study Design
The study population comprised 290 consecutive patients
with well-differentiated thyroid cancer (defined as follicular or
papillary carcinoma) seen at the Department of Nuclear Medicine, Singapore General Hospital over a 10 year period from
January 1989 to October 1999. From January to April 2000, these
patients were sent by mail a self-administered questionnaire (in
English and Mandarin) containing the SF-36 and assessing sociodemographic, disease, and treatment related status. To improve the response rate, the survey methodology and questionnaire design were constructed using the Total Design Method.2
This study was approved by the Ethics Committee of the National
University Hospital.

Tan et al.: Quality of Life in Thyroid Cancer Survivors

507

Instruments
The definition of HRQOL is the extent to which ones usual
or expected physical, emotional, and social well-being are affected
by a medical condition or its treatment.3
The SF-36 is a generic QOL instrument. This comprehensive short-form instrument with 36 questions can be selfadministered to yield a health profile comprising eight domains:
physical functioning (PF), role limitations caused by physical
problems (RP), bodily pain (BP), general health (GH), vitality
(VT), social functioning (SF), role limitations caused by emotional
problems (RE), and mental health (MH). In Singapore, both English (UK) and Chinese (simplified characters) versions of SF-36
(version 1) were validated in patients with systematic lupus erythematosus by Thumboo et al.4,5 and later in a community-based
population survey of 5,503 Singaporeans.6,7 In these studies, both
language versions of SF-36 showed satisfactory construct validity
and internal consistency reliability.

Statistical Analysis
The SF-36 was used to generate eight domain scores on a
scale ranging from 0 to 100.8 Mean SF-36 scores for the study
sample were compared with their population norms using onesample t tests. To calculate the population norms for SF-36
scores, the distributions of age, sex, race, and survey language
(English vs. Chinese) of our study sample were described and
used as weights to calculate weighted mean SF-36 scores for a
representative sample of the Singaporean general population
whose SF-36 scores were obtained from a previous study.7 The
weighted mean scores represented the functioning and well-being
levels for a healthy population that was the same as our study
sample in terms of age, sex, race, and language, thus serving as
adjusted population norms for characterizing the reductions in
QOL of our patients. Cohens effect size9 was calculated to evaluate the magnitude of reduction in QOL for the patients. The
effect size was the difference between patients mean scores and
adjusted population norms divided by the SD of patients SF-36
scores. An effect size of 0.2, 0.5, and 0.8 indicate small, moderate,
and large differences, respectively.
To identify the determinants of QOL, we first examined the
effects of patients characteristics on each SF-36 scale using univariate analysis of variance tests and then included those significant variables (defined as a P value of less than .05) in multiple
linear regression models, one for each SF-36 scale. Patients characteristics examined included sex, age, race, educational level,
working status, language used when answering the questionnaire, time since diagnosis, number of surgeries, hoarse voice
more than 6 months, long-term calcium supplementation, the
number of times patient underwent surgery or radio-iodine treatments, and the number of days spent on medical appointments in
the previous year. All statistical analyses were performed using
SAS for Windows (version 9.1, Cary, NC) with all tests being
two-tailed and significance level being .05.

RESULTS
Patient Characteristics
Of the 290 in the targeted study sample, 152 patients
mailed back completed questionnaires, representing a response rate of 52.4%. Compared with respondents, nonrespondents were older (mean age, 61 vs. 47 yr, P .01) and
were more likely to be ethnic Malays (18.2% vs. 7.2%, P
.05). Eight patients were removed from the statistical
analysis because of incomplete responses in their questionnaires. The demographic characteristics of the 144
patients are shown in Table I. The mean (SD) age was 47.8
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508

TABLE I.
Sociodemographic Characteristics of Respondents.
n (%)

Female sex
Marital status
Married
Single/divorced/widowed
Education
06 years
712 years
12 years
Unknown
Employment status
Working (full time or part time)
Unemployed/retired
Race
Chinese
Malay
Indian

107 (74.3)
117 (81.3)
27 (18.7)
43 (29.9)
72 (50.0)
26 (18.0)
3 (2.1)
77 (53.8)
67 (46.2)
123 (85.4)
10 (6.9)
11 (7.6)

(13.7) years, with a range of 18 to 82 years. Of the respondents, 26.3% were male, 51.2% had 7 to 12 years of formal
education, 81.3% were married, and 53.8% were working.

