Alum Jax Cole Thyroid Cancer Epidemic of Overdiagnosis

Alum Jax Cole American Idol_Thyroid_CancerAlum Jax Cole
Thyroid Cancer Epidemic of Overdiagnosis

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.”

Thyroid Cancer Incidence and Mortality_Jeffrey Dach MDAbove 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)

DES  Diethyl-Stilbestrol

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)

Premarin

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.

Prempro

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.

Conclusion:

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.

Articles with Related Interest:

The Thyroid Nodule Epidemic

Links and References

1) ‘American Idol’ Alum Jax Is Battling Thyroid Cancer
August 9, 2016 @ 10:20 AM By Nicholas Hautman

She went to a local urgent-care center, where doctors discovered 18 tumors on her thyroid — 12 of which tested positive for cancer — and diagnosed her with Hashimoto’s disease, a type of hypothyroidism.

2)  ‘American Idol’ Alum Jax Cole Diagnosed with Thyroid Cancer
Former “American Idol” contestant Jackie “Jax” Cole is battling thyroid cancer.

Cole revealed she was diagnosed with cancer in April and has already undergone surgery to remove her thyroid and nearby lymph nodes.

Despite hearing the diagnosis, Cole tried to make light of the situation. She said, “The first thing I did when I found out about the cancer was crack a joke.

3)  ‘American Idol’ finalist Jax says she has thyroid cancer
Jax was diagnosed in the spring and underwent surgery to remove the thyroid and several lymph nodes. The 20-year-old singer and songwriter from East Brunswick became chronically ill with respiratory and exhaustion issues during her journey on “American Idol.”

4)  JAMA Otolaryngol Head Neck Surg. 2014 Feb 20. doi: 10.1001/jamaoto.2014.1. [Epub ahead of print]
Current Thyroid Cancer Trends in the United States.
Davies L1, Welch HG2. IMPORTANCE We have previously reported on a doubling of thyroid cancer incidence-largely due to the detection of small papillary cancers. Because they are commonly found in people who have died of other causes, and because thyroid cancer mortality had been stable, we argued that the increased incidence represented overdiagnosis. OBJECTIVE To determine whether thyroid cancer incidence has stabilized. DESIGN Analysis of secular trends in patients diagnosed with thyroid cancer, 1975 to 2009, using the Surveillance, Epidemiology, and End Results (SEER) program and thyroid cancer mortality from the National Vital Statistics System. SETTING Nine SEER areas (SEER 9): Atlanta, Georgia; Connecticut; Detroit, Michigan; Hawaii; Iowa; New Mexico; San Francisco-Oakland, California; Seattle-Puget Sound, Washington; and Utah. PARTICIPANTS Men and women older than 18 years diagnosed as having a thyroid cancer between 1975 and 2009 who lived in the SEER 9 areas. INTERVENTIONS None. MAIN OUTCOMES AND MEASURES Thyroid cancer incidence, histologic type, tumor size, and patient mortality. RESULTS Since 1975, the incidence of thyroid cancer has now nearly tripled, from 4.9 to 14.3 per 100 000 individuals (absolute increase, 9.4 per 100 000; relative rate [RR], 2.9; 95% CI, 2.7-3.1). Virtually the entire increase was attributable to papillary thyroid cancer: from 3.4 to 12.5 per 100 000 (absolute increase, 9.1 per 100 000; RR, 3.7; 95% CI, 3.4-4.0). The absolute increase in thyroid cancer in women (from 6.5 to 21.4 = 14.9 per 100 000 women) was almost 4 times greater than that of men (from 3.1 to 6.9 = 3.8 per 100 000 men). The mortality rate from thyroid cancer was stable between 1975 and 2009 (approximately 0.5 deaths per 100 000). CONCLUSIONS AND RELEVANCE 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.

