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EDITORIAL
Year : 2015  |  Volume : 12  |  Issue : 2  |  Page : 43-45

Thyroid cancer: Controversy about over-diagnosis versus the perils of underdiagnosis


Department of Clinical Endocrinology and Research, Chellaram Diabetes Institute, Pune, Maharashtra, India

Date of Web Publication8-May-2015

Correspondence Address:
Ambika Gopalakrishnan Unnikrishnan
CEO and Chief Endocrinologist, Chellaram Diabetes Institute, Lalani Quantum, Bavdhan, Pune 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.156713

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How to cite this article:
Unnikrishnan AG, Bhatt AA. Thyroid cancer: Controversy about over-diagnosis versus the perils of underdiagnosis. Thyroid Res Pract 2015;12:43-5

How to cite this URL:
Unnikrishnan AG, Bhatt AA. Thyroid cancer: Controversy about over-diagnosis versus the perils of underdiagnosis. Thyroid Res Pract [serial online] 2015 [cited 2019 Dec 15];12:43-5. Available from: http://www.thetrp.net/text.asp?2015/12/2/43/156713

In recent times, it has been reported that thyroid cancer is increasing. [1] Interestingly, this increase has been not restricted to any particular gender, age, or socioeconomic status.

In the past decade, the use of ultrasound of the neck has become common. This has led to the increasing diagnosis of incidental thyroid nodules, or incidentalomas also called as 'a disease of modern technology'. [2] Another special situation is the widespread availability of positron emission tomography(PET), which has also resulted in the diagnosis of PET-detected thyroid incidentaloma, which poses another unique challenge to the treating physician.

Therefore, it has been argued that the increase in diagnosis of thyroid cancer is attributable to detection of early, indolent cases, not from an actual increase in occurrence. Additionally, this rapid increase in the prevalence of thyroid cancers cannot be explained in the setting of stable underlying environmental risk factors and also the genetic changes leading to neoplasia are unlikely to happen very rapidly. The most dramatic report on this issue was published in the New England Journal of Medicine, which reported a remarkable increase in thyroid cancer diagnoses from the Republic of Korea. [3] The article highlights a popular concern in that country; as the incidence of thyroid cancer reportedly increased 15-fold between 1993 and 2011. Indeed the authors state that thyroid cancer is the most common cancer diagnosed in the Republic of Korea, with 40,000 cases diagnosed in the year 2011 alone! The most common type of thyroid cancer detected was papillary thyroid cancer. The authors attribute this to the wide-spread screening of people for thyroid cancer with a relatively cheap and noninvasive investigation, that is, ultrasonography (USG) thyroid as well as increased awareness of their population about diagnosis and treatment of cancers in early stages. At the same time, the report also stresses that despite the increase in prevalence, the mortality did not increase. This led those authors to suggest the possibility of over-diagnosis and to consider whether such an intensive screening thyroid cancer will indeed help in improving mortality, morbidity, quality of life, and overall outcome.

This increasing concern about over-diagnosis has been addressed from other parts of the world. For example from Australia, where there was a rapid increase in the diagnosis of thyroid cancer. A study was carried out in Queensland, and the authors reported that the age-standardized incidence increased from 2.2/100,000 to 10.6/100,000 between 1982 and 2008. The increase was true for both early stage and advanced cancers, though the rise in incidence was higher for early-stage cancers. [4] Can it therefore be argued that this increase in early diagnosis rather than the late detection could be an advantage for the patients with thyroid cancer?

Undoubtedly, thyroid cancer is best diagnosed early. In addition, with current advances in thyroid surgery and radioiodine therapy, the prognosis of thyroid cancer when appropriately treated is very good. Despite that, thyroid cancer surgery, especially, radical total thyroidectomy does result in complications like hoarseness of voice and hypoparathyroidism, not to mention permanent hypothyroidism. Hence, there is a distinct reason to be concerned about the benefits and risks of treatment of thyroid cancer.

Little is understood about the true incidence and prevalence of thyroid cancer in India. Earlier, it was reported in India that the age-adjusted incidence rates of thyroid cancer per 100,000 are about 1 for males and 1.8 for females, and that the commonest type of thyroid cancer is papillary thyroid cancer, followed by follicular thyroid cancer. [5],[6] The report about prevalence of thyroid malignancy in India comes from the eight city study that focused on the prevalence of thyroid dysfunction. About 0.1% of subjects from this study gave a history of thyroid malignancy. [7] As expected in a disease which is treated with a favorable outcome/survival, prevalence rates of present or past disease are higher than the incidence. More studies are needed from India, as both these reports have limitations. However, this clearly indicates that the problem of thyroid cancers in India (with an incident rate of 1-1.8 per 100,000) is grossly underestimated when compared to that in Australia (incidence 10.6/100,000 population) and Korea (incidence 70 per 100,000 population). Therefore, is it likely that in India, problem of thyroid cancer need not necessarily be that of over diagnosis but rather of under-diagnosis. Additionally, these clinical studies from Republic of Korea and Australia may not necessarily be applicable to the Indian settings. For example, it has been reported that the outcomes of treatment are poorer in iodine deficient regions due to higher prevalence of undifferentiated cancers in these areas. [8]