Disease and Treatment

Mean duration of disease since diagnosis was 77
(range, 5326) months. Ninety percent had surgical intervention, with 84% requiring radioiodine treatment. Of
those requiring radiotherapy, the median number of treatments required was 2 (range, 135).
Forty-six percent suffered from hoarseness for more
than 6 months, and 54% required long-term calcium supplementation. Most of these patients with welldifferentiated cancers had total thyroidectomy and were
subsequently referred for radio-iodine therapy.

Quality of Life
SF-36 scores of the study population versus the general Singaporean population (adjusted for age, sex, race,
and survey language) are shown in Table II. There was a
statistically significant decrease in SF-36 scores between
thyroid cancer survivors and the general population in all
domains except for SF.
The results of multiple linear regression are as
shown in Table III. PF was worse in those survivors who
were aged 50 years or older. MH scores were better in
those who had more than 12 years of formal education.
Being employed had a positive influence on RP and RE
scores. Compared with Chinese, ethnic Malay/Indian had
lower scores in BP, SF, RE, and MH domains. Patients
who underwent two or more surgeries reported significantly better RE scores. Eleven percent of the respondents
had stopped thyroxine in the 6 weeks before the study. We
would expect the SF-36 scores for these patients would be
lower because of the symptoms of hypothyroidism.10,11
However, this was not seen in our study population.
Tan et al.: Quality of Life in Thyroid Cancer Survivors

TABLE II.
Quality of Life in Surviving Subjects With Differentiated Thyroid Carcinoma.
Subjects (n 144)
SF-36 Scale

Mean

Standard Deviation

Mean for
Normal
Population*

Physical functioning
Role physical
Bodily pain
General health
Vitality
Social functioning
Role emotional
Mental health

76.3
70.7
74.3
61.0
57.1
78.7
70.1
67.3

25.6
40.0
26.6
24.4
21.3
24.1
41.5
20.2

82.1
83.5
79.9
68.3
63.5
75.2
80.2
71.8

Difference

Effect Size

P Value

5.8
12.8
5.6
7.3
6.4
3.6
10.0
4.5

0.23
0.32
0.21
0.30
0.30
0.15
0.24
0.22

.007
.001
.012
.001
.001
.077
.004
.009

*Adjusted for age, sex, race, and survey language.

One-sample t tests.
Effect size is the difference between patients mean scores and adjusted population norms divided by
standard deviation of patients SF-36 scores. An effect size of 0.2, 0.5, and 0.8 indicates small, moderate, and large
difference, respectively.

DISCUSSION
Well-differentiated thyroid cancer is associated with
relative survival rates exceeding 90%. The QOL studies in
thyroid cancer have not been well studied, especially in
the Asian population. Using SF-36, we have shown that
there is a decrease in all the domains of the SF-36 except
for SF in thyroid cancer survivors compared with the
general population. The magnitude of those observed decreases was small, although statistical significance was
reached for a given P value of .05.
In our study, the effect size for PF, RP, GH, VT and
SF scales were small, with a range of 0.22 to 0.30, whereas
the remaining scales of BP, RE, and MH had effect sizes
less than 0.2. The latter finding is similar to data from the
Medicare Health Outcomes Survey.12 The effect size varied with the type of cancer and was significantly increased
when comparing patients who were currently under treatment for cancer.
We have shown that the morbidity of thyroid cancer
and its treatment does lead to a decrease in PF in survivors, especially in those above the age of 50. After taking
into account the comorbidity in the older group of patients,

