Editing Patient Pathways: Thyroid Cancer

<span id="thyroid-cancer"></span>
= Thyroid cancer =

Thyroid cancer is a malignant disease that affects the thyroid, a small gland located in the front of the neck which plays a key role in regulating metabolism.

In Croatia, the incidence of thyroid cancer is showing an increasing trend, with several hundred new cases diagnosed each year. This disease more commonly affects women than men, and is most commonly diagnosed in middle age. Due to the complexity of treatment and various therapeutic options, which include surgical procedures, radioactive iodine, and hormone therapy, patients with thyroid cancer are faced with numerous challenges. Therefore, it is necessary to provide comprehensive support measures that include medical care, psychological support and education in order to improve the quality of life of patients and facilitate coping with the disease. Although the incidence is on the rise, mortality rates have remained relatively stable.

Thyroid cancer is divided into four categories: papillary, follicular, medullary, and anaplastic thyroid cancer. Differentiated thyroid cancer, which includes papillary and follicular cancer, accounts for more than 90% of all diagnoses. Standard treatments, such as thyroidectomy followed by radioiodine therapy, are relatively effective for these types of cancer. However, rare variants such as anaplastic thyroid carcinoma pose significant challenges due to their aggressive nature and limited treatment options.

<span id="patient-pathways"></span>
= Patient pathways =

Creating a comprehensive thyroid cancer treatment plan includes steps from initial presentation and diagnosis to treatment and follow-up. Here is a detailed plan:

<span id="diagnostics"></span>
== 1. Diagnostics ==

The patient presents with symptoms such as a lump in the neck, voice changes, difficulty swallowing, neck pain, or shortness of breath.

'''Consultation with a general practitioner (GP):''' The patient visits a general practitioner.

'''Medical history and physical examination:''' Detailed patient history, neck palpation.

'''Initial tests:''' Blood tests to assess thyroid function (TSH, T3, T4).

'''Referral to a specialist''' Referral to an endocrinologist or head and neck specialist for further evaluation.

'''Diagnostic evaluation'''

'''Thyroid ultrasound:''' Visualization of nodules and assessment of their characteristics.

'''Fine needle aspiration (FNA):''' Taking a tissue sample from the nodule for cytological examination.

'''Cytology:''' Pathological examination to confirm the diagnosis of cancer.

'''CT or MRI:''' To assess extracapsular invasion and metastases.

'''Thyroid scintigraphy:''' For functional assessment of the nodule.

'''PET scan:''' In case of suspected distant metastases.

'''Laboratory tests:''' Blood tests for tumor markers (e.g. calcitonin and carcinoembryonic antigen for medullary carcinoma).

<span id="treatment"></span>
== 2. Treatment ==

'''Multidisciplinary Teak (MDT) meeting'''

'''MDT discussion:''' Review of diagnostic findings with specialists including endocrinologists, surgeons, oncologists, radiologists, and pathologists.

'''Treatment plan development:''' Based on tumor stage (TNM system), type of thyroid cancer, and the patient’s overall health.

'''Treatment options'''

'''Surgical Treatment:''' The main treatment for most types of thyroid cancer.

'''Lobectomy:''' Removal of one lobe of the thyroid gland.

'''Total thyroidectomy:''' Removal of the entire thyroid gland.

'''Radioactive iodine therapy (RAI):''' to destroy any remaining cancer cells after surgery.

'''External radiotherapy''' is used in rare cases when RAI is not appropriate.

'''Thyrotropin hormone therapy:''' Suppressive therapy with levothyroxine to reduce stimulation of potentially remaining cancer cells.

'''Targeted therapy:''' In the case of advanced cancer that does not respond to standard treatments (e.g. tyrosine kinase inhibitor for medullary carcinoma).

<span id="after-treatment-follow-up-rehabilitation-and-survival"></span>
== 3. After treatment: follow-up, rehabilitation and survival ==

'''Follow-up after treatment:''' Regular check-ups with physical examinations and blood tests (TSH, thyroglobulin).

'''Periodic imaging''' (ultrasound, CT or MRI) to monitor for recurrence.

'''Thyroid scintigraphy''' to assess residual thyroid cells.

