Wednesday, August 28, 2013

Too much medicine? Thyroid and CFS

Analysis: Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours

Tuesday, August 27, 2013 - 09:08

New imaging techniques are fuelling an epidemic in diagnosis and
treatment of thyroid cancers that are unlikely to ever progress
cause symptoms or death, warn experts on today.

New technologies such as ultrasound, CT and MRI scanning can detect
thyroid nodules as small as 2mm – many of these small nodules are
papillary thyroid cancers.

In the US, cases have tripled in the past 30 years - from 3.6 per
100,000 in 1973 to 11.6 per 100,000 in 2009 – making it one of the
fastest growing diagnoses. Yet the death rate from papillary thyroid
cancer has remained stable.

This expanding gap between incidence of thyroid cancer and deaths
suggests that low risk cancers are being overdiagnosed and
, argue Dr Juan Brito and colleagues at the Mayo Clinic in

This is exposing patients to unnecessary and harmful treatment that is
inconsistent with their prognosis, they warn, and they say both the
overdiagnosis and overtreatment of this form of cancer need to be
fully recognised.

The article is part of a series looking at the risks and harms of
overdiagnosis in a range of common conditions. The series, together
with the Preventing Overdiagnosis conference in September, are part of
the BMJ's Too Much Medicine campaign to help tackle the threat to
health and the waste of money caused by unnecessary care.

The authors say that unnecessary thyroidectomy (the surgical removal
of all or part of the thyroid gland) is costly and carries a risk of
complications such as low calcium levels and nerve injury. In the US,
the number of thyroidectomies for thyroid cancer has risen by 60% over
the past 10 years at an estimated cost of $416m (£270m; €316m).

Using radioactive iodine in patients with low risk thyroid cancer has
also increased from one in 300 patients to two in five patients
between 1973 and 2006, despite recommendations against using it, they

They acknowledge that inferring overdiagnosis of thyroid cancer has
limitations, but say that uncertainty about the benefits and harms of
immediate treatment for low risk papillary thyroid cancer "should spur
clinicians to engage patients in shared decision making … to ensure
treatment is consistent with the research evidence and patient goals."

They suggest a term that conveys favorable prognosis for low risk
thyroid cancers (microPapillary Lesions of Indolent Course or
microPLIC)) and makes it easier to give patients the choice of active
surveillance over immediate and often intensive treatment. And they
call for research to identify the appropriate care for these patients.


Free full text:

Thyroid cancer: zealous imaging has increased detection and treatment
of low risk tumours


Too Much Medicine

BMJ 2013; 347 doi: (Published 27
August 2013)
Cite this as: BMJ 2013;347:f4706

Juan P Brito, instructor of medicine12,
John C Morris, professor1,
Victor M Montori, professor12

Author Affiliations

Correspondence to: V M Montori

Summary box

Clinical context—Thyroid cancer is the most common endocrine
malignancy and one of the fastest growing diagnoses

Diagnostic change—Introduction of neck ultrasonography into routine
endocrinological practice in the 1980s with guided biopsy in the late
1990s, plus increased use of computed tomography and magnetic
resonance imaging for other conditions

Rationale for change—New imaging methods allow the detection and
biopsy of thyroid nodules as small as 2 mm

Leap of faith—Patients with small papillary cancers will benefit from
their removal

Increase in disease—Worldwide increase in incidence of thyroid cancer
since the early 1980s but with considerable variation between
countries. In the US the incidence of thyroid cancer has increased
from 3.6 cases/100 000 population in 1973 to 11.6 cases/100 000 in
2009. Small papillary thyroid cancers, the most indolent form of
thyroid cancer, account for 90% of cases

Evidence of overdiagnosis—The expanding gap between the incidence of
thyroid cancer and stable death rates from papillary thyroid cancer
(0.5/100 000 in 1979 and 2009). Observational evidence shows that
small papillary thyroid cancers, which are a common autopsy finding,
may never progress to cause symptoms or death

Harms from overdiagnosis—Patients having thyroidectomy experience
physical complications, financial and psychosocial burdens, and need
lifelong thyroid replacement therapy

Limitations—Inference about overdiagnosis of thyroid cancer is based
on epidemiological and observational evidence

Conclusion – The incidence of small and indolent thyroid cancer is
increasing, exposing patients to treatments inconsistent with their
prognosis. We suggest a term that conveys the favourable prognosis for
low risk thyroid cancers (micropapillary lesions of indolent course or
microPLICs) and call for research to identify the appropriate care for
these patients

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