Volume 213 - Issue 4
Estimating the magnitude of cancer overdiagnosis in Australia
Author: Diana L Learoyd
Med J Aust 2020; 213 (4): 189-189.e1. || doi: 10.5694/mja2.50575
Published online: 17 August 2020
Published online: 17 August 2020
To the Editor: The issue of cancer overdiagnosis highlighted by Glasziou and colleagues1 is not new. The problem lies in how clinicians translate caution into the care of individual patients.
In August 2019, non‐clinician epidemiologists, via the media, alarmed and confused many post‐menopausal women by reminding us that menopausal hormone therapy (MHT) mildly increases breast cancer risk.2 This was already known; breast cancer is common in post‐menopausal women, with or without a history of MHT use. Women taking MHT understandably comply with government‐recommended and funded screening mammography.3
Thyroid cancer overdiagnosis has been recognised for many years and is addressed in international evidence‐based management guidelines.4,5 The Royal Australasian College of Physicians has the EVOLVE program, endorsed by the Endocrine Society of Australia, to guide clinicians to order fewer thyroid ultrasounds.6 The adoption of thyroid ultrasound reporting systems such as TIRADS has already reduced the number of thyroid fine needle biopsies.7 Furthermore, active surveillance, rather than surgical intervention, is now advocated and supported by evidence for the management of small low risk thyroid cancers.5 Data from overseas show that older patients may accept surveillance over surgery, but younger patients demand intervention due to uncertainty about tumour behaviour. Active surveillance becomes expensive with time.8
Clinicians face anxious patients seeking guidance over mixed messages from the popular press. Genomics and better personalised medicine may eventually allow prognostication. For now, addressing clinical and family histories, physical examination, and appropriate investigations are done on a case‐by‐case basis. Thyroid cancer guidelines have already been adjusted and expanded to outline an individualised approach.
Competing interests
No relevant disclosures.
References
- Glasziou PP, Jones MA, Pathirana T, et al. Estimating the magnitude of cancer overdiagnosis in Australia. Med J Aust 2020; 212: 163–168. https://www.mja.com.au/journal/2020/212/4/estimating-magnitude-cancer-overdiagnosis-australia
- Beral V, Peto R, Pirie K, Reeves G. Menopausal hormone therapy and 20 year breast cancer mortality. Lancet 2019; 394: 1139.
- Australian Institute of Health and Welfare. Breast screen Australia monitoring report 2018 [Cancer series 112; Cat. No. CAN116]. Canberra: AIHW, 2018. https://www.aihw.gov.au/getmedia/c28cd408-de89-454f-9dd0-ee99e9163567/aihw-can-116.pdf.aspx?inline=true (viewed Mar 2020).
- Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016; 26: 1–133.
- McLeod DSA, Zhang L, Durante C, Cooper DS. Contemporary debates in adult papillary thyroid cancer management. Endocr Rev 2019; 40: 1481–1499.
- Royal Australasian College of Physicians, Endocrine Society of Australia. EVOLVE programme: top 5 low‐value practices and interventions — recommendation 1. RACP/ESA, 2017. https://evolve.edu.au/recommendations/esa (viewed Mar 2020).
- Grani G, Lamartina L, Ascoli V, et al. Reducing the number of unnecessary thyroid biopsies while improving diagnostic accuracy: toward the “right” TIRADS. J Clin Endocrinol Metab 2019; 104: 95–102.
- Lin JF, Jonker PKC, Cunich M, et al. Surgery alone for papillary thyroid microcarcinoma is less costly and more effective than long term active surveillance. Surgery 2020 Jan; 167: 110–116.