In 1999, the Korean government launched a nationwide medical screening program, which resulted in a 15-fold increase in the incidence of nail cancer, but no change in the death rate from nail cancer. Should early screening be continued without saving lives?
For most patients with microscopic cancer, observation and testing are the most appropriate means of management. But for another small percentage of patients, surgery is essential. The problem is that it is difficult to screen out intermediate and high-risk patients from the general patient population. Foreign countries advocate precise treatment of nail cancer, but at present, even standardized treatment cannot be done in China.
From 8:00 am onwards, thyroid cancer surgeries are performed one after another. It is another busy day for Gao Ming, director of the Thyroid Cancer Committee of China Anti-Cancer Association and vice president of Tianjin Cancer Hospital.
In this hospital, which has the largest volume of thyroid cancer (hereafter referred to as thyroid cancer) surgeries in China, the number of thyroid cancer surgeries reached 4,773 in 2014 alone. It is estimated that the number of surgeries this year will exceed 5,400.
”The prevalence is soaring, inpatients are increasing, and the number and weight of patients with malignant tumors is increasing.” Gao Ming lamented that in the late 1990s, the incidence rate of nail cancer was not even in the top ten compared with other malignant tumors, but nowadays, among the female groups in first and second-tier cities, the incidence rate of nail cancer is basically in the top three, and some have even jumped to the top of the list.
The thyroid gland, which looks like a butterfly, secretes hormones that are vital to the human body. When swallowing, it can move up and down with the larynx, just like a butterfly dancing. However, over the years, this “butterfly” has frequently flapped its wings, triggering widespread controversy in the medical community.
In 2010, the Endocrinology Branch of the Chinese Medical Association conducted an epidemiological survey of thyroid disease in 10 cities, including Beijing, Chengdu, Guangzhou, Guiyang, Jinan, Nanjing, Shanghai, Shenyang, Wuhan and Xi’an. The results showed that the prevalence of thyroid nodules was as high as 18.6%, of which 5-15% were malignant, i.e. thyroid cancer.
Is this phenomenon related to the iodized salt policy and the increased intake of iodine? Is this the result of over-screening of the thyroid gland? Is there currently over-treatment of thyroid cancer in China? Southern Weekend reporter went to different places and invited the most authoritative experts in this field in China to give answers.
There are reasons for the “epidemic” of nail cancer
”The increase in the frequency of examinations and the increase in the sensitivity of examination means are the most important reasons for the rising prevalence of nail cancer.” In the opinion of Teng Weiping, vice chairman of the Liaoning Provincial Committee of the Chinese People’s Political Consultative Conference and director of the Endocrinology Branch of the Chinese Medical Association, it would be more accurate to say that the detection rate has increased rather than the prevalence rate.
The thyroid gland is in the front of the human neck and on both sides of the trachea. In the past, most examinations were performed by palpation, and the chances of detecting thyroid lesions were not high due to the location and size of the nodules in the thyroid gland, the thickness of the patient’s neck, obesity, and the experience of the examiner. In fact, the rate of nail cancer has reached 6-23% in routine autopsies in the 1980s, but because the tumor was mild, the patient did not show significant clinical symptoms until death. With the advent of high-frequency ultrasound technology of the thyroid, tiny nodules of 1.5-2 mm in diameter can be easily detected.
However, the prevalence does not equate to the actual incidence. It is generally accepted in academia that the actual incidence of nail cancer has not increased, but the percentage of papillary nail cancer has increased from 70% to about 90% now. Teng Weiping pointed out that although no further epidemiological investigation of tumors has been done, the international mainstream view is that it may be related to increased iodine intake.
In 2009, the policy of “salt iodization” was caught in a whirlwind of controversy. Since then, the national authorities have revised the national salt iodization regulations and promulgated a new national standard for salt iodization. The new standard reduced the iodine content of salt and abandoned the “one-size-fits-all” national standard for iodized salt, authorizing provinces to float ±30% from the national standard based on local iodine resources.
”The relationship between excess iodine and thyroid nodules and nail cancer lacks convincing evidence-based medical evidence, although there are some epidemiological reports.” What has been conclusively proven is that iodine excess leads to a significant increase in thyroid autoimmunity and hypothyroidism, noted Teng Weiping.
