Thyroid Cancer and Pelvic Health

When I was diagnosed with Thyroid Cancer, I’ll be honest, one of my first thoughts was “Thank goodness this won’t directly affect my pelvic floor.” I think as someone who has experienced pelvic floor problems in the past and worked in the pelvic health field for many years, this is probably a somewhat normal reaction, but it wasn’t the standard from my parents and other loved ones. They wanted answers and information and because Thyroid cancer didn’t fall into my niche knowledge of pelvic health, I had to do some research.

Let’s start by saying that thyroid Cancer is the most pervasive endocrine cancer in the world (Bray, 2018). It is the sixth most common cancer in females in the United States (Siegel, 2019). Thyroid cancer incidence and outcomes depend on where the patient lives with Ethiopia and the Philippines having the highest death rates (Deng, 2020). There has been a rise in the diagnosis of thyroid cancer which studies attribute to access to health care, ultrasound, training of those doing the ultrasound, use of fine needle aspiration biopsy, and changes in monitoring and management guidelines (Megwalu & Moon, 2022). The five-year survival rate for people diagnosed with Thyroid Cancer is around 98.5% (Boucai et al. 2024). There are a few types of Thyroid Cancer and Papillary Thyroid Cancer accounts for 84% of all cases (Boucai et al. 2024). There are also follicular, medullary, and anaplastic forms making up the remaining cases  (Boucai et al. 2024).

When I tell people I have Thyroid Cancer one of their first questions is “What were your symptoms, how did you know?!” The short answer is, I didn’t know. My cancer journey started when I found out I had a 3 cm nodule that had grown a “significant” amount since my last ultrasound. My endocrinologist said the growth was enough to warrant a fine needle aspiration biopsy. In reading about this diagnosis, it seems many cases of Thyroid Cancers are asymptomatic and detected during a routine physical examination or found incidentally with diagnostic imaging  (Boucai et al. 2024).

Some other symptoms, mostly related to a growing tumor could include lumps in the throat, a hoarse voice lasting three or more weeks, trouble swallowing or breathing, neck pain/pressure, and swollen cervical lymph nodes. If we had a patient with such complaints, referring them to their primary provider for further diagnostics would be very appropriate. Medullary thyroid cancer does have the ability to increase bowel movements and cause diarrhea and therefore should be on a pelvic health provider’s radar for differential diagnosis. The good news is that the solution to most cases of Thyroid Cancer is surgical removal of the thyroid with the option to perform radioactive iodine ablation treatment. There are other targeted therapies available if the cancer does not respond to radioactive iodine including antiangiogenic multikinase inhibitors and medications for specific genetic mutations (Boucai et al. 2024).

Let’s get to the good part, the therapeutic indications! How can we best support our patients going through Thyroid Cancer or after they have completed treatment?
There are a few things to consider and based on the setting you work on, you may or may not be the one to provide these services.

First, if the patient has a partial or total thyroidectomy, they will have a surgical incision which means a scar to work on and connective tissue restriction. We can help them to mobilize and soften this scar to maintain their cervical range of motion and help the scar to heal better, be less painful, and be more visually appealing. If the therapist has the training, education, and/or application of lymphatic drainage is also very valuable in this healing time.

The patient will have activity restrictions for 1 - 4 weeks depending on the severity of the procedure, including needing rest, eating soft foods, avoiding extremes of ROM of the neck and upper extremities, and regaining vocal control. Working with a patient prior to surgery to review ways to conserve energy and prepare themselves and their home for surgery can be invaluable, especially if the patient doesn’t have a huge support system available post-operatively. Food shopping, meal prepping, and convenience stations set up in the home can make post-operative recovery much smoother.

From personal experience, the throat irritation from the intubation was the most annoying and longest-lasting symptom. My surgeon used electrical stimulation with my intubation to my vocal cords to avoid damage to them. The mucous and hoarseness this created lasted a full 7 days. I still had voice limitations for about a month after and had to work to regain my full voice. Everyone handles pain differently though, and others may feel more pain. My provider, a very seasoned ENT, said they typically found post-thyroid patients had less discomfort than their patients with tonsillectomy or adenoid removal. This can give your patient a benchmark of what to expect if they’ve had one of those surgeries. We can give recommendations to our clients to help with pain management such as using rest, ice, gentle movement, breathing exercises, and meditation to help manage the discomfort, while also taking their pain medication regularly.

As a pelvic floor therapist, as soon as I hear pain medication is involved, I want to make sure that we are keeping the bowels happy. If we have a patient expecting this type of surgery and treatment, we can help guide them to fiber-filled foods and fluid intake to avoid constipation (as long as they don’t have restrictions). If constipation is not something they typically experience, this may be their first introduction to things like osmotic laxatives and a squatty potty and we can be the person who presents them with this education if they need it.