'''Rehabilitation'''

'''Physical therapy''' for recovery from surgery.

'''Psychosocial support:''' Counseling and support groups for emotional well-being.

'''Long-term care for survivors:''' Monitoring late effects of treatment. Promoting health and lifestyle changes to improve overall well-being.

'''Secondary prevention:''' Screening for other malignancies and maintaining a healthy lifestyle.

<span id="palliative-care-if-applicable"></span>
== 4. Palliative care (if applicable) ==

'''Palliative treatments:''' To relieve symptoms and improve quality of life in advanced cancer.

'''Pain management:''' Medications, nerve blocks.

'''Symptom control:''' Managing shortness of breath, pain, etc.

'''Hospice care:''' For end-of-life care if curative treatment is no longer an option.

<span id="challenges-faced-by-thyroid-cancer-patients-during-their-therapeutic-journey"></span>
= Challenges faced by thyroid cancer patients during their therapeutic journey =

<span id="challenges-during-diagnositc-evaluation"></span>
== Challenges during diagnositc evaluation ==

Being diagnosed with thyroid cancer can be stressful and challenging for patients. Support during this phase can significantly improve the patient’s emotional and physical condition. Patients with thyroid cancer face various difficulties during diagnosis, such as physical, psychological, financial and professional difficulties, and lack of information.

'''Physical challenges'''

'''Symptoms of the disease:''' Swelling in the neck is often the first symptom of thyroid cancer, which can cause discomfort and anxiety.

'''Difficulty swallowing or breathing:''' The tumor can press on the esophagus or trachea. '''Voice changes:''' Hoarseness or loss of voice due to pressure on the vocal cords. Pain and discomfort during biopsy.

'''Psychological challenges'''

Fear of a cancer diagnosis, uncertainty about treatment: fear of possible complications and side effects of treatment. The use of radioactive iodine for thyroid imaging during scintigraphy can cause anxiety. The process of emotional acceptance of a cancer diagnosis can be very stressful and challenging. The patient needs emotional support, which puts pressure on family and friends to provide support.

'''Social isolation:''' feeling isolated due to illness and the need for privacy.

'''Financial and professional challenges'''

Absence from work: Frequent medical check-ups and treatments can cause absence from work, which can affect career and financial stability. The costs of diagnostics and treatment, insufficient health insurance.

'''Lack of information'''

Patients often have difficulties in finding reliable and understandable information about the disease, diagnostic procedures, treatment options, and their rights.

'''Insufficiently clear communication with doctors:''' the complexity of medical terminology and lack of time during consultations can make it difficult to fully understand the diagnosis and treatment options.

<span id="challenges-during-treatment"></span>
== Challenges during treatment ==

'''Physical challenges'''

Pain in the neck or swelling, hoarseness or voice changes, difficulty swallowing.

'''Metabolic problems:''' hypothyroidism or hyperthyroidism due to changes in thyroid hormone levels, which can cause fatigue, weight changes, mood swings, and other symptoms.

'''Lack of energy:''' constant fatigue and exhaustion due to treatment and hormonal imbalance.

'''Nutritional problems:''' Difficulty eating food due to nausea, loss of appetite or difficulty swallowing.

'''Weight changes:''' weight gain or loss due to hormonal changes.

'''Psychological challenges'''

'''Hypothyroidism or Hyperthyroidism:''' Thyroid hormone imbalance can cause symptoms such as fatigue, weight gain, cold sensitivity (hypothyroidism), or weight loss, nervousness, and insomnia (hyperthyroidism) - Endocrinologist.

'''Scars from surgical procedures''' can affect appearance and self-confidence.

'''Hypocalcemia (Low blood calcium levels):''' A possible consequence of surgical removal of the parathyroid glands.

'''Cardiovascular problems:''' Hormonal imbalance can affect heart function.

'''Hair loss:''' Can occur due to radiation therapy or chemotherapy.

'''Skin problems:''' Dry skin, itching, or rash due to therapy.

'''Eye problems:''' Dry eyes or irritation due to radiation therapy.

'''Metabolic problems:''' Changes in metabolism due to hormonal therapies.

'''Psychological challenges'''

'''Fear and anxiety:''' fear of the disease, treatment, side effects and uncertainty of outcome, anxiety related to regular check-ups and fear of recurrence.