In late December 2012, three obstetricians and gynecologists at the Union Hospital of Tongji Medical College of Huazhong University of Science and Technology were simultaneously diagnosed with thyroid cancer. Because the disease was associated with a personal history of radiation exposure, the three associate professors, who had worked in the same operating rooms for six years, ultimately blamed the disease on improper radiation protection measures in the two upstairs orthopedic operating rooms.
Each person’s chances of developing cancer vary, as does their individual constitution and sensitivity to radiation, and it is difficult to determine a necessary link between the two. Environmental pollution, excessive stress, hormone levels, obesity and diabetes can all be triggers for the development of nail cancer.
Should I turn off the ultrasound machine?
Advances in screening tools have made early detection of nail cancer possible. However, a paper in the New England Journal of Medicine, a leading international medical journal, has sparked a debate and reflection on “overdiagnosis”.
In 1999, the Korean government launched a nationwide medical screening program to reduce cancer and common diseases. The screening program did not include nail cancer screening, but because it required only a simple step, a neck ultrasound, doctors encouraged patients to participate and they were happy to do so.
The screening led to an unexpected result: in 20 years, the incidence of nail cancer increased 15 times, and this originally rare cancer became the most common cancer in Korea. However, there was no change in the mortality rate of nail cancer.
Complications did follow. After nail cancer surgery, about 10 percent of patients developed calcium metabolism problems, and 2 percent developed vocal cord paralysis.
”Overdiagnosis diverts medical resources and frightens patients. The biggest problem is that it spawns overtreatment.” Hilbert Welch, one of the article’s authors and a professor at Dartmouth College, questioned, “Should early screening continue when it’s not saving lives?”
Early screening and diagnosis allows the public to know their health status, and the overall benefits outweigh the harms, “The point is not to test, but to avoid non-essential testing whenever possible.”
Ultrasonography is necessary to confirm the diagnosis of thyroid nodules and is the preferred method of thyroid nodule diagnosis recommended by the American Thyroid Association and the European Thyroid Association. In the Domestic Guidelines for the Treatment of Thyroid Nodules and Differentiated Thyroid Cancer (hereinafter referred to as the Guidelines), “all patients with thyroid nodules should undergo ultrasound examination of the neck” is listed as level A, which means “highly recommended”.
However, Liu Chao found that some hospitals had to use CT imaging for nodules that could clearly be diagnosed with ultrasound. In some cases, excess iodine was used in the contrast agent, and the patient’s thyroid function was normal, but the unnecessary test induced hypothyroidism.
Such cases are not uncommon among the patients seen by Chao Liu. Overdiagnosis occurs not only in local hospitals in second and third-tier cities, but also in tertiary hospitals.
”We are in the same circle, and there are things I am embarrassed to say to patients.” Liu Chao said, but every time he receives such cases, he feels “especially painful”.
On the one hand, there is overdiagnosis, but on the other hand, the necessary diagnostic methods are limited.
Fine needle aspiration is the “gold standard” for determining the benignity and malignancy of thyroid nodules, and it is the most sensitive and specific diagnostic method, and has become a routine test for thyroid nodules abroad because it is less invasive, faster and more accurate. However, in China, due to the limitation of doctors’ cytopathological diagnosis level, fine needle aspiration is not yet popular, which leads many patients to undergo surgery before the nature of nodules is clear.
How many nail cancers are overtreated?
Overdiagnosis often spawns overtreatment.
For 30-year-old Meng Tong (a pseudonym), overtreatment turned her from a bright, beautiful woman with a successful career to a depressed, sick woman.
In August 2014, she visited a tertiary hospital in Shanghai for swollen and painful lymph in her neck, and an ultrasound examination revealed: thyroid nodules. Without exhausting detailed examination and differential diagnosis of benign and malignant, she was told: highly suspicious of malignant tumor, requiring surgery.
During the surgery, her bilateral thyroid glands were removed, which became the beginning of a nightmare. After the surgery, sequelae such as sluggishness, weakness, drowsiness, chest tightness, dyspnea, arrhythmia and endocrine disorder followed.
