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USPSTF Recommends Against Screening for Thyroid Cancer; ThyCa Disagrees on Neck Palpation

05/2017

The U.S. Preventive Services Task Force (USPSTF) recommends against ultrasound and neck palpation screening for thyroid cancer in adults without any signs or symptoms unless they are in a high-risk category. The Task Force report appears in the May 9 issue of JAMA, the Journal of the American Medical Association.

USPSTF said that this is a D recommendation, indicating that there is moderate or high certainty that screening has no net benefit or that the harms outweigh the benefits. 

ThyCa strongly disagrees with the recommendation against palpation, for two main reasons. 

Why ThyCa Disagrees

First, by the time there are signs and symptoms such as voice changes, breathing difficulties, or visible swelling in the neck, the thyroid cancer has progressed beyond the point where treatment can usually be successful.

For high-risk thyroid cancers like medullary, anaplastic, and aggressive variants of papillary and follicular thyroid cancer, detection needs to happen earlier, before there are signs and symptoms to allow for the best outcomes.

Also, after symptoms appear, it can take weeks or months to get the initial appointment for further checking, and the diagnostic process itself can also be lengthy. For high-risk thyroid cancers, both these factors can cause extensive delays before treatment. This time may be critical to the outcome for the patient.

Second, as noted in several sources, the death rate from thyroid cancer has steadily increased in recent years, contrary to the USPSTF statement that the mortality rate has not changed substantially. This contrasts with most cancers, for which mortality has steadily declined. 

The mortality increase was noted in some of the JAMA editorials that accompanied the USPSTF statement.

Thus, Anne R. Cappola, M.D., Sc.M., of the University of Pennsylvania, wrote, “Recent data from the Surveillance, Epidemiology, and End Results 9 cancer registry program focused on cancer stage at diagnosis and its relationship to mortality, and found an increase in thyroid cancer incidence–based mortality of approximately 1.1% per year. Both the incidence of advanced-stage papillary thyroid carcinoma and mortality among these individuals increased over time. These data would not be explained simply by overdiagnosis.” 

Julie Ann Sosa, M.D., M.A., of Duke University, added to this point in her editorial in JAMA Surgery, also on May 9, 2017. She wrote, “… the overall incidence of thyroid cancer has increased by 3% annually over the last 3 decades, with increases observed in both the incidence and mortality rates for advanced-stage papillary thyroid cancer (3.5% per year since 1981).”

“Overall incidence-based mortality for thyroid cancer from 1994 to 2013 substantially increased (1.1% per year), and it increased even faster for patients diagnosed with advanced-stage papillary thyroid cancer (2.9% per year). These findings are consistent with a true increase in the occurrence of thyroid cancer in the United States, expanding on the data reported by Chen et al in 2009 and challenging the prevailing hypothesis that overdiagnosis is the sole culprit for the changing epidemiology.”

More Reasons for Neck Palpation

Dr. Sosa, who is a ThyCa Medical Advisor, also pointed out that neck checks by palpation are important for finding other conditions in addition to thyroid nodules.

Dr. Sosa wrote, “… the recommendation against neck palpation as a screening tool for thyroid cancer could be overinterpreted by some clinicians as the USPSTF providing license to exclude examination of the neck as an essential component of routine clinical care and fastidious physical examination.”

“Palpation of the thyroid gland itself, along with the central and lateral compartments of the anterior neck, can provide important information about thyroid nodules, goiter, lymphadenopathy, bruits, thrills, and other findings that could have critical bearing on a litany of benign and malignant conditions that extend far beyond the thyroid.”

“Therefore, it would seem to be important to assert somewhere in the USPSTF statement that neck palpation should remain a necessary pillar of a good physical examination. In this vein, there is evidence that a good thyroid examination can be fairly easily taught and that it correlates rather well with ultrasonography for estimation of thyroid gland size.”

For all these reasons, ThyCa continues to urge people to ask for neck checks at their regular medical appointments. A neck check by palpation is different from screening by ultrasound. ThyCa agrees that neck ultrasounds should not be routine. A neck check needs only the fingers of a trained medical professional, not any special equipment, and is quick and easy to do. 

For Further Reading

ThyCa’s website will add more information. Here are some sources for further reading.