Thyroid Cancer Epidemic of Overdiagnosis
The last 40 years have shown triple the incidence of thyroid cancer in women, yet the mortality rate has remained the same. Why are physicians so quick to diagnose women with thyroid cancer?
American Idol Alum Jax Cole
The American Idol finalist Alum Jax Cole announced that she underwent thyroid surgery in April after discovering a “lump in her neck”. She is now receiving radiation treatments, presumably radioactive iodine (I-131), after the finding of thyroid cancer at surgery.(1-3)
An Epidemic of Overdiagnosis of Thyroid Cancer In Women
According to Dr Gilbert Welch in 2014 Otolaryngology, there is an epidemic of overdiagnosis of thyroid cancer in young women.(4)
Since 1975, the incidence of thyroid cancer in women has more than tripled from 6.5 to 21.4 per 100,000 women, mostly from papillary cancer.
However, the “mortality rate from thyroid cancer was stable between 1975 and 2009 (approximately 0.5 deaths per 100 000).”
In other words, mortality from thyroid cancer did not increase, even though the incidence tripled. If this was real cancer, one would expect increase in mortality numbers. There was none.
Dr Welch concludes:
“There is an ongoing epidemic of thyroid cancer in the United States. The epidemiology of the increased incidence, however, suggests that it is not an epidemic of disease but rather an epidemic of diagnosis. The problem is particularly acute for women, who have lower autopsy prevalence of thyroid cancer than men but higher cancer detection rates by a 3:1 ratio.”
Above Chart shows thyroid cancer rising incidence females (GREEN Arrow), while thyroid cancer mortality is unchanged (flat line RED Arrow). Chart courtesy of Davies, Louise, and H. Gilbert Welch. (4) “Current thyroid cancer trends in the United States.” JAMA Otolaryngology–Head & Neck Surgery 140.4 (2014): 317-322.
Dr Robert Udelsman reported in Thyroid 2014, on”The Epidemic of Thyroid Cancer in the United States”. (16) He says:
“The increased detection of thyroid cancer results in surgery and radioactive thyroid treatment that may be of limited benefit.”
“The autopsy prevalence rate of occult thyroid cancer in the Finnish population is 35.6%, suggesting that thyroid cancer is both common and clinically insignificant for the vast majority of individuals”
“It is likely that the majority of diagnosed thyroid cancer patients will not benefit from surgical and/or adjuvant interventions. “
Pathologists: Many Thyroid Cancers Should be Reclassified
Dr Nikiforov writes in JAMA Oncology 2016 that many thyroid cancers are really not cancer and should be reclassified.(6) An example is the encapsulated follicular variant of papillary thyroid carcinoma. These cases are treated as having conventional thyroid cancer, yet they are not really cancer, Dr Nikiforov says this type of pathology does not require radioactive iodine after surgery.
In 2016, Dr Lester Thompson reviews 94 cases of thyroid cancer with the pathology diagnosis of “Encapsulated follicular papillary thyroid carcinoma”. (17) Because of the indolent nature, they recommended changing the pathology classification to “Noninvasive Follicular Thyroid Neoplasm” Dr Lester Thompson went on to say: These are “exceedingly indolent tumors, best managed conservatively by lobectomy or thyroidectomy alone, without radioablative iodine or suppression therapy.”(17)
Thyroid Cancer: What are the Drivers of Overdiagnosis:
1) Advent of High Resolution Ultrasound imaging and thyroid screening programs which detect ever smaller “abnormalities”.
2) Commercial and professional vested interests. Hospitals make more money if they do more thyroid biopsies, thyroidectomies, and radioactive iodine treatments. Thyroidectomy creates a patient on thyroid medicine for life.
3) Conflicted panels such as the American Thyroid Association, and the Endocrine Society write guidelines that expand disease definitions and encourage overdiagnosis.
4) Malpractice Litigation punishes underdiagnosis but not overdiagnosis.
5) Health system incentives encourage more testing and more treatment.
6) Cultural beliefs that more is better; faith in early detection unmodified by its risks. (12) Paraphrased from Ray Moynihan. “Preventing overdiagnosis how to stop harming the healthy .” Bmj (2012).
Medical Iatrogenesis in Women
Dr. Adriane Fugh-Berman states very clearly, “there is a tradition in U.S. medicine of excessive medical and surgical interventions on women”.(14)
Over-Diagnosis of “Hysteria” in Women.