Feb 2014: Article by Welch in JAMA Otolaryngology .Since 1975, the incidence of thyroid cancer has now nearly tripled, from 5 to 15 per 100,000 population mostly from papillary thyroid cancer. The ongoing epidemic of thyroid cancer in the United States “is not an epidemic of disease but rather an epidemic of diagnosis. The problem is particularly acute for women,”

Thyroid cancer reclassified- Encapsulated given Benign Label

5) It’s Not Cancer: Doctors Reclassify a Thyroid Tumor The New York Times By GINA KOLATA APRIL 14, 2016,

6) Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma A Paradigm Shift to Reduce Overtreatment of Indolent Tumors Jama Oncology 2016   YE Nikiforov, RR Seethala, G Tallini

Importance Although growing evidence points to highly indolent behavior of encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC), most patients with EFVPTC are treated as having conventional thyroid cancer.

7) Editorials – Thyroid Nodules: Is It Time to Turn Off the US Machines? by John J. Cronan, MD June 2008 Radiology, 247, 602-604.

8)  Durante C, Costante G, Lucisano G, et al. The Natural History of Benign Thyroid Nodules. JAMA. 2015;313(9):926-935.

Conclusions and Relevance: Among patients with asymptomatic, sonographically or cytologically benign thyroid nodules, the majority of nodules exhibited no significant size increase during 5 years of follow-up and thyroid cancer was rare. These findings support consideration of revision of current guideline recommendations for follow-up of asymptomatic thyroid nodules.

9)  Hoang, Jenny K., Xuan V. Nguyen, and Louise Davies. “Overdiagnosis of thyroid cancer: answers to five key questions.” Academic radiology 22.8 (2015): 1024-1029.
Thyroid cancer fulfills the criteria for overdiagnosis by having a reservoir of indolent cancers and practice patterns leading to the diagnosis of incidental cancers from the reservoir. The occurrence of overdiagnosis is also supported by population-based data showing an alarming rise in thyroid cancer incidence without change in mortality. Because one of the activities leading to overdiagnosis is the workup of incidental thyroid nodules detected on imaging, it is critical that radiologists understand the issue of overdiagnosis and their role in the problem and solution. This article addresses 1) essential thyroid cancer facts, 2) the evidence supporting overdiagnosis, 3) the role of radiology in overdiagnosis, 4) harms of overdiagnosis, and 5) steps radiologists can take to minimize the problem.

10)   Hoang, Jenny K., and David Seidenwurm. “Caution Against Overinvestigation of Small Thyroid Nodules.” JAMA Otolaryngology–Head & Neck Surgery 142.1 (2016): 102-103.

11)   Brito, Juan P., et al. “Papillary lesions of indolent course: reducing the overdiagnosis of indolent papillary thyroid cancer and unnecessary treatment.” Future Oncology 10.1 (2014): 1-4.

12)  Moynihan, Ray, Jenny Doust, and David Henry. “Preventing overdiagnosis how to stop harming the healthy .” Bmj e3502 (2012).

Thyroid cancer :While the chances of tests detecting a thyroid “abnormality”
are high, the risk it will ever cause harm is low.3 27 Analysis of
rising incidence shows many of the newly diagnosed thyroid
cancers are the smaller and less aggressive forms not requiring
treatment,28 which itself carries the risk of damaged nerves and
long term medication.3

Drivers of overdiagnosis
• Technological changes detecting ever smaller “abnormalities”
• Commercial and professional vested interests
• Conflicted panels producing expanded disease definitions and writing guidelines
• Legal incentives that punish underdiagnosis but not overdiagnosis
• Health system incentives favouring more tests and treatments
• Cultural beliefs that more is better; faith in early detection unmodified by its risks

13) Fugh-Berman A.chapter in  Reader’s Companion to U.S. Women’s History. by Mankiller, Wilma Pearl. The reader’s companion to US women’s history. Houghton Mifflin Harcourt, 1999.

14) Death by Medicine Gary Null Praktikos Books, 2010

15) FDA Approval of PAxil for Menopausal Symptoms Medical Iatrogenesis in Women.

