Assessment of Patients’ Quality-of-Life Post-Thyroidectomy

Introduction: The assessment of quality of life (QOL) after thyroidectomy has been a focus of medical research, aiming to understand its impact on patients' overall well-being and functional status. Studies have examined the physical, psychological, and social dimensions of QOL, providing valuable insights into the outcomes of thyroidectomy and improving patient care. The aim of the study is to evaluate the long-term impact of different aspects of patients' quality of life post-thyroidectomy. Methods: This cross-sectional study was conducted in Taif City and included 100 participants post-thyroidectomy. Data were collected from medical records and telephone interviews using the modified Arabic version of the EROTC QLQ-H&N43 questionnaire. The collected data were analyzed using R software version 4.2.2. Results: The majority of the 100 participants were female (76%), and most were over 50 years old (38%). The types of surgery performed included hemithyroidectomy (36%), subtotal thyroidectomy (6%), and total thyroidectomy (58%). Participants reported difficulties related to their senses, body satisfaction, sexual satisfaction, eating, speaking, and social interactions. Pain in the mouth and jaw, as well as swallowing difficulties, showed variations among the surgery groups. Other symptoms, such as tooth problems, dry mouth, and swelling in the neck, did not differ significantly among the groups. Numbness in the hands or feet was associated with a subtotal or total thyroidectomy. Difficulties with enjoying meals, eating in front of others, and communication issues showed variations among the surgery groups. Conclusion: This study provided insights into the QOL of thyroidectomy survivors in Taif City. Participants reported challenges related to sensory, body, and sexual issues, as well as difficulties with eating, speaking, and social interactions. The findings highlight the need for interventions and support to address these challenges and optimize the QOL of thyroidectomy patients. Furthermore, research is warranted to explore specific factors contributing to these difficulties and to develop targeted interventions for better patient outcomes.


Introduction
Thyroid carcinoma (TC) is the endocrine system's most often diagnosed cancer and one of the ten most common cancers in 2020.Incidence rates in females are three times greater globally than in males (10.1 versus 3.1 per 100,000).In 2020, there were 586,000 new instances of TC worldwide; nevertheless, the incidence of cancer-related mortality remained very low, with an anticipated 44,000 deaths in both genders combined (0.5 per 100,000 in women and 0.3 per 100,000 in men) [1].The Surveillance, Epidemiology, and End Results (SEER) 2011-2017 data indicates that 98.3% of TC patients had a five-year relative survival rate.65.9% of TC cases are caused by localized tumors, which have a 99.9% five-year relative survival rate, which is considered excellent [2].For Saudi women, thyroid cancer came in second, and for Saudi men, it came in tenth.In 2020, 1044 cases of thyroid cancer were reported among Saudi nationals, making up 7.4% of all newly diagnosed cancer cases.There were 228 (21.8%) males and 816 (78.2%) females affected by thyroid cancer, for a female-to-male ratio of 358 to 100 [3].
The assessment of quality of life (QOL) post-thyroidectomy has gained significant attention in the medical community.Multiple studies have delved into the long-term consequences of thyroidectomy, aiming to evaluate the impact on patients' overall well-being and functional status [4,5].By examining numerous aspects, such as the physical, psychological, and social dimensions of QOL, researchers have provided valuable insights into the outcomes of thyroidectomy, hence contributing to improving patient care and enhancing their postoperative experiences.
Examinations of the physical dimension of QOL have indicated that most individuals who have undergone thyroidectomy in Taif achieve satisfactory outcomes in terms of overall physical health.Research has focused on various aspects, such as voice quality, swallowing function, and scar appearance.Findings suggest that most patients report no significant changes in their voice or swallowing after thyroidectomy, providing reassurance and reducing concerns regarding potential negative effects.Additionally, studies have investigated the cosmetic outcomes of surgery, highlighting the importance of surgeon experience and techniques in minimizing scar visibility, ultimately leading to greater patient satisfaction [6].
Regarding the psychological dimension of QOL, several studies have emphasized patients' emotional wellbeing post-thyroidectomy.Findings have demonstrated that, while many individuals experience temporary emotional disturbances related to the surgery, long-term psychological outcomes generally improve over time.In fact, the majority of patients report higher levels of self-esteem and body image postthyroidectomy, as the removal of a diseased or abnormal thyroid gland can alleviate anxiety and distress associated with the underlying condition.However, additional research is needed to explore the specific factors contributing to these positive psychological outcomes and to identify potential interventions for those experiencing psychological distress following thyroidectomy [7,8].
The social dimension of QOL post-thyroidectomy has also been explored, aiming to understand the impact of the surgery on patients' social interactions and overall social well-being.Studies in this area have indicated that most individuals do not perceive any negative consequences on their social lives after thyroidectomy.However, some patients may experience challenges adjusting to changes in their appearance or vocal function, which can potentially affect their confidence and social interactions.Further investigation into the specific areas causing social difficulties, along with interventions to support patients in overcoming these challenges, would be beneficial for optimizing the social dimension of QOL post-thyroidectomy [9].
Certain individuals may require lifelong assistance in adjusting to thyroid hormone replacement therapy following a thyroidectomy [7].Despite an increasing body of evidence in the medical literature showing these patients' unmet needs [7,10], physicians still frequently underestimate the difficulties these patients encounter [11].Moreover, only a limited number of studies [12,13] have investigated the long-term impact on quality of life (QOL).To bridge the gap between patients' needs and the services provided and to close the gap that exists between the services offered and the needs of the patients [14], it is crucial to develop an effective postoperative care program to enhance the long-term QOL of thyroid cancer survivors.This study addresses this knowledge gap by evaluating the long-term QOL (5-15 years post-thyroidectomy) of thyroid tumor survivors and identifying the factors significantly associated with a negative impact.

