In reply: We agree with Learoyd that the main problem now lies with translating our knowledge of overdiagnosis of cancer into the care of individual patients. Clinicians’ increasing awareness of the problems caused by overdiagnosis is welcome, and particularly the recognition and guidelines by influential organisations such as the Royal Australasian College of Physicians, the Endocrine Society of Australia, the Cancer Council, and others. The change