16)  The Epidemic of Thyroid Cancer in the United States: The Role of Endocrinologists and Ultrasounds
Thyroid. 2014 Mar 1; 24(3): 472–479.
Robert Udelsman corresponding author1 and Yawei Zhang2
Background: The incidence of thyroid cancer has increased at an alarming rate in both men and women in the United States. The etiology of this epidemic is unclear. We tested the hypothesis that a significant component of this epidemic is due to increased detection of occult disease. We examined whether the density of endocrinologists and general surgeons as well as employment of cervical ultrasonography were factors associated with this epidemic.
Methods: Thyroid cancer incidence rates by states were obtained from the United States Cancer Statistics 1999–2009 reported by the National Program of Cancer Registries. The densities of endocrinologists and general surgeons and the employment of cervical ultrasonography were calculated on a statewide basis and correlated with the incidence of thyroid cancer.
Results: Age-standardized incidence rates of thyroid cancer have increased in every state in the United States. Significant regional variations were noted, with the highest incidence rates in the northeast and the lowest in the south. The incidence rates were significantly correlated with the density of endocrinologists (r=0.58, p<0.0001 for males; r=0.44, p=0.0031 for females) and the employment of cervical ultrasonography (r=0.40, p=0.0091 for males; r=0.36, p=0.0197 for females). Both the density of endocrinologists and general surgeons and employment of cervical ultrasonography could explain 57% of the variability in state-level incidence for males and 49% for females.
Conclusions: These data offer evidence to suggest that the epidemic of thyroid cancer is due to increased detection of a reservoir of previously occult disease. The increased detection of thyroid cancer results in therapeutic interventions including surgery and radioactive thyroid treatment that may be of limited benefit.

17) Encapsulated follicular papillary thyroid carcinoma change to Noninvasive Follicular Thyroid Neoplasm Thompson Lester 2016

Thompson, Lester DR. “Ninety-four cases of encapsulated follicular variant of papillary thyroid carcinoma: A name change to Noninvasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features would help prevent overtreatment.” Modern Pathology 1 (2016): 10.

noninvasive follicular thyroid neoplasm with papillary-like nuclear features (formerly encapsulated follicular variant of papillary
thyroid carcinoma without invasion) are exceedingly indolent tumors, best managed conservatively by lobectomy or thyroidectomy alone, without radioablative iodine or suppression therapy.

18) Reclassified: From Thyroid Cancer to Good Cancer to Not Cancer
Dr Sarah Boston, Veterinary cancer surgeon and cancer survivor writes…

19)  Nikiforov, Y. E., et al. “Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: A Paradigm Shift to Reduce Overtreatment of Indolent Tumors.” JAMA oncology (2016).

20) Brito, Juan P., John C. Morris, and Victor M. Montori. “Thyroid cancer :zealous imaging has increased detection and treatment of low risk tumours ” (2013): f4706.

Charts

21) MANAGED CARE May 2014 Snapshot
Overdiagnosing Thyroid Cancer: What’s in a name?

22) Davies, Louise, and H. Gilbert Welch. “Current thyroid cancer trends in the United States.” JAMA Otolaryngology–Head & Neck Surgery 140.4 (2014): 317-322.

23)  L. Furuya-Kanamori, K. J. L. Bell, J. Clark, P. Glasziou, S. A. R. Doi. Prevalence of Differentiated Thyroid Cancer in Autopsy Studies Over Six Decades: A Meta-Analysis. Journal of Clinical Oncology, 2016;
Differentiated thyroid cancer (DTC) incidence has been reported to have increased three- to 15-fold in the past few decades. It is unclear whether this represents overdiagnosis or a true increase in incidence. Therefore, the current study aimed to estimate the prevalence of incidental DTC in published autopsy series and determine whether this prevalence has been increasing over time.
Conclusion The current study confirms that iDTC is common, but the observed increasing incidence 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.

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Jeffrey Dach MD
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Alum Jax Cole Thyroid Cancer Epidemic of Overdiagnosis
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Alum Jax Cole Thyroid Cancer Epidemic of Overdiagnosis
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Alum Jax Cole Thyroid Cancer Epidemic of Overdiagnosis
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Jeffrey Dach MD