There will be a few things going on hormonally after the surgery. Because the thyroid has been removed, the patient will be hypothyroid unless they take synthetic thyroid hormone or have a partial thyroidectomy where the remaining half has continued to function and adjust. Hypothyroidism can cause many symptoms, but related to our patients in pelvic health, we might see constipation, fatigue, skin changes, menstrual cycle changes, musculoskeletal complaints, and intolerance to temperature changes. If we see our patient experiencing any of these, we can refer them back to their provider to have their levels checked. We can also tailor our plan of care to adjust for some of these things.

Another more life-threatening complication that can happen is disruption of the parathyroid glands. These produce the calcium needed to regulate muscles and nerves. With calcium levels too low, a person can experience some uncomfortable and possibly dangerous symptoms such as feeling foggy and confused, muscle tremors, heart arrhythmias, and even seizures if the levels get too low. These little guys sit right under the thyroid and can be traumatized or accidentally removed with the thyroid. After surgery, patients will likely be taking a calcium supplement and have instructions to take it if they feel this way, but they may need a reminder from their very caring and observant therapist.

When we think about how else Thyroid Cancer could affect our patients, I think it is important to consider the emotional aspect. Even though it’s a very common, easy-to-treat cancer with a high “cure rate,” it is still cancer. From personal experience, providers are so used to treating more sick people, that they have an almost blase attitude towards the treatment. I’ve spoken to others with endocrine cancer and heard similar stories. We have the “friendly” cancer, why stress or make haste about anything? There is a lack of haste or urgency, which can feel disconcerting when you just want to be cancer-free ASAP.

The incision, if surgery is needed, is directly to the anterior aspect of the neck. It's hard to hide the scar unless you wear a turtleneck. Most surgeons try to make the incision in a fold of the neck, but this may not be possible if lymph nodes also need to be dissected. Scars also take about a year to remodel and “silver.” We can further help our patients feel more confident with their scars by reminding them to avoid sunlight and utilize silicone patches to soften and protect the area to allow the scar to mature into a minimally noticeable line. There is still a reminder every time the patient looks in the mirror and this may affect all aspects of their life including their confidence in areas like sexual intimacy.

The last area to consider would be if a person needs the radioactive iodine treatment. Although this treatment is not “aggressive” like chemo or traditional targeted radiation, it can be a stressor to a patient. Radioactive iodine ablation has an extensive prep, multi-procedure application, and post-treatment quarantine phase that can be very disruptive to a person’s life. Pelvic health providers won’t be actively managing this phase, but being a friendly ear to bounce iodine-free recipe ideas off of and commiserate with the inability to ingest dairy for 3+ weeks can help make your patient feel supported and heard.

I have been fortunate enough to take Herman & Wallace’s Oncology series and so I felt prepared to treat and manage patients with these types of cancer. It was my own Thyroid Cancer journey that gave me hands-on experience with what it is like to be a cancer patient. It's been interesting to have to advocate in a medical system that doesn’t always listen to patients. I’ve also had to re-find who I am after having a pretty significant medical episode. These experiences always help give me perspective to be a better provider to my patients and bring more personalized care to them. I encourage you to take these classes, as cancer really affects so many lives. My most comforting providers during this time have been those who have taken the time to answer my questions, hold space for my worries, and have humor with me during this bizarre time.

The HW Oncology Series includes:

• Oncology of the Pelvic Floor Level 1 - Introduction (*Certified Lymphatic Therapists may skip this course)
  • The next scheduled course is on November 2-3
• Oncology of the Pelvic Floor Level 2A - Male Pelvic and Colorectal Cancers
  • The next scheduled course is on September 7-8
• Oncology of the Pelvic Floor Level 2B - Urogynecological Cancers
  • The next scheduled course is on December 7-8

References:

• Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 68(6), 394-424.
• Boucai, L., Zafereo, M., & Cabanillas, M. E. (2024). Thyroid cancer: a review. Jama, 331(5), 425-435.
• Deng, Y., Li, H., Wang, M., Li, N., Tian, T., Wu, Y., ... & Dai, Z. (2020). Global burden of thyroid cancer from 1990 to 2017. JAMA network Open, 3(6), e208759-e208759.
• Megwalu, U. C., & Moon, P. K. (2022). Thyroid cancer incidence and mortality trends in the United States: 2000–2018. Thyroid, 32(5), 560-570.
• Siegel RL, Miller KD, Jemal A 2019 Cancer statistics, 2019. CA Cancer J Clin 66:7–30.

AUTHOR BIO:

Mora Pluchino, PT, DPT, PRPC

I am a graduate of Stockton University with my BS in Biology (2007) and Doctorate of Physical Therapy (2009). I have experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. I began treating Pelvic Health patients in 2016 and now have experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much I have not treated since beginning this journey and I am always happy to further my education to better help my patients meet their goals.

I strive to help all of my patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, I opened my own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. I have been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. I have also been a TA with Herman & Wallace since 2020 and have over 150 hours of lab instruction experience.