'''Depression:''' feelings of hopelessness, loss of interest in everyday activities, isolation.

'''Changes in body image:''' discomfort due to physical changes such as scars or weight changes.

'''Treatment stress:''' psychological stress due to intensive treatments and their impact on everyday life.

'''Relationship with partner:''' sexual problems, decreased libido, and emotional distance due to illness.

'''Family Relationships:''' tensions within the family due to stress, role changes, and responsibilities.

'''Social Isolation:''' withdrawal from social activities due to fatigue, discomfort, or fear of exposure to infections during therapy.

'''Financial and professional challenges'''

'''Reduced work capacity''' due to fatigue, side effects of treatment and emotional problems.

'''Absence from work:''' Frequent medical appointments and treatments requiring time off work, which can affect career and financial stability.

High costs of medication, surgery, therapies and other medical services, travel and accommodation costs for patients who have to travel to health care centers. Reduced income due to reduced work capacity or job loss. Ongoing costs associated with long-term monitoring and health maintenance.

'''Lack of information'''

The need to understand complex medical information and make informed decisions. Difficulties in making treatment decisions due to lack of reliable and understandable information or conflicting advice. Unawareness of patient rights.

Lack of information on healthcare providers during treatment.

<span id="challenges-during-rehabilitation-and-disease-monitoring"></span>
== Challenges during rehabilitation and disease monitoring ==

'''Physical challenges'''

'''Hypothyroidism or hyperthyroidism:''' Imbalances in thyroid hormone levels can cause fatigue, weight gain, depression, anxiety, mood swings, and other symptoms.

'''Neck pain and scars:''' postoperative pain and aesthetic problems due to scars.

'''Voice changes:''' hoarseness or loss of voice due to surgery or therapy.

'''Psychological challenges'''

'''Fear of recurrence:''' Persistent fear of cancer recurrence.

'''Anxiety and depression:''' psychological stress and emotional problems associated with the experience of cancer.

'''Social isolation:''' reduced social interaction due to fatigue, anxiety or other symptoms.

'''Financial and professional challenges'''

'''Returning to work:''' Difficulties returning to work due to physical and emotional limitations. Long-term financial burden associated with ongoing medical costs.

<span id="challenges-during-palliative-care"></span>
== Challenges during palliative care ==

The difficulties faced by patients diagnosed with thyroid cancer in Croatia and their families during palliative care are manifold and encompass several key aspects:

'''Limited access to palliative care:''' There is a significant gap between the demand for palliative care and available resources. Insufficient capacities of specialized palliative care providers.

'''Psychological challenges'''

The psychosocial and emotional burden of patients and their families is often great. Family caregivers often face high levels of stress and emotional burden.

'''Cultural and ethical issues:''' Reluctance to discuss end-of-life issues can hinder the provision of effective palliative care. Ethical challenges in decision-making and care provision can also create additional stress for families and healthcare professionals.

'''Financial challenges'''

The cost of care can be a significant burden on families, especially given the long-term nature of palliative care. Economic pressure can further exacerbate the stress experienced by patients and their families, affecting their overall well-being and quality of life.

'''Challenges in care coordination:''' Effective palliative care requires coordination among various healthcare providers. In Croatia, there are challenges related to care coordination between hospitals, palliative care units, and home care services.

Addressing these challenges requires a comprehensive approach that includes improving access to palliative care, providing emotional and psychological support to families, addressing economic burdens, and ensuring effective care coordination. In addition, public education and raising awareness of the benefits of palliative care can help reduce cultural and ethical barriers.

'''Coordination of health care'''

'''Regular check-ups:''' It is important to continue with regular check-ups to monitor for cancer recurrence or side effects of treatment. This includes blood tests and scans, such as ultrasound and radioiodine scans, depending on the risk of the cancer coming back.

Patients with thyroid cancer face various challenges during their diagnostic, therapeutic and rehabilitation journey, including physical, psychological, financial and professional difficulties, lack of information, and coordination of healthcare.

Providing comprehensive support that includes medical care, psychological support, education and social services can significantly improve the quality of life and treatment outcomes for these patients.