Perhaps one of the early examples of medical iatrogenesis in women occurred in the 1800’s in Paris with the over-diagnosis of “Hysteria” by Dr Charcot Dr. Martin Charcot of the Paris hospital La Salpetriere diagnosed, ten “Hysterical” women each day, The number of women diagnosed as “Hysteria” increased 17-fold from from 1% in 1841 to 17% in 1883.(13,14)
A more recent historical example of medical iatrogenesis in women is the 1938 story of DES (Diethylstilbestrol) the first synthetic hormone replacement drug. This carcinogenic monster hormone was approved by the FDA and given to millions of women from 1940 until it was banned in 1975 because it was shown carcinogenic. The first report of cervical cancer in the daughters of DES treated women was published in April 1971 in the New England Journal of Medicine.(15)
Our next example of medical iatrogenesis in women is Premarin, a horse estrogen isolated from the urine of pregnant horses. Available since FDA approval in 1942, Premarin has caused an estimated 15,000 cases of endometrial cancer, representing the largest epidemic of serious iatrogenic disease ever reported.(15) One might think this would be the end of any drug. However Premarin was promptly rehabilitated with the addition of another synthetic hormone, a progestin, to prevent endometrial cancer. Thus, in 1995, Prempro was born, a synthetic hormone pill containing both Premarin (the horse estrogen) and Provera (the progestin). Again, this was FDA approved, thought safe and handed out freely to millions of women.
Our next example of medical iatrogenesis in women is Prempro , the combination of Premarin with Provera (medroxyprogersterone) found to cause breast cancer and heart disease. Four large scale studies showed increased breast cancer and heart disease from this estrogen-progestin combination pill. The Breast Cancer Detection Demonstration Project, published in 2000, showed an eight fold increase in breast cancer for estrogen-progestin users.(15) The Swedish Record Review, published in 1996, had a fourfold increase in breast cancer with progestin use.(15) The Million Woman study, published in Lancet in 2003, had a fourfold increase in breast cancer for estrogen-progestin combination users compared to estrogen alone users.(15) Finally in 2002, JAMA published the Women’s Health Initiative (WHI), an NIH funded study terminated early because of increased breast cancer and heart disease in the estrogen-progestin users.(15) Incredibly, the medical system is still dispensing this discredited drug to women.
SSRI Antidepressants Shown to be No More Effective Than Placebo
The next example medial iatrogeneiss in women is SSRI antidepressant drugs that were shown to have little benefit for patients with mild to moderate depression. The benefits of SSRI drugs are equivalent to placebo pills.(15). Adverse side effects include sexual dysfunction, movement disorders, increased suicidality, mania and violence and withdrawal effects. In spite of this, the discredited SSRI drugs are still being dispensed freely to millions of women.
Mistreatment of Women by the Medical System – Excessive Hysterectomies
The National Women’s Health Network has written extensively on the overuse of hysterectomies. Ernst Bartsich, M.D., a surgeon at Cornell in New York. says ” Of the 617,000 hysterectomies performed annually, “from 76 to 85 percent” may be unnecessary. “(CNN) Thus representing another example of mistreatment of women by the medical system.(15)
More Discredited Treatments Used on Women:
Radical Mastectomy: A disfiguring operation which provided no benefit compared to lesser procedures such as lumpectomy.
Bone Marrow Transplantation for Breast Cancer: Which was abandoned when studies showed it offered no benefit.(Welch BMJ 2002)
Kyphoplasty for Osteoporotic Fracture: Was discredited when studies found no benefit compared to a sham procedure
Arthroscopy for Osteoarthritis: Was abandoned after studies found no benefit compared to conservative treatment.
Screening mammograms: For under 50 age women offers more harm than benefit.
Drs Welch, Udelsman, Nikiforov and Moynihan have come forward to alert the public to the “Epidemic of Overdiagnosis of Thyroid Cancer”, a form of medical iatrogenesis in young women. Since Alum Jax Cole’s pathology report was not made public, we don’t know if her particular case was overdiagnosis.
Based on the epidemiology data alone, many young women with thyroid cancer are overdiagnosed. How many? For every 43 women diagnosed with thyroid cancer, one (2.3%) will die from metastatic thyroid cancer, and the other 42 (97.7%) will eventually die from other causes. About 1,070 women die from thyroid cancer annually. This number has not changed over 30 years in spite of aggressive detection and treatment. For comparison, about 41,000 women die from breast cancer annually.
Update August 2016: Autopsy studies do not mirror the increasing incidence of thyroid cancer, again indicating a problem with overdiagnosis (23):
“the observed increasing incidence (of thyroid cancer) is not mirrored by prevalence within autopsy studies and, therefore, is unlikely to reflect a true population-level increase in tumorigenesis. This strongly suggests that the current increasing incidence of iDTC most likely reflects diagnostic detection increasing over time. ” (23) by L. Furuya-Kanamori, Prevalence of Differentiated Thyroid Cancer in Autopsy Studies Over Six Decades: A Meta-Analysis. Journal of Clinical Oncology, 2016.