On a fresh spring day in May, I lay ramrod still as Anne Busseniers stuck a small needle into my neck to retrieve cells from a nodule, or growth, on my thyroid. A few minutes later, after a second stick, Busseniers smeared some slides, aimed hot air from a hair dryer at them and took an initial look through the microscope.
My history has finally caught up with me, I thought.
At age 4, with enlarged tonsils and frequent ear infections, I had been given radiation aimed at the eustachian tubes. According to David Cooper, a thyroid specialist at Sinai Hospital in Baltimore, more than 1 million American children had similar treatments in the early years of the baby boom, not only for enlarged tonsils but also for enlarged thymus glands, ringworm, large birthmarks on the face and acne.
The treatments were discontinued in the early '60s when they became linked to an increased risk for cancer of the thyroid, the gland that hugs the windpipe and produces the hormone thyroxine. More recent studies show that individuals who had been treated for cancer with radiation are developing thyroid cancer.
"Many people who have been radiated in the chest area--typically for lymphomas--get thyroid cancer," said Cooper, who heads the division of endocrinology at Sinai. "We used to think that in radiation for cancer the thyroid would be blasted away and all you'd get was hypothyroidism. But that's wrong."
The good news is that most types of thyroid cancer are among the most curable cancers: The survival rate five years after treatment is 95 percent.
I learned about my radiation treatments in 1975, a year before my mother's death, when she mailed me a dog-eared note. It read, "Jane had around 1949 a total of 250 R's [rads] over a period of six weeks with face and neck carefully screened." A rad is a measure of radiation absorbed by flesh. One rad is equal to the dose from five mammograms. In radiation for cancer, a patient can get many thousands of rads, depending on which organs are involved.
I filed this news away for a day of reckoning I knew would come eventually. That day arrived in April of this year when my physician felt a lump on my thyroid.
The American Thyroid Association recommends that anyone who had these radiation treatments as a child get as much information about them as possible, especially the dosage, the number of treatments, the outcome and the age at which they occurred. The group also suggests having your doctor examine your thyroid annually by palpating it to detect nodules.
The number of people diagnosed each year with thyroid nodules is growing. In 1994, according to the National Cancer Institute (NCI), 13,000 Americans were diagnosed with thyroid cancer. In 1999, the tally is expected to reach 18,000, a 40 percent jump in just five years.
"We don't know all the reasons for the increased numbers," said Elaine Ron, a cancer epidemiologist with the NCI in Bethesda. "Partially, it's that the population of the U.S. is increasing and there are better tools for detecting. There's more publicity, so you're more likely to get your thyroid palpated in a physical exam than you were a few years ago."
But recent studies, said Ron, also show that childhood radiation for tonsillitis and other minor ailments can lead to thyroid cancer more than 40 years later. "The risk continues," she said. "The younger you were when you had the radiation, the higher your risk."
According to published studies, 20 to 30 percent of people who develop thyroid abnormalities have a history of radiation exposure. And at least 30 percent of irradiated patients who go to surgery for nodules can expect to have them diagnosed as cancerous.
Busseniers is a physician in private practice who only does "fine needle aspiration," more commonly known as needle biopsy. Of about 1,000 biopsies she performs each year, 600 are on thyroids.
While nuclear scans and ultrasound tests can assess the size of nodules, needle biopsies are used to determine whether a thyroid lump is benign or malignant. "It's the only way we can get a tissue sample without going to surgery," said Busseniers. "Scans are not going to tell us what's in the lump." Even so, in about 15 percent of biopsies, the pathologist cannot determine whether the lump is benign or malignant.
In my case--an "indeterminate" lump and a history of radiation to the neck as a child--the three surgeons I saw recommended a total thyroidectomy. Why not a partial one? Because, I was told, it's not possible to tell if the lumps are benign until they are analyzed after the operation. Also, having had childhood radiation, I was at increased risk for cancer in the portion of the gland that would be left behind after a partial thyroidectomy.
Physician friends gave me invaluable advice during the lead-up to my surgery. They explained that the most important thing about the needle biopsy is not the skill in sticking the needle into the neck but in reading the slides produced by the procedure. They urged me to get a second reading of the slides before going to surgery, which I did. They also said I should get a second reading of the post-operative slides of my thyroid, which I did.
My outcome was good: The two growths on my thyroid were benign. My stitches were removed 10 days after the surgery and I began a lifetime regime of taking synthetic thyroid hormone. The healing process began.
It's okay, Mom. I've reached closure. At least on this one.
Jane Friedman is a writer living in Chevy Chase.