<span id="supportive-activities-for-thyroid-cancer-patients"></span>
= Supportive activities for thyroid cancer patients =

A coordinated multidisciplinary approach to providing supportive care in healthcare settings is essential to help patients throughout their treatment journey.

Such an approach significantly improves the quality of life of patients with thyroid cancer, helping them to cope more easily with the difficulties that the disease and treatment bring.

Civil society organizations, such as patient associations and cancer charities, can play a key role in informing patients about such supportive activities. Also, associations can, with the help of experts, organize and provide some of the necessary support to patients in order to reduce physical, psychological, financial and professional difficulties, lack of reliable and understandable information and strengthening the coordination of healthcare, not only within the health system, but also through activities aimed at active patient involvement in the development of better national health guidelines and policies.

<span id="supportive-activities-provided-by-healthcare-institutions"></span>
== Supportive activities provided by healthcare institutions ==

'''Supportive activities for physical challenges'''

Supportive activities for thyroid cancer patients within the healthcare system cover a wide range of services aimed at improving the overall quality of life for patients.

Along with medical care, which includes regular monitoring through blood tests, ultrasound, MRI or CT scans, and follow-up by specialist physicians, for optimal management of physical ailments, patients should have access to a multidisciplinary team of experts.

'''Endocrinologist:''' Managing hormonal imbalances and metabolic problems.

'''Oncologist:''' Comprehensive cancer treatment management.

'''Nutritionist:''' Nutritional counseling and weight management.

'''Otolaryngologist:''' Difficulty swallowing, breathing and voice.

'''Thoracic surgeon:''' Surgical treatment of cancer and postoperative care.

'''Speech therapist:''' Voice rehabilitation.

'''Physiotherapist:''' Pain management and improved mobility.

'''Specialist in pain:''' Postoperative pain control.

'''Plastic surgeon:''' Aesthetic procedures and scar management.

'''Dermatologist:''' Skin problems and hair loss.

'''Cardiologist:''' Monitoring and treatment of cardiovascular problems.

'''Ophthalmologist:''' Eye problems related to therapy.

This comprehensive approach ensures that patients receive adequate care for all physical aspects of thyroid cancer treatment, improving their overall quality of life during and after treatment.

'''Supportive activities for psychological challenges'''

'''Patients with cancer and their families''' almost inevitably face numerous psychological difficulties throughout the entire therapeutic journey. Professional psychological help in the form of individual counseling, group therapy, counseling with a partner and family counseling is a key part of support for oncology patients. Also, the psychiatrist can recommend psychopharmacotherapy as support for patients.

'''Supportive activities to provide reliable and understandable information'''

'''Informed consent:''' A signed form is proof that a conversation in which the doctor provides the patient with information about diagnostic and therapeutic procedures, risks, complications, and alternative treatments has led to mutual understanding. Detailed but easy-to-understand educational content for patients is essential in this process, but often not available.

'''The right to a second medical opinion''' is guaranteed by the Patient Rights Protection Act. The patient always has the right to seek a second medical opinion about their health condition. Every healthcare professional of high professional qualifications and appropriate specialization who has not participated in the direct provision of a certain type of healthcare service to the patient is obliged to give a second medical opinion to the patient at their oral or written request. In addition to the patient, the physician can also initiate the procedure of seeking a second opinion. In the case of diagnosing a rare disease, the inability to find (adequate) therapy, the lack of technological equipment of the healthcare institution, which prevents or makes it difficult to establish a diagnosis or the course of therapy, doctors often seek the help and confirmation of their colleagues from other institutions in order to provide the best possible approach to each patient.

<span id="supportive-activities-provided-by-associations"></span>
== Supportive activities provided by associations ==

'''Supportive activities for physical challenges'''

'''Support related to side effects of treatment:''' organizing workshops and informative activities that educate patients on ways to manage side effects. Providing brochures and online resources with practical tips.

'''Support related to symptoms of the disease:''' access to medical professionals for early intervention and treatment of symptoms.

'''Organization of counseling centers''' where patients can get advice from medical experts and psychologists. Inclusion of medical advisors in support programs.

