May 11, 2017

Routine screenings for thyroid cancer do more harm than good, USPSTF says

Daily Briefing

    The U.S. Preventive Services Task Force (USPSTF) has issued new guidance against thyroid cancer screenings for low-risk, asymptomatic adults, stating that the potential risks of the screenings outweigh the benefits.

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    The recommendation updates the panel's 1996 guidelines, which provided similar guidance.

    USPSTF recommendation

    USPSTF gave thyroid cancer screenings a "D" recommendation, saying the harms of screening low-risk, asymptomatic patients for thyroid cancer generally outweigh the benefits. The "D" recommendation discourages the use of screening with either neck palpation or ultrasonography in this patient population, MedPage Today reports.

    In its guidance, the panel explained that thyroid cancer treatments typically involve "surgery with or without radioactive iodine therapy." But, they wrote, currently there are no studies examining the "benefit of finding and treating thyroid cancer in people with no symptoms."

    The panel said that the harms posed by screening and treatment are "at least moderate," citing "adequate evidence of harms of treatment and indirect evidence that overdiagnosis and overtreatment are likely to be substantial with population-based screening."

    The task force also cited evidence from studies showing the rate of thyroid cancer diagnoses have increased by roughly 4.5 percent over the past ten years, faster than any other type of cancer, but the mortality rate has stayed roughly the same. According to USPSTF, thyroid cancer patients have a very good five-year overall survival rate of 98.1 percent.

    As a result of the evidence, USPSTF said, the overall benefits of thyroid cancer screening and treatment are "small, given the relative rarity of thyroid cancer, the apparent lack of difference in outcomes between treatment and surveillance (for the most common tumor types), and observational evidence showing no change in mortality over time after introduction of a mass screening program."

    According to USPSTF, a patient should be concerned about thyroid cancer when symptoms present themselves. "As soon as somebody has symptoms, such as a swelling in the neck or change in their voice or swallowing, or pain in the neck … you're in a different ballpark," said Seth Landefeld, chair of the Department of Medicine at the University of Alabama, Birmingham and panel member. "You really want to sort those symptoms out."

    Editorials

    In an editorial accompanying the recommendation, Dartmouth University's Louise Davies and colleagues praised the guidance. "As physicians guided by the principle of 'first, do no harm,' we should be relieved that the USPSTF reached this conclusion," the authors wrote.

    They wrote that the likely benefit of a cancer screening must outweigh the potential harm. "In cancer screening, this means that the test should effectively detect cancers that would go on to cause morbidity or death and that are more treatable if found earlier," they wrote. "According to the USPSTF, thyroid cancer screening does not meet these requirements."

    In a separate editorial, Julie Ann Sosa of Duke University and colleagues wrote that while USPSTF acknowledges that its recommendation does not extend to asymptomatic high-risk patients—including those with a history of radiation exposure in childhood, or those with inherited genetic syndromes—that advice should be clearly stated in the recommendation.

    Sosa and colleagues also expressed concern that USPSTF's recommendation against neck palpitation as a screening tool could be overinterpreted, spurring some providers to exclude the practice as "an essential component" of routine clinical care for conditions beyond the thyroid. They recommended USPTF clarify that "neck palpation should remain a necessary pillar of a good physical examination"  (Bassett, Medpage Today, 5/9; Harris, "Shots," NPR, 5/9; Jin, JAMA, 5/9). 

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