Hence, the makers of clinical guidelines now have to walk a thin line that avoids over-diagnosis, at the same time avoids the perils of under-diagnosis. Rather than focusing on genetic preoperative diagnosis; especially in a country where it is difficult to even implement ultrasound-guided fine-needle aspiration cytology in all cases of thyroid nodules, it is important to generate an India-specific data of the present scenario. It is also prudent to develop a country-specific approach to the management of commonly encountered subsets of thyroid malignancy. The papillary thyroid microcarcinoma is for instance, a case in point. While thyroid lobectomy/hemithyroidectomy is advised in recommendations by American Thyroid Association for small, low-risk, isolated, intrathyroidal papillary carcinomas in the absence of cervical nodal metastases, [9] if a multifocal carcinoma is diagnosed, would that not require completion thyroidectomy? [10] On the other hand, given that some papillary thyroid microcarcinomas, especially those harboring mutations, could be more rapidly progressive, these lesions arguably need a more aggressive management approach. Preoperative genetic testing has been shown to be effective. [11] However, genetic testing being expensive, it can hardly be considered a routine option in a developing country like India.

What then, is the correct diagnostic approach in India? Well, the obvious answer is that more data is required. A nationwide study on the clinical features and prognosis of thyroid cancer in India is important. A similar study has been carried out in chronic pancreatitis, another puzzling and mysterious disease; and this clarified many aspects of the disease among Indians. [12] Also, it is important to undertake population studies that ascertain the true incidence and prevalence of thyroid cancer in India. There have been past attempts to write consensus statements on management of thyroid nodules in India. [13] The future efforts to form guidelines to tackle the issue of thyroid malignancy should weigh the benefit of a favorable prognosis from early diagnosis and treatment with the risk of causing a physical, psychological, and financial burden from unnecessary screening. The time is ripe to take this work forward to the next level and to collaboratively work for the betterment of subjects affected with, or those at risk of thyroid cancers in India.

 
  References Top

1.
Kim TY, Kim WG, Kim WB, Shong YK. Current status and future perspectives in differentiated thyroid cancer. Endocrinol Metab (Seoul) 2014;29:217-25.  Back to cited text no. 1
    
2.
Chidiac RM, Aron DC. Incidentalomas. A disease of modern technology. Endocrinol Metab Clin North Am 1997;26:233-53.  Back to cited text no. 2
    
3.
Ahn HS, Kim HJ, Welch HG. Korea's thyroid-cancer "epidemic"- -screening and overdiagnosis. N Engl J Med 2014;371:1765-7.  Back to cited text no. 3
    
4.
Pandeya N, McLeod DS, Balasubramaniam K, Baade PD, Youl PH, Bain CJ, et al. Increasing thyroid cancer incidence in Queensland, Australia 1982-2008 - true increase or overdiagnosis? Clin Endocrinol (Oxf) 2015.  Back to cited text no. 4
    
5.
Gangadharan P, Nair MK, Pradeep VM. Thyroid cancer in Kerala. In: Shah AH, Samuel AM, Rao RS, editors. Thyroid Cancer- An Indian Perspective. Mumbai: Quest Publications; 1999. p. 17-32.  Back to cited text no. 5
    
6.
Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15:S78-81.  Back to cited text no. 6
    
7.
Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian J Endocrinol Metab 2013;17:647-52.  Back to cited text no. 7
    
8.
Schneider AB, Ron E. Carcinoma of the follicular epithelium. Epidemiology and Pathogenesis. In: Braverman LE, Utiger RD, editors. Werner and Ingbar's The Thyroid: A fundamental and Clinical Text. 9 th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 889-926.  Back to cited text no. 8
    
9.
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. American Thyroid Association Guidelines Taskforce. Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Taskforce. Thyroid 2006;16:109-42.  Back to cited text no. 9
    
10.
Unnikrishnan AG, Detroja NM, Bharath R, Jayakumar RV, Kumar H. The "hemi-uncertainty" of papillary microcarcinoma of the thyroid. Thyroid Res Pract 2008;5:3-5.  Back to cited text no. 10
  Medknow Journal  
11.
Alexander EK, Kennedy GC, Baloch ZW, Cibas ES, Chudova D, Diggans J, et al. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med 2012;367:705-15.  Back to cited text no. 11
    
12.
Balakrishnan V, Unnikrishnan AG, Thomas V, Choudhuri G, Veeraraju P, Singh SP, et al. Chronic pancreatitis. A prospective nationwide study of 1,086 subjects from India. JOP 2008;9:593-600.  Back to cited text no. 12
    
13.
Unnikrishnan AG, Kalra S, Baruah M, Nair G, Nair V, Bantwal G, et al. Endocrine Society of India management guidelines for patients with thyroid nodules: A position statement. Indian J Endocrinol Metab 2011;15:2-8.  Back to cited text no. 13
    




 

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