'''Support related to metabolic disorders, eating problems and lack of energy:''' connecting patients with nutritionists and endocrinologists through organized events and online consultations to personalize the patient’s diet plan and collaboration of fitness and nutrition experts for personalized recommendations for moderate exercise. Organizing practical workshops on proper nutrition, creating educational materials.

'''Supportive activities for psychological challenges'''

Offer free or subsidized psychological counseling, organize support groups and helplines for psychological support.

In the case of depressive disorders, support in finding a psychiatrist and therapist, and cooperation between associations and them. Organizing support groups for conversation and exchange of experiences.

Organizing workshops and therapy groups that focus on body positivity and accepting change.

Providing free courses in meditation, yoga, and relaxation techniques. Creating online resources and apps to support stress management.

Associations can organize workshops for couples, including counseling with experts on sexual health.

Organizing family therapy sessions and workshops that involve all family members in the support process.

Connecting with peer groups and social activities. Organizing social events, online forums and support groups where patients can connect and share their experiences.

'''Supportive activities for financial and professional challenges'''

Advice on labor rights and adaptation of the workplace. Providing legal advice and support for talking to employers about adapting the workplace. Organizing workshops on workers’ rights.

Connecting patients with financial advisors and organizing workshops on managing finances during treatment.

Providing information on financial support, organizing fundraising campaigns and assistance in applying for financial assistance.

Connecting patients with social workers and providing free financial counseling.

'''Education on long-term financial planning.'''

Supportive activities to provide reliable and understandable information necessary for informed participation in the treatment process

'''Understanding the disease and treatment:''' Education and information materials. Organizing educational seminars and workshops with medical professionals. Distribution of brochures and online resources about the disease and treatment.

<span id="examples-of-successful-supportive-activities-of-croatian-associations"></span>
= Examples of successful supportive activities of croatian associations =

Civil society organizations and patient associations play a vital role in providing support to thyroid cancer patients. These groups often offer peer support systems where patients can connect with others going through similar experiences, providing a sense of community and mutual understanding.

They can also organize educational workshops and seminars to inform and educate patients, empowering them to actively participate in the treatment process.

Patient associations are also actively involved in healthcare and social care policies by raising public and political stakeholders’ awareness of patients’ needs and the patients about their rights.

A large number of civil society organizations in Croatia provide support to cancer patients. A larger number of associations in Croatia are listed in the directory, while we are highlighting a few of them here:

'''Association SVE za NJU'''

The Association “SVE za NJU” provides psychological support to women with cancer. They organize individual and group therapies, and counseling that helps patients cope with emotional and psychological challenges. Through their support programs, many women have received the necessary emotional support, which helped them cope better with the diagnosis and treatment. All branches provide psychological help led by professionals.

The association regularly organizes workshops and educational programs where patients can learn more about their illness, treatment, and lifestyle during and after therapy. Educational programs help in making informed decisions about their care.

'''Croatian League Against Cancer'''

The “Mama budi zdrava” campaign is aimed at raising awareness of the importance of preventive check-ups and early detection of breast cancer. They organize lectures, distribute information materials, and provide free mammograms.

'''Program “Nisi sama ideš s nama!”'''

The program provides logistical support to patients by organizing transportation to hospitals and medical centers for patients who are unable to come to therapy on their own.

This program has facilitated access to treatment for many patients, especially those living in rural areas or without their own transportation.

'''Association P.I.N.K. – life'''

The association “P.I.N.K. – life” provides support not only to breast cancer patients but also to their families. They organize workshops and group therapy activities for family members to help them better understand the disease and how best to support their loved ones.

These activities help families cope better with the stress and challenges brought on by their loved one’s illness, improving the overall quality of life for the entire family.

The association conducts educational activities that promote a healthy lifestyle and cancer prevention. This includes lectures, workshops on healthy eating and physical activity.

'''Association ILCO'''

The association “ILCO” provides specific support to patients with a colostomy through support and counseling groups. They help patients adjust to life with a colostomy by sharing advice on stoma care and emotional adjustment. Many patients with a colostomy report an improved quality of life thanks to practical advice and emotional support received through these groups.

'''Association Život na dar'''

The association “Život na dar” organizes educational workshops and seminars for patients with thyroid cancer, providing information about the disease, treatment, and life after surgery.

