Breaking Down or Waking Up? Psychological Distress and Sleep Disturbance in Patients With Thyroid Nodules and Cancer.

Psychological distress following a cancer diagnosis is an undeniable and nearly universal experience. In 2020, the National Comprehensive Cancer Network issued guidelines for patients with distress during cancer care (https://www.nccn.org/patients/guidelines/content/PDF/distress-patient.pdf). But what about distress after the detection of a small thyroid nodule?

The study by Li et al., “Psychological distress and sleep disturbance throughout thyroid nodules screening, diagnosis and treatment,” provides important new evidence to guide clinicians on the emotional experience of patients with thyroid nodules throughout their clinical workup and management (1). One critically important finding of their study is that psychological distress and sleep disturbance increase after detection of a thyroid nodule in individuals undergoing screening cervical ultrasounds for thyroid cancer. The timing of distress this early in patients’ diagnostic process after obtaining an ultrasound reporting a thyroid nodule is important for clinicians to recognize for multiple reasons.

First, many screening-detected thyroid nodules are clinically insignificant. Screening has the potential to result in overdiagnosis of benign, indolent nodules resulting in negative effects on patient’s psychological health (2). Therefore, the current study questions the practice of screening for thyroid cancer in healthy adults with no known risk factors for the disease. Screening for thyroid cancer is an often-debated topic that is still practiced in many countries but has been shown to significantly increase the incidence of thyroid cancer over expected rates (3). Screening is not currently supported by the United States Preventive Services Task Force (4). Clinicians and researchers who are opposed to screening reference data on overdiagnosis, in which the incidence of the disease increases without any change in the overall morbidity or mortality. Such overdiagnosis inevitably leads to overtreatment and the potential for unnecessary and unavoidable treatment complications. The current study’s findings provide critical additional evidence supporting the argument against screening because of unnecessary psychological distress and sleep disturbance, which is a likely symptom of distress.

The finding of psychological distress and sleep disturbance following ultrasound detection of a thyroid nodule is also clinically important because patients often receive little psychosocial or informational support after their cervical ultrasound. A vital lack of such support has previously been shown later in the diagnostic and treatment period (5). Depending on where patients receive health care, they may receive their ultrasound report through an electronic message or health record portal without any physician guidance or education. The delivery of a diagnosis in this manner without explanation has the potential to compound patient’s emotional reactions and distress. A simple Google search for “thyroid nodule” retrieves results that mention “cancerous,” “worry,” “lump,” “abnormal cells,” and other terms associated with cancer. Studies have shown that a new lump often signals cancer until proven otherwise. The word “cancer” itself evokes thoughts and fear of imminent death in many individuals. Therefore, it is important that clinicians educate patients about thyroid nodules, prepare patients for anticipated ultrasound results, and be available to discuss the findings.

Another important finding of the study by Li et al. is that, among patients who had a thyroid nodule discovered on screening ultrasound, those with suspicious findings on their ultrasound had increased psychological distress and worse sleep quality when compared to patients whose ultrasound findings were benign. Although prior studies have shown that patients have strong emotional reactions once diagnosed with an indeterminate thyroid nodule or thyroid cancer on fine-needle aspiration, this study is one of the first to highlight how early psychological distress occurs in the diagnostic process (6). Inadequate emotional, psychological, and educational support during the ultrasound and biopsy period has the potential to affect later treatment decision making. Once diagnosed with thyroid cancer, shared decision making is necessary to identify the optimal treatment for each patient: active surveillance, thyroid lobectomy, or total thyroidectomy with or without neck dissection. However, decision making may be clouded by so-called “scared decision making” that results from lack of knowledge about thyroid cancer and the nearly universal societal fear and stigma associated with cancer.

Not surprisingly, the current study also found that patients experienced worsening of their anxiety, depression, unhealthy emotions, and sleep quality after diagnosis of malignancy. Prior studies have similarly shown that a diagnosis of thyroid cancer results in adverse emotional and psychological outcomes (7). Emotions such as fear and worry have additionally been shown to persist posttreatment related to fear of recurrence even in those with low-risk disease and an excellent prognosis (8). Of interest, no significant differences in distress and sleep outcomes were noted in the study by Li et al. in patients with papillary thyroid cancer undergoing surgical treatment vs. active surveillance, though the study may not have been powered to detect such differences.

The strengths of the current study include the use of validated instruments to evaluate sleep quality and psychological distress using measures specific for anxiety, depression, emotional distress, and sleep quality. The prospective, longitudinal study design and the inclusion of patients who did not have symptoms and were undergoing screening were also major strengths. Studies often focus exclusively on patients already diagnosed with thyroid cancer and neglect earlier phases in the diagnostic process. Limitations of the study include the lack of a validated cancer-specific measure of emotional or psychosocial distress, the exclusion of patients with a history of thyroid surgery, and the lack of description about the use of paired t tests or other statistical analyses to account for repeated measures.

Although limitations exist, this study emphasizes critical areas in the patient experience where clinicians have the opportunity to improve the psychosocial and educational support for patients undergoing evaluation and treatment for thyroid nodules and thyroid cancer. Patients experience symptoms of distress that break down their psyche affecting their sleep health and quality of life. These findings should act as a wake-up call for clinicians and researchers to more adequately support patients with thyroid nodules and thyroid cancer throughout their experience and devise ways to provide robust emotional and informational support.