Materials And Methods
This study employed a cross-sectional design to examine the quality of life among thyroidectomy patients in Taif City.The study population consisted of adults aged 12 years and older who were followed for 5 to 15 years post-thyroidectomy due to either benign or malignant causes.Individuals who had undergone surgery less than five years ago or more than 15 years ago, those younger than 12, and participants residing outside of Taif City were excluded from the study.
Al Hada Armed Forces Hospital, Prince Mansour Military Hospital, and Prince Sultan Military Hospital were the three government hospitals from which the data was gathered.From, which we identified 537 patients and contacted them.Only 100 individuals were included in the study; the remaining patients were not surgically treated, were misdiagnosed, died, or refused to be part of the research.From the medical records system, contact details and basic demographic information (gender, age, socioeconomic status, precise diagnosis, number of years post-surgery) were retrospectively gathered and confirmed during the phone survey.
The Arabic version of the European Organization for Research and Treatment of Cancer's head and neck cancer-specific quality of life questionnaire (EROTC QLQ) [6] -H&N43 was filled out by the participants over the phone.The questionnaire has been modified using yes or no questions.

Data analysis
The collected data underwent cleaning and organization in an Excel spreadsheet before being imported into R software version 4.2.2.Descriptive statistics were used to analyze continuous data using the mean and standard deviation, while categorical data were summarized with frequencies and percentages.A Fisher exact test was used to assess the relationship between the type of thyroidectomy surgery and respondent pain and swallowing difficulties.It was also used to draw an association between the type of thyroidectomy surgery and trouble with social eating and social contact among the respondents.

Ethical considerations
Three government hospitals, Prince Mansour Military Hospital, Prince Sultan Military Hospital, and Al Hada Armed Forces Hospital, gave their ethical approval for this study (Registration No. H-02-T-078).Informed consent was obtained from participants after a clear explanation of the study's objectives.Participants were assured of their right to withdraw at any point, and the anonymity and confidentiality of their responses were rigorously maintained throughout the study.Most participants were female (76%) and over 50 years old (38%).Most participants were married (72%), had primary school education (31%), and were not currently working (64%).The types of surgery performed were hemithyroidectomy (36%), subtotal thyroidectomy (6%), and total thyroidectomy (58%).
A notable proportion reported experiencing various pains and swallowing difficulties.Specifically, 18% reported pain in the mouth, 16% in the jaw, and 46% in the throat.Swallowing problems were reported by 22% of participants, with 37% experiencing difficulties swallowing solid food.Additionally, 48% reported problems with their teeth, 27% had issues due to tooth loss, and 38% felt numbness in their hands or feet, as depicted in Table 2.  Regarding the problems related to senses, body satisfaction, and sexual satisfaction, 19% felt dissatisfied with their bodies and experienced weight loss.Among those with weight loss, six (32%) expressed worry about it.Some participants experienced problems with their sense of smell (12%) and taste (13%).Additionally, 20% reported decreased interest in sex, while 22% felt less sexual enjoyment.Skin problems were reported by 38% of participants, including rash (15%) and skin color change (18%).Concerns about test results and future health were expressed by 57% and 63% of participants, respectively.Difficulties in injury healing were reported by 16% of participants, as depicted in Table 3.A significant association was observed between the type of surgery and numbness in the hands or feet (p = 0.041).A higher percentage of individuals who underwent subtotal thyroidectomy (3, 50%) or total thyroidectomy (27, 47%) reported experiencing numbness in their hands or feet compared to those who had a hemithyroidectomy (8, 22%).
A higher percentage of respondents reported experiencing pain in the mouth in the subtotal thyroidectomy group (33%) compared to the other two groups.A higher proportion of individuals in the subtotal thyroidectomy group reported experiencing jaw pain (33%) compared to the other groups (11% and 17% for hemithyroidectomy and total thyroidectomy, respectively).Respondents in the total thyroidectomy group reported the highest percentage of throat pain (52%), followed by the subtotal thyroidectomy group (50%) and the hemithyroidectomy group (36%).
It is noteworthy that the subtotal thyroidectomy group had the highest percentage of individuals reporting problems with swallowing three (50%), followed by the total thyroidectomy group 12 (21%), and the hemithyroidectomy group seven (19%).However, the subtotal thyroidectomy group had the highest percentage of respondents reporting problems with teeth and losing teeth (17% and 22%, respectively), as depicted in Table 5. Have you had pain in your mouth?0.  A significant association (p = 0.046) was found between coughing and surgery type; individuals who underwent subtotal thyroidectomy reported more difficulties with coughing (4, 67%) compared to those who had a hemithyroidectomy (7, 19%) or a total thyroidectomy (18, 31%).Furthermore, no significant differences were found among the surgery groups in terms of problems going out in public (p = 0.9), enjoying meals (p = 0.7), eating in front of family (p = 0.4), or others (p = 0.8), and speaking problems (p > 0.05), as depicted in Table 6.