These examples illustrate how Croatian associations provide valuable support to cancer patients, improving their quality of life through education, psychological support to patients and their families, logistical support, and health promotion.

<span id="available-supportive-content-for-cancer-patients"></span>
= Available supportive content for cancer patients =

The Croatian translation of several Patient Guides was carried out by the Association of Women with Cancer SVE za NJU based on the approval of the European Society for Medical Oncology (ESMO).

'''ESMO Patient Guide Living with Cancer'''

This Patient Guide about living with cancer was prepared by the European Society for Medical Oncology (ESMO) and the European Cancer Patient Coalition (ECPC) in collaboration with the International Psycho-Oncology Society (IPOS), to help you and people like you during this important time in your life. In this Guide, you can find information about support in coping with the new life reality, life after primary treatment, preventive care, and long-term follow-up. It will also help you in keeping a personal health record, i.e., planning your health care while living with cancer.

The guide was translated by Dea Ajduković, Ph.D., and the translation was reviewed by Natalija Dedić Plavetić, Ph.D., Marko Jakopović, MD, PhD, and on behalf of the patients, psychologist Ljiljana Vukota from the SVE za NJU association.

https://www.esmo.org/content/download/131276/2458900/1/ESMO-Vodic-za-Bolesnike-Zivot-s-Rakom.pdf

'''ESMO Personalized Medicine in Oncology: Patient Guide'''

This Patient Guide was initiated by the ESMO Personalized Medicine Working Group to help patients, their families, and friends better understand the factors that may impact the personalized approach to cancer prevention, diagnosis, and treatment.

This booklet outlines current knowledge about the basic principles of personalized medicine by illustrating its application in several types of tumors. Personalized medicine represents the future of cancer treatment, and for it to become a reality in the near future and enable better treatment of tumors, the role of patients is crucial.

In this expanding and evolving approach, ESMO is committed to educating patients so that they can better understand its key principles and their own contribution to therapeutic progress. Well-informed patients and their families are essential for faster implementation of scientific breakthroughs into better treatments for patients with cancer.

The Croatian translation of the Guide was made possible by the Association of Women with Cancer SVE za NJU based on the approval of the European Society for Medical Oncology (ESMO). The Croatian translation was reviewed by: Prof. Ljiljana Šerman, Prof. Floriana Bulić-Jakuš and Mrs. Ljiljana Vukota.

https://www.esmo.org/content/download/385655/7486427/1/HR-Personalizirana-Medicina-u-Onkologiji-Vodic-za-Bolesnike.pdf

'''ESMO Side Effects Associated with Immunotherapy and their Management: A Patient Guide'''

This guide was prepared to help you and your family, friends, and caregivers better understand the side effects associated with immunotherapy and their management. It provides information on the most common toxicities associated with modern immunotherapies (known as “immune checkpoint inhibitors”), how your oncology team may manage these symptoms and some approaches that you can take yourself to help reduce their impact.

The medical information described in this document is based on the ESMO Clinical Practice Guidelines for the Management of Immunotherapy Toxicities, which were developed to assist clinicians in diagnosing, treating, and monitoring these events. All ESMO Clinical Practice Guidelines are prepared and reviewed by leading experts using evidence from the latest clinical trials, scientific research, and expert opinion.

The Croatian translation of the guide was reviewed by: a representative of the Croatian Society of Medical Oncology: Natalija Dedić Plavetić, Ph.D., a representative of the Croatian Thoracic Society: Prof. Marko Jakopović, Ph.D., a representative of the Association of Women with Cancer SVE za NJU: Ljiljana Vukota.

'''ESMO Cancer Patient Guide during the COVID-19 Pandemic'''

The Guide contains information about the COVID-19 disease and its symptoms, as well as measures you can take to reduce your risk of infection. Also, the guide provides information about the impact of the COVID-19 pandemic on various aspects of cancer treatment, including possible changes to your treatment plan and medical check-ups that may be needed to protect you from infection.

