12. Rehabilitation – Thyroid Cancer

In Germany, patients are legally entitled to follow-up treatment after every surgery, radioiodine therapy or radiotherapy for thyroid cancer.

The statutory pension insurances are the most frequently responsible service providers. According to German social legislation, people with disabilities or at risk of disability receive rehabilitation services to promote their self-determination and equal participation in society, to avoid disadvantages or to counteract them. The services are provided by the responsible rehabilitation provider in accordance with the Ninth Book of the German Social Code (SGB) and the benefit laws applicable to the respective rehabilitation provider (e.g. SGB V in the case of the statutory health insurance or SGB VI in the case of the German Pension Insurance, Deutsche Rentenversicherung, DRV) [1303], [1304], [1305].

In addition to follow-up treatment, it is possible to apply to the cost bearers for treatment at any time during the illness. The prerequisites for approval are a justified "need for rehabilitation" and a positive "rehabilitation prognosis".

The aim of oncological rehabilitation is to regain physical, mental and social well-being and to return to everyday family, social and professional normality. Other goals include maintaining the ability to work and avoiding the need for long-term care.

Some of the consequences of thyroid cancer and thyroid cancer therapy occur immediately after treatment, for example local secondary disorders due to the surgery or radioiodine therapy, discomfort caused by the cervical scar, difficulty swallowing, restricted throat mobility or dry mouth, difficulty swallowing, hoarseness or functional disorders due to recurrent paresis, dyspnea, lymphedema or disorders of calcium metabolism as a result of postoperative hypoparathyroidism [1306].

Other secondary disorders are often only noticed at a later stage, such as chronic tumor-associated fatigue syndrome, problems with thyroid hormone regulation, anxiety and depression.

If patients are eligible for follow-up treatment, they shall be informed and advised by the treating centers about the eligibility, content and benefits of a follow-up treatment measure with reference to their right to choose an appropriate facility.

Oncological rehabilitation for thyroid cancer patients shall take place in suitable facilities. The prerequisite is the existence of an indication-specific concept aimed at the specific needs and a corresponding approval from the German Pension Insurance (indication group 11l, oncological diseases/thyroid). Multimodal rehabilitation treatments are carried out in these facilities, which include various basic elements: Exercise, nutrition, psyche, information on illness and health, social counseling and socio-medical assessment (occupational).

Specific counseling contents are: Biology, diagnostics and therapies of the various thyroid cancers, new therapy options for advanced thyroid cancer, important laboratory values in thyroid cancers, function of the thyroid and parathyroid glands, signs of hypothyroidism and hyperthyroidism, training on thyroid hormone substitution (timing of thyroid hormone intake, TSH target ranges, possible errors or factors influencing the results of laboratory tests, in particular the Tg value), dealing with hypoparathyroidism and calcium substitution, tumor aftercare, safe sources of information, thyroid self-help and self-help organizations.

Often underestimated reasons for oncological rehabilitation are fatigue, anxiety and depression:

Cancer-related fatigue is a common burden of thyroid cancer patients. Yukari Maki et al. showed a prevalence of 41.8% in long-term survivors with no evidence of persistent or recurrent disease. The diagnostics for this are described in the S3 guideline on fatigue [1307]. In thyroid cancer patients, particular attention is paid to the laboratory parameters for thyroid hormone replacement and the calcium-phosphate balance. The forms of therapy with positive connotations in the guideline (exercise training, cognitive behavioral therapy and psychological intervention) are part of the therapeutic offer of oncological rehabilitation (5).

Thyroid cancer patients have poorer scores for depression and anxiety compared to patients with other cancers (non-Hodgkin's lymphoma, breast cancer, prostate cancer, colorectal cancer, uterine cancer, prostate cancer) [1308]. There is evidence of a correlation with the intensity of TSH-suppressive thyroid hormone substitution [1309], [1310]. Various therapeutic elements of oncological rehabilitation are suitable for achieving positive effects in patients with anxiety and depression.

Many therapies provided within oncological rehabilitation are evidence-based. For methodological reasons, most studies are available for breast cancer, prostate cancer and colorectal cancer. The transferability of the results to thyroid cancer patients appears plausible.