New thyroid guidelines demonstrate why we need an independent USPSTF

Michael Joyce produces multimedia at HealthNewsReview.org and tweets as @mlmjoyce

The incidence of thyroid cancer has increased nearly 5 percent per year over the past decade, but the mortality from thyroid cancer has barely budged for nearly 40 years.

thyroid screeningThis suggests that identifying more cases of thyroid cancer hasn’t improved the health of the American public, an impression confirmed yesterday in new guidelines issued by the US Preventive Services Task Force (USPSTF) — an independent, volunteer panel of experts in prevention and evidence-based medicine — which recommended against the routine screening for thyroid cancer in adults without signs or symptoms

This was a so-called “D” rating which means the panel maintains a moderate to high degree of certainty that such screening has no benefit, or that the potential harms clearly outweigh the benefits.

H. Gilbert Welch MD

The recommendation was published in this week’s Journal of the American Medical Association, or JAMA.

I almost didn’t write about this. It’s no secret that thyroid cancer is being overdiagnosed. Journalists have been covering this issue for years.

But there were two things I didn’t know.

And they were brought to my attention in a compelling editorial (by Dr. Gilbert Welch, Dartmouth Institute for Health Policy and Clinical Practice) that accompanied the USPSTF recommendations in JAMA.

Screen the healthy & get special interests into the USPSTF?

First, is his explanation of why there might have been such a steep climb in the rate of thyroid cancer detection — a faster climb, by the way, than any other cancer over the past decade. It’s not so much the incidental finding of thyroid abnormalities while doctors were scanning the neck for other problems; although this certainly may have played a role.

From the “check your neck” campaign.

Rather, Welch points to a highly organized “check your neck” campaign by the Light of Life Foundation (we wrote about this 3 years ago). This thyroid cancer patient advocacy group receives strong financial support from drug companies who sell products related to thyroid cancer treatment. For them to advocate for screening of healthy individuals without symptoms of thyroid disease is highly suspect. It also may have been highly successful and had significant influence on over-screening.

And this dovetails nicely into Welch’s second point. He mentions a recent push to include specialty care physicians and “relevant stakeholders from the medical products manufacturing community” as part of the USPSTF. He sees this as a threat to the independent voice of the USPSTF. In the case of thyroid cancer …

“Would it really be helpful to include manufacturers of neck ultrasonographic equipment and thyroid replacement drugs in the evaluation of thyroid cancer screening?”

Welch sees this as an example of “regulatory capture”:

“The few parties with a high-stakes interest in policy decisions can be be expected to focus their resources in obtaining the recommendations they prefer, while the rest of us are less energized because we have only a tiny individual stake in the outcome …. and mass screening (like with thyroid cancer) certainly meets the prerequisite of having financial benefit concentrated among the few, while the costs and harms are spread across the many.”

This makes a strong case for why we need an independent USPSTF.

Dr. Aaron Carroll is the director of the Center for Health Policy and Professionalism Research, and a columnist for the New York Times. Here is what he wrote in his blog, The Incidental Economist, regarding the vital importance of the USPSTF:

“We so often act as if everything in medicine is an unequivocal benefit. That’s simply not the case. Everything has harms as well. Ideally the benefits outweigh the harms. Sometimes, however, that is not the case … how can we decide what works and what doesn’t? …  that’s why we need comparative effectiveness research. That’s why we need bodies like the USPSTF. Independent organizations made up of people who understand the research and can inform us how some things compare to others. They’re not perfect but they are transparent, accountable and public.”

Put another way: we need a group completely dedicated to making sure that how we screen for diseases is based on evidence, not profit margins.

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