The Croatian translation was reviewed by: Prim. Paula Podolski, Ph.D., President of the Croatian Senological Society, Borislav Belev, Ph.D., medical oncologist, National Representative of the Croatian Society of Medical Oncology at ESMO, and Ljiljana Vukota, representative of the SVE za NJU association.

http://www.svezanju.hr/lijecenje-raka-tijekom-pandemije-covid-19-esmo-vodic-za-bolesnike/

'''ESPEN practical guideline: Clinical Nutrition in cancer'''

Malnutrition is a common feature of cancer patients and is a consequence of the presence of the tumor and medical and surgical anti-cancer treatments.

Malnutrition negatively affects the quality of life and toxicity of treatment and it is estimated that 10-20% of cancer patients die from the consequences of malnutrition, not from the tumor itself. Therefore, nutrition plays a key role in the multimodal treatment of cancer.

Strong evidence shows that nutritional problems should be considered from the time of cancer diagnosis, within the diagnostic and therapeutic pathway, and should run parallel to antineoplastic treatment. However, worldwide, cancer-related malnutrition is still largely unrecognized, underestimated, and undertreated in clinical practice.

These evidence-based guidelines have been developed to translate the current best evidence and expert opinion into recommendations for multidisciplinary teams responsible for the identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients.

<span id="content-for-patients-diagnosed-for-thyroid-patients"></span>
= Content for patients diagnosed for thyroid patients =

'''Brochure for patients'''

Brochure for patients Thyroid Cancer which covers information: where the thyroid gland is located and what its role is, what thyroid cancer is, how thyroid cancer is detected and treated, why regular check-ups that detect whether the malignant disease has returned or spread to other parts of the body are very important.

The brochure was produced by the Representative Office of Genzyme Europe B.V., Hektorovićeva 2/VI, Grand Center Zagreb, www.genzyme.com (Genzyme is now part of the Sanofi Corporation). The authors are not listed.

https://stitnjaca.hr/Brosura_za_pacijente_Rak_stitnjace.pdf

<span id="directory-of-associations-that-offer-supportive-activities-to-cancer-patients"></span>
= Directory of associations that offer supportive activities to cancer patients =

<span id="zagreb"></span>
== Zagreb ==

'''Croatian League Against Cancer'''

Offer: Psychological support, support groups, education, financial assistance.

Contact:

Address: Ilica 197, 10000 Zagreb

Telephone: +38513775572, 0995361 386

Email: info@hlpr.hr

Web: https://www.hlpr.hr

'''Association Institute for Gastrointestinal Tumors (Iget)'''

Activities: Counseling, education, campaigns to promote healthy lifestyle habits, connecting patient associations and medical professionals, development of informative content for patients

Contact:

Address: Ilica 197, 10000 Zagreb

Telephone: +385955578 587

Email: info@ iget.hr

Web: https://iget.hr

'''Association SVE za NJU'''

Offer: Psychological support, education, information, support groups.

Contact:

Address: Kneza Mislava 10, 10000 Zagreb

Telephone: +38516418765

Email: info@svezanju.hr

Web: http://svezanju.hr

'''Coalition of Associations in Healthcare (KUZ)'''

Patient Rights Advocacy: KUZ is dedicated to protecting patient rights and representing their interests before healthcare institutions.

Education: Organization of workshops and lectures on patient rights.

Public Campaigns: Campaigns to raise awareness of patient rights and better access to healthcare services.

Counseling: Providing legal and administrative support to patients.

Contact:

Address: Trpimirova 11, 10000 Zagreb

Phone: +38514572100

Email: President Ivica Belina: ivica.belina50@gmail.com

Web: https://www.kuz.hr/

'''Croatian Society of Prostate Cancer Patients (HDBRP)'''

Activities: Providing psychological support, counseling and information to prostate cancer patients and their families, organizing lectures, distributing educational materials, and campaigns to raise awareness of prostate cancer prevention and early detection, organizing support groups where patients can share their experiences and receive emotional support, campaigns to raise awareness of prostate cancer and the importance of regular check-ups.

Contact:

Address: Ilica 65/1, 10000 Zagreb

Phone: not listed

Email: info@hdbrp.hr

Web: https://www.hdbrp.hr

'''Association for Thyroid Disease Patients'''

Activities: Providing individual and group psychological support to patients diagnosed with thyroid diseases, organizing workshops, lectures, and distributing educational materials about thyroid diseases, counseling and supporting patients in the rehabilitation process after treatment, campaigns to raise awareness of thyroid diseases and the importance of early detection and treatment, Information platform that provides advice on diet, treatment and symptom management.