Her father brought her to another tertiary hospital in Shanghai, where the endocrinologist made it clear that the surgery was simply redundant. Given that the surgery had aggravated the hypothyroidism, the doctor judged that in addition to the lifelong medication, “it might not be possible to have another child in this life”. Devastated by this, Meng Tong gradually developed depressive symptoms and had to undergo psychiatric treatment.
”The key to overtreatment lies in the mastery of the indications for surgery.” Teng Weiping said, though he also implicitly pointed out the complexity of the problem, which “involves the financial interests of hospitals, doctors and doctor-patient disputes.”
According to a thyroid surgeon at a tertiary hospital in Guangdong, at district and county level hospitals, thyroid specialists are very lax in their grasp of surgical indications in order to maintain the number of patients in the department. Surgery is performed on patients without surgical indications, resulting in a significantly higher rate of non-essential thyroid nodule surgery. In fact, some thyroid nodules are multicentric and benign nodules, even when removed, can still recur later. Hidden nodules can also grow under the influence of thyroid stimulating hormones, and surgical intervention is completely unnecessary. In addition, if not performed properly, the surgery can damage areas such as the recurrent laryngeal nerve and parathyroid glands, causing unnecessary damage to the patient.
”Lumpectomy for thyroid disease has almost become a signature in China.” The doctor lamented that this technology is inferior to open surgery, both in terms of clearance scope and cost effectiveness, and is rarely carried out in Europe and the United States. But under the banner of “minimally invasive cosmetic” and with the many consumables required for the procedure, lumpectomy is “going crazy” in China.
Lu Hankui also admitted that from the cases he has received, overtreatment does exist in individual hospitals and doctors, but in his opinion, the word “overly aggressive” seems to be more appropriate, due to the digital performance assessment mechanism and the limitations of medical technology itself, “overly aggressive “Sometimes it is the helplessness of doctors under the current medical management system.
The aforementioned anonymous Guangdong doctor also reflected that in China, only a small percentage of particularly highly respected doctors dare to pat themselves on the back and say to patients, “No surgery is needed.” After all, in a tense doctor-patient situation, no doctor wants to incur unnecessary trouble because of a possible missed diagnosis.
The bias toward aggressive treatment is also motivated by the patient’s overwhelming anxiety.
Before surgery, each of Lu Hankui’s patients receives a “patient information sheet,” which begins not with obscure medical principles or textbook precautions, but with two simple sentences: “First of all, I hope you are not nervous, and I hope you are not afraid of radiation. “
Lu Hankui can feel the patients’ nervousness and fear. Almost every morning, he encounters patients who are crying, and patients who have been discharged from the hospital keep calling him. After thyroidectomy, you need to take medication for life, and some people feel uncomfortable as soon as they pick up the pills.
He sometimes sends patients a popular science brochure, but they don’t answer: “Dr. Lu, I’ll do whatever you say, but I don’t want to see the word ‘cancer’ in the brochure.”
Fear of cancer is not a “Chinese characteristic”; in 2014, Memorial Sloan-Kettering Cancer Center launched the Wait-and-See Program for thyroid cancer. Patients diagnosed with microscopic thyroid cancer can choose not to have it removed for now, but to have regular checkups.
However, patients did not “buy” into the program. Michael Tuttle, the program’s director, said that the program was not “well received” by patients. Michael Tuttle, head of the program, told Southern Weekend that there were few participants and doctors were worried about being sued by patients for missing the best time to treat them.
As a special expert of the China Health Education Center, Lu Hankui believes that the public should have a better understanding of thyroid disease as a whole and avoid panic about thyroid cancer; doctors should also communicate with patients accurately and effectively, rather than simply diagnosing and treating them. More importantly, it is important to establish a trustworthy database for thyroid disease diagnosis and treatment to lay a solid foundation for screening norms, treatment pathways, and individualized performance assessment of medical practices for thyroid disease.
Currently, domestic and international experts have agreed on the treatment of benign thyroid nodules: most can be withheld and a 6-12 month follow-up interval maintained. The controversy over overtreatment focuses on how to deal with malignant cancers less than 1 cm in diameter, i.e., microscopic cancers.
