Louise Davies

Current Thyroid Cancer Trends in the United States

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.

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasises the reporting of three key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognising that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

Epidemiology of head and neck cancer in the United States.

Background Cancer rates of the head and neck are traditionally linked to public health issues. Objective To describe the epidemiology of head and neck cancer in the United States. Design and Setting National Cancer Institutes Surveillance Epidemiology and End Results (SEER) program. RESULTS: A total of 75,000 cases of head and neck cancer were diagnosed in 2001. Incidence is rising in thyroid (up 52%), bone (43%) soft tissues (20%), salivary (20%), tongue (16%), tonsil (12%), and nose (12%). Incidence is falling in lip (down 58%), hypopharynx (35%), cervical esophagus (32%), oropharyngeal mucosa (26%), and larynx (26%). There were 30,000 deaths from head and neck cancer in 2001. Mortality has decreased to some degree at all sites except thyroid where it was stable. Conclusion Many head and neck cancers have changing incidence and mortality rates contrary to expected changes given trends in public health issues. Further investigation of risk factors, diagnostic practices, and management strategies is warranted. EBM rating: 2C

The Increasing Incidence of Thyroid Cancer: The Influence of Access to Care

BACKGROUND The rapidly rising incidence of papillary thyroid cancer may be due to overdiagnosis of a reservoir of subclinical disease. To conclude that overdiagnosis is occurring, evidence for an association between access to health care and the incidence of cancer is necessary. METHODS We used Surveillance, Epidemiology, and End Results (SEER) data to examine U.S. papillary thyroid cancer incidence trends in Medicare-age and non-Medicare-age cohorts over three decades. We performed an ecologic analysis across 497 U.S. counties, examining the association of nine county-level socioeconomic markers of health care access and the incidence of papillary thyroid cancer. RESULTS Papillary thyroid cancer incidence is rising most rapidly in Americans over age 65 years (annual percentage change, 8.8%), who have broad health insurance coverage through Medicare. Among those under 65, in whom health insurance coverage is not universal, the rate of increase has been slower (annual percentage change, 6.4%). Over three decades, the mortality rate from thyroid cancer has not changed. Across U.S. counties, incidence ranged widely, from 0 to 29.7 per 100,000. County papillary thyroid cancer incidence was significantly correlated with all nine sociodemographic markers of health care access: it was positively correlated with rates of college education, white-collar employment, and family income; and negatively correlated with the percentage of residents who were uninsured, in poverty, unemployed, of nonwhite ethnicity, non-English speaking, and lacking high school education. CONCLUSION Markers for higher levels of health care access, both sociodemographic and age-based, are associated with higher papillary thyroid cancer incidence rates. More papillary thyroid cancers are diagnosed among populations with wider access to healthcare. Despite the threefold increase in incidence over three decades, the mortality rate remains unchanged. Together with the large subclinical reservoir of occult papillary thyroid cancers, these data provide supportive evidence for the widespread overdiagnosis of this entity.

Thyroid Cancer Survival in the United States: Observational Data From 1973 to 2005

OBJECTIVE To compare the survival rate of people with papillary thyroid cancer limited to the thyroid gland who have not had immediate, definitive treatment for their thyroid cancer with the survival rate of those who have had such treatment. DESIGN Cohort study of incident cancer cases and initial treatment data from the National Cancer Institutes Surveillance, Epidemiology, and End Results (SEER) program. Data on cause of death was taken from the National Vital Statistics System. PATIENTS Patients with papillary thyroid cancer limited to the thyroid gland. MAIN OUTCOME MEASURE Cancer-specific survival. RESULTS Of all eligible people in the data (n = 35,663), 1.2% did not undergo immediate, definitive treatment (n = 440). The life table estimate of their 20-year cancer-specific survival rate was 97% (95% confidence interval [CI], 96%-100%). The corresponding estimate for the patients who did receive treatment was 99% (95% CI, 93%-100%). Among those who did not receive immediate, definitive treatment, 6 died from their cancer. This number is not statistically different from the number of thyroid cancer deaths in the treated group over the same period (n = 161) (P = .09). CONCLUSION Papillary thyroid cancers of any size that are limited to the thyroid gland (no extraglandular extension or lymph node metastases at presentation) have favorable outcomes whether or not they are treated in the first year after diagnosis and whether they are treated by hemithyroidectomy or total thyroidectomy.

The increasing incidence of small thyroid cancers: where are the cases coming from?

To identify the trigger events that lead to the detection of otherwise asymptomatic thyroid cancers.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY DISEASE STATE CLINICAL REVIEW: THE INCREASING INCIDENCE OF THYROID CANCER.

OBJECTIVE (1) Describe current epidemiology of thyroid cancer in the United States; (2) evaluate hypothesized causes of the increased incidence of thyroid cancer; and (3) suggest next steps in research and clinical action. METHODS Analysis of data from Surveillance, Epidemiology and End Results System and the National Center for Vital Statistics. Literature review of published English-language articles through December 31, 2013. RESULTS The incidence of thyroid cancer has tripled over the past 30 years, whereas mortality is stable. The increase is mainly comprised of smaller tumors. These facts together suggest the major reason for the increased incidence is detection of subclinical, nonlethal disease. This has likely occurred through: health care system access, incidental detection on imaging, more frequent biopsy, greater volumes of and extent of surgery, and changes in pathology practices. Because larger-size tumors have increased in incidence also, it is possible that there is a concomitant true rise in thyroid cancer incidence. The only clearly identifiable contributor is radiation exposure, which has likely resulted in a few additional cases annually. The contribution of the following causes to the increasing incidence is unclear: iodine excess or insufficiency, diabetes and obesity, and molecular disruptions. The following mechanisms do not currently have strong evidence to support a link with the development of thyroid cancer: estrogen, dietary nitrate, and autoimmune thyroid disease. CONCLUSION Research should focus on illuminating which thyroid cancers need treatment. Patients should be advised of the benefits as well as harms that can occur with treatment of incidentally identified, small, asymptomatic thyroid cancers.

Mortality and major morbidity after tonsillectomy

To report data on death or permanent disability after tonsillectomy.

Problem of the Old and the Cold

A pilot winter study of body temperatures using new measuring techniques was tested on 72 volunteers aged 65 or more living in Portsmouth. The body temperatures were related to their environmental temperature and living conditions. No case of serious hypothermia was found, but the study confirms that elderly people have lower body temperatures and suggests that the coldest individuals tended to be the least aware of discomfort from the cold; this may well place them “at risk” for developing hypothermia.

Changing Trends in the Incidence of Thyroid Cancer in the United States

The incidence of thyroid cancer in the United States has tripled in 30 years, rising rapidly since the 1990s. This substantial increase, chiefly comprising small papillary cancers, has been attributed to widespread diagnosis of subclinical disease.1 Autopsy studies show a sizeable prevalence (5%–30%) of clinically occult thyroid cancer in asymptomatic persons. The rising diagnosis of thyroid cancer has been linked to increasing health care utilization and imaging practices,2–4 which have led to the increased discovery of small papillary thyroid cancers, which generally exhibit indolent behavior.