Contact:

Address: Ulica Frane Petrića 5, 10000 Zagreb

Telephone: +38513464 723

Email: udruga.stitnjaca@gmail.com

Web: https://stitnjaca.eu/

'''Association Krijesnica''' Offer: Psychological support, legal assistance, financial assistance, workshops.

Contact:

Address: Prilaz Gjure Dežalića 50, 10000 Zagreb

Telephone: +38513770477

Email: info@krijesnica.hr

Web: https://krijesnica.hr/

<span id="split-dalmatia-county"></span>
== Split-Dalmatia County ==

'''County League Against Cancer – Split'''

Offer: Education, support groups, psychological assistance.

Contact:

Address: Spinčićeva 1, 21000 Split

Telephone: 021 556 476

Email: office@zlpr.hr

Web: https://www.zlpr.hr/liga/

'''Croatian Association for the Promotion of Patient Rights'''

Activities: Advising on patient rights and assistance in accessing health services, education, and information

Contact

Address: Zrinsko Frankopanska 2b, 21000 Split

Telephone: +385915027861

Email: info@pravapacijenata.hr

Web: https://pravapacijenata.hr/

<span id="primorje-gorski-kotar-county"></span>
== Primorje-Gorski Kotar County ==

'''Association Nada Rijeka'''

Offer: Psychological support, education, workshops.

Contact:

Address: Milana Smokvine Tvrdog 5/1, 51 000 Rijeka

Telephone: 051 371 062, 097 613 9715

Email: klub.nada.rijeka@gmail.com

Web: https://klub-nada-rijeka.hr/

<span id="osijek-baranja-county"></span>
== Osijek-Baranja County ==

'''Association Mammae Osijek'''

Offer: Psychological support, information, support groups.

Contact:

Address: J. Leovića 4 (Health Center “Drava”), 31000 Osijek

Telephone: 031 373366, 091/480-1102

Email: klubmammaeos@gmail.com

Web: https://mammae-klub-osijek.hr/

<span id="istria-county"></span>
== Istria County ==

'''League Against Cancer Pula, Stoma Club Pula'''

Offer: Education, patient support, information.

Contact:

Address: Nobileova 1, 52100 Pula

Telephone: 052 222 795

Email: liga.protiv.raka@pu.t-com.hr

Web: https://www.ilco.hr/index.php/drustva/pula

<span id="zadar-county"></span>
== Zadar County ==

'''League Against Cancer Zadar'''

Offer: Psychological support, education, information.

Contact:

Address: Veslačka 12, 23000 Zadar

Phone: +385 23 627 783

Email: info@ligaprotivrakazadar.hr

Web: https://ligaprotivrakazadar.hr/

<span id="šibenik-knin-county"></span>
== Šibenik-Knin County ==

'''League Against Cancer of Šibenik-Knin County'''

Offer: Education, support groups, psychological assistance.

Contact:

Address: Trg Nikole Tomasea 2, 22000 Šibenik

Phone: 022 218993

Email: liga.sibenik@gmail.com

Find them on Facebook Liga protiv raka Šibeniko-kninske županije

<span id="varaždin-county"></span>
== Varaždin County ==

'''Association Mammae Club Varaždin'''

Offer: Psychological support, education, workshops.

Contact:

Address: Graberje 33, 42000 Varaždin

Telephone: 042/206-900

Email: mammae.klub.varazdin@ vz.t-com.hr

Web: https://rakdojke.com/

<span id="vukovar-srijem-county"></span>
== Vukovar-Srijem County ==

'''League Against Cancer Vinkovci'''

Offer: Education, support groups, information.

Contact:

Address: Trg bana Josipa Šokčevića 1, 32100 Vinkovci

Find them on Facebook Liga protiv raka Vinkovci

<span id="međimurje-county"></span>
== Međimurje County ==

'''Association County League Against Cancer – Čakovec'''

Offer: Psychological support, education, information.

Contact:

Address: A. Schulteissa 19, 40000 Čakovec

Phone: -

Email: liga.protiv.raka.medjimurje@gmail.com

Web: https://www.zlprck.hr/