our finding could be caused by the fact that patients above

the age of 60 tolerated the symptoms of pretreatment
hypothyroidism and radioiodine treatment less well than
their younger counterparts.10
Survivors who were working scored better in the RP
and RE domains. This reinforces the beneficial effects of
work on the physical and emotional aspects of their lives
or shows that these patients were less affected by the
disease and thus still able to continue working. Returning
to work as soon as possible should be a goal in the management of these patients.
A study on DTC survivors who are on thyroidstimulating hormone suppressive thyroxine showed MH
scores of 65.0 compared with a score of 72.4 in their
reference population aged 51 to 60 years. A 44% prevalence of anxiety was noted in both hypothyroid and euthyroid DTC survivors, which was much higher than the
reference population or in patients with successfully
treated testicular cancer (6%) or patients with nonthyroid
cancers in a radiotherapy unit (19%). The authors concluded that anxiety in DTC survivors was independent of

TABLE III.
Regression Coefficients of Factors Influencing Quality of Life in Survivors With Differentiated Thyroid Cancer.
PF

Age 4049 years

Age 50 years
12 years of education
Working
Indian/Malay
2 or more surgeries
5 appointment days in past 12 months
Adjusted R2

10.0
15.1*
10.5
6.3

RP

11.0
16.8*

BP

9.4
8.9
30.0

GH

7.1
6.2

VT

6.2
6.3

SF

RE

7.9*
12.5*

MH

9.3*

23.1

38.2

16.6

18.8

13.1

16.1

14.2*
29.4
15.7*
22.0

0.29

0.27

0.24

0.15

0.13

0.13

0.16

20.9
8.2*
0.18

Only factors that were statistically significant in univariate analysis of variance tests were included in these multiple regression models (one for each SF-36 scale).
*P .05; P .01; P .001.
Compared with Chinese.
PF physical functioning; RP role physical; BP bodily pain; GH general health; VT vitality; SF social functioning; RE role emotional; MH
mental health; R2 coefficient of determination.

Laryngoscope 117: March 2007

Tan et al.: Quality of Life in Thyroid Cancer Survivors

509

the thyroid function and should be strongly considered in

the aftercare of DTC survivors.13
We found that higher educational level was associated with better MH scores among survivors. This could
be because of better understanding of the disease and its
treatment, which may lessen anxiety and depression and
improve coping and lessen the psychologic impact of the
disease. Conversely, this lower MH could also be caused
by a sense of helplessness with a lesser understanding of
the disease. Medical professionals can address this by
targeting those patients of lower educational level for
additional counseling on the disease using simplified language appropriate for lay people and by avoiding medical
jargon, which may isolate this group.
Those survivors who spent more days on medical
appointments had a global decrease in SF-36 scores. This
likely reflects a subgroup of patients who suffered more
from the morbidity of disease or toxicity of treatment.
We recognize several limitations in this study. First,
the lack of information regarding thyroid hormone therapy and the degree of suppression achieved, which may
affect the HRQOL in these patients, is not recorded. With
regard to thyroid function, the sample is likely to be a
mixed sample, with a proportion of those who had stopped
thyroxine in the 6 weeks before the study being hypothyroid and others being hyper- or possibly euthyroid. Second, it would have been helpful if information were obtained about the extent of disease because patients with
metastases would be expected to consume more health
care, a major determinant of QOL in our study.

CONCLUSION
DTC patients are often told of the excellent prognosis, with most patients having near normal life expectancy. However, patients experience the life-long stress of
the diagnosis of cancer.14 Our study and others in the
literature have clearly shown that there is a significant
decrease in the QOL in these patients. These issues need
to be addressed by health care providers.
Our study also indicates that among thyroid cancer
survivors, the elderly and the poorer educated need more
attention with regard to follow-up and education. Clearly,

Laryngoscope 117: March 2007

510

the goal of returning to work benefits this group of patients and should be encouraged to improve their QOL.

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Tan et al.: Quality of Life in Thyroid Cancer Survivors