”Microscopic thyroid cancer is like a sage fruit that doesn’t grow into a tomato.” In an academic conference, an expert once said that microscopic cancer is a type of tumor with very low malignancy, which almost never leads to death and has a 10-year survival rate of 98%.
This image analogy also caused Gao Ming to think: Is microscopic cancer equal to low-risk cancer? Is it the same as early stage cancer? He has witnessed many cases of “small primary foci with large metastases”, and has seen many cases of microscopic cancer and invasion of the laryngeal nerve and tracheal adhesions that affect the prognosis of patients. He believes that for most microscopic cancer patients, early diagnosis is naturally a reasonable treatment; however, for some microscopic cancer patients, surgery is essential.
”The problem is not overtreatment, but our inability to screen out intermediate and high-risk patients from the general patient population.” Gao Ming said that under the leadership of the Thyroid Cancer Professional Committee, the Expert Consensus on the Treatment of Microscopic Papillary Thyroid Cancer in China is being formulated and is expected to be promulgated by the end of the year, “Strictly following the guidelines for scientific operation can reduce the overtreatment of microscopic cancer to a certain extent.”
How far is it from precision?
In 2014, Obama proposed “precision medicine” in his State of the Union address, which has become a new concept hotly debated in domestic medical circles.
”Now we can’t talk about precision treatment, because we haven’t even reached the level of standardized treatment.” Teng Weiping said bluntly.
In 2014, at the 3rd China Thyroid Surgery Summit Forum, “precision treatment” was listed as one of the six major directions of clinical basic research in thyroid disease. But Gao also stressed the importance of standardization, “standardization is the basis of precision.
Not long ago, he saw a patient with a thyroid hematoma. The patient reported being diagnosed with a thyroid nodule at “the best hospital for thyroid treatment” in China. The doctor did not specify the benignity or malignancy of the nodules, but simply stuck a needle in each of the three nodules, claiming that “acupuncture therapy” is less invasive, more effective, and leaves no scars. The three silver needles are expensive, requiring nearly 30,000 yuan for treatment. The doctor was not careful in sticking the needles in the thyroid gland, which in turn created a large hematoma.
Driven by curiosity, Gao Ming searched online for “the best hospital for thyroid cancer treatment in China”. He was full of confidence: Tianjin Cancer Hospital is the leading hospital in China, so it is not a problem to enter the top three, right? However, the search result made him dumbfounded, “How come we are not listed in the top five or six?”
He continued to search for “Tianjin Thyroid Hospital”, but still no trace. Gao Ming noticed that the top of the list were all unknown hospitals.
”The lack of standardized treatment, this must not be chaos?” Gao Ming is a little anxious, “I can pass on the standardized treatment experience to these doctors, but the network I can not manage ah!”
At present, from tertiary hospitals to county and township level primary hospitals, thyroid surgery has been commonly carried out. But for the huge number of doctors, the state does not have any qualification restrictions on access.
The treatment of thyroid disease involves surgery, endocrinology, nuclear medicine, imaging, pathology and many other departments, which is a typical interdisciplinary specialty. The academic background and clinical experience of doctors in different departments vary, and it is not uncommon to see a lack of understanding of the development of thyroid disease and a lack of standardized treatment.
Ideally, the establishment of thyroid specialties in each hospital, consisting of departments such as surgery, endocrinology and nuclear medicine, could solve the problem of standardization, but due to the complex administrative approval procedures involved, most hospitals in China, except for a few, are still fragmented in their various disciplines.
”It is imperative for each hospital to establish its own coordination mechanism for thyroid cancer treatment and receive systematic training on the Guidelines so that patients can enjoy standardized treatment.” Teng Weiping called for this.
In July 2015, in order to popularize the concept of standardized treatment and multidisciplinary treatment of thyroid cancer, the Thyroid Cancer Committee of China Anti-Cancer Association launched the “China Tour”. During the lecture tour, a slide show by Gao Ming caught the attention of participating doctors.
”He pointed to the Statue of Liberty on the slide, and underneath the right hand of the goddess, he typed eight words: “calm, scientific, standardized and precise. Calm, scientific, standardized, precise.”