Thyroid Screening: ThyCa’s Comments on the USPSTF Draft Recommendations

(Background Note: In November 2016, the United States Preventive Services Task Force (USPSTF) issued a draft statement that recommended against thyroid screening through palpation or ultrasound.  USPSTF invited comments from the public through December 26, 2016.) 

December 23, 2016 

From: Gary Bloom, Executive Director. ThyCa: Thyroid Cancer Survivors’ Association, Inc. www.thyca.org

Thank you for the opportunity to comment on your draft statement. 

ThyCa: Thyroid Cancer Survivors’ Association, Inc. strongly disagrees with the USPSTF recommendation against palpation to screen for thyroid nodules. ThyCa agrees with USPSTF on ultrasounds. 

ThyCa urges neck palpation for all patients for the following reasons: 

1. Thyroid cancer usually has no symptoms until it is very advanced at which time it is either difficult or impossible to treat successfully. Also, very few people have a history of high radiation exposure or family members with thyroid cancer. Therefore, early detection is crucial for saving the lives of patients who have medullary, anaplastic, and aggressive variants of papillary and follicular thyroid cancer. 

2. Palpation/neck check is quick to do, using only the fingers as part of a regular appointment. It does not require special equipment. There is no additional cost to performing palpation. Nodules larger than 1 - 1.5 centimeters can be further analyzed to determine if cancer is present, and what type it is. 

3. USPSTF’s recommendation against palpation means that very few patients will be diagnosed at an early stage with any type of thyroid cancer when cancer is more treatable, should active treatment be necessary.

4. USPSTF’s draft and background report barely mention medullary, anaplastic, and aggressive variants of papillary and follicular thyroid cancer, instead focusing mainly on highly treatable papillary thyroid cancer.

5. The few treatments available for either high-risk or advanced metastatic thyroid cancers measure progression-free disease time rather than cure. This is different from other cancers, where multiple treatment choices are available. This lack of effective treatments makes early detection more critical in thyroid cancer, as the only way to save the lives of most of those who currently die of this disease.

6. Finding a nodule does not mean that treatment will always follow. The next step is to determine whether cancer is present, and, if so, what type. Following diagnosis, a decision can be made whether or not active treatment is needed. However, the USPSTF draft and background document focused far more on treatment than on the diagnostic step.

7. The Academy of General Dentistry currently recommends neck exams. These also find conditions other than thyroid nodules 

8. The USPSTF statement about mortality is incorrect, for several reasons.  

a. It uses a rounded off death rate (0.5).
b. It adds the adjective “about.”
c. It does not discuss why the thyroid cancer mortality rate is not declining, while many other cancers have declining mortality rates.
d. Most importantly, it omitted sources that explain that the death rate from thyroid cancer has actually increased in recent years in the United States. Deaths have increased faster than the population increase. The National Cancer Institute noted that mortality from thyroid cancer rose 0.8 % per year from 2002 to 2011.   

Similarly, in 2015 Dana Farber Cancer Institute reported that “the mortality rate appears flat mainly because it was charted over a relatively long time – 35 years. Had it covered just the last 10 years, critics say, it would show that the death rate from thyroid disease is increasing faster than any other cancer except liver cancer.”

9. The USPSTF draft and background document acknowledge the limitations of the available research, and acknowledge that there is “inadequate evidence to assess the harms of screening.” 

It is surprising that USPSTF would oppose palpation without proposing an alternative effective way to save lives. 

We urge USPSTF to recommend palpation.