Thyroid cancer overdiagnoses, cameras in the operating room, and a research agenda for overuse

September 3, 2015

In order to bring you more of the news you want to read, RightCare Weekly summarizes and interprets three important articles and provides headlines linking to the many other articles and editorials you’ll find interesting. As always, RightCare Weekly presents articles related to moving our healthcare system toward the right care for all patients.

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The incidence of thyroid cancer, now the ninth most common cancer in the United States, has surged while mortality from this cancer remains unchanged. What gives? In a Medscape interview, R. Michael Tuttle, MD, from Sloan Kettering Cancer Center, says the cancer is being over-diagnosed and smaller cancers are being detected and treated. “…Much of what we are diagnosing is not clinically relevant at all—the vast majority of these thyroid nodules would have stayed small for 100 years without any intervention,” he explained. Ultrasounds and fine needle aspiration biopsies are finding early, small nodule disease, Tuttle said. New guidelines expected soon from the American Thyroid Association may recommend against biopsying smaller nodules; only repeat ultrasounds may be recommended in its place. Surgical interventions are not without risk; they can damage nerves, the vocal cord or the parathyroid, he warns.  In a commentary written earlier this year for the Lown Institute, Korean physician Sang Won Shin, MD, reports that thyroid cancer is the most common cancer in his country, comprising 30 percent of all cancers and primarily found by an abundance of ultrasonography screening and a popular mistaken belief that detecting early thyroid cancer will save lives. “As we see the incidence of thyroid cancer rising in other parts of the globe, without declining mortality,” he wrote, “it should be regarded as a serious warning signal of worldwide overuse of medical technology.” Addendum: In an update received today, Shin reports that recent news accounts are reporting that thyroid surgeries in Korea have dropped about 20-30 percent since he wrote the commentary, but there have been no changes in screening policies or recommendations.


Preventable medical errors often leave patients and their families wondering what exactly transpired. Tom Jackman in The Washington Post explains that the process of piecing together what went wrong in an operating room relies on the memories of those involved and whatever notes were taken during the procedure or shortly thereafter. Wade Ayer, founder of the National Organization for Medical Malpractice Victims, and others champion video recording in operating rooms as a potential solution. Proponents tout recording surgeries as a way to capture the reasons behind adverse events and deter bad behavior by clinicians—a mechanism that “offers transparency, truth and accuracy,” says Ayer. Some surgeons are also on board, arguing that recording surgeries will help them to reflect critically on operations and improve their performance. While patients and clinicians agree that transparency is crucial, there are concerns that providing data to patients might have unintended negative consequences. Lisa Rosenbaum, MD, in the New England Journal of Medicine, weighs in on ProPublica’s recent surgeon scorecard and transparency, warning: “No amount of transparency can overcome the fact that, when it comes to value, we don’t all see eye to eye. The real promise of transparency… lies in finding better ways to let our patients see what we see.”


This week in The BMJ, Shannon Brownlee, MSc, Vikas Saini, MD and Adam Elshaug, MPH, PhD, from the Lown Institute, as well as seven others, propose an agenda for coordinated research to improve understanding of medical overuse. Their paper, Setting a Research Agenda for Medical Overuse, indicates significant gaps in knowledge about the scope, causes and consequences of overuse. The authors advocate standardizing terms for overdiagnosis and overtreatment to help build awareness, developing public agencies to monitor overuse and harm to patients, and improved comprehension of overuse by review and guidelines panels. “With concerted research efforts, the coming years could greatly improve our knowledge of overuse to maximize the benefits of medical care,” the authors concluded. Brownlee presented on the paper, along with two of the co-authors, at the Preventing Overdiagnosis Conference in Washington, DC on Tuesday.




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