Characteristic
front of family and other people, the majority of both females and males reported no issues.However, a higher percentage of females (14, 18%), compared to males (3, 13%), had problems eating in front of others.The associations between gender and eating in front of family and other people were not statistically significant.
Regarding communication difficulties, 14 (18%) females and 5 (21%) males reported problems talking to other people, and 12 (16%) females and 7 (29%) males experienced difficulties talking on the telephone.However, these associations between gender and communication problems were not statistically significant.Similarly, when asked about speaking clearly and dealing with coughing, there were no statistically significant associations between gender and these issues.
Lastly, the table examined the association between gender and problems going out in public.Both females and males reported minimal difficulties in this aspect, with no statistically significant association found, as depicted in Table 7.
study conducted in China investigating health-related quality of life (HrQoL) among differentiated thyroid carcinoma patients concluded that, in the first three months, HrQoL among the total thyroidectomy group is worse with more postoperative problems, yet this difference disappears in the long term (6, 12 months) [16].
A review article raised a different finding; it reports that, when compared with hemithyroidectomy patients, total thyroidectomy patients may experience more impairment in social and physical HrQoL, yet there is no statistical difference in psychological HrQoL or long-term global HrQoL [17].However, another interesting prospective is the comparison between QoL according to surgical approach, endoscopic versus classical open procedure.The study concluded that endoscopic thyroidectomy patients showed better improvement in physical and emotional functions compared to open thyroidectomy.Nevertheless, postoperative pain was more commonly reported with the endoscopic approach of thyroidectomy [18].
Based on the outcome of this study, it is recommended that patients be actively involved in decision-making and be thoroughly informed about complications both pre-and post-operatively.They should also be involved in managing and increasing their quality of life after thyroidectomy procedures of any type.

Strengths and limitations
The limitations of this study include the use of medical records, which could be inaccurate in reporting, and the assessment in the long term, which raised the concern of recall bias, yet these limitations were accounted for by the relatively large sample size to minimize the effect of such bias.

Conclusions
This study concluded that the most reported problems post-thyroidectomy in the long term were worry about health in the future and worry about test results, which necessitate paying more attention to these aspects and discussing them with thyroid cancer survivors both preoperatively and in the postoperative follow-up with the help of a social worker.Nevertheless, there is no significant difference in life quality between total thyroidectomy and hemithyroidectomy in terms of quality of life.Further future research with a larger sample size and more centers involved is recommended.

TABLE 3 : Senses problems, body, and sexual satisfaction among the respondent
challenges eating in front of others.Communication issues were also prevalent, with 19% reporting problems talking to others, talking on the telephone, and speaking in a noisy environment.Additionally, 20% had difficulties speaking clearly, and 29% experienced problems with coughing.Social participation was affected by 10% of participants who reported difficulties going out in public, as depicted in Table4.N = 100 1Have you had problems enjoying your meals?

TABLE 4 : Trouble with social eating and social contact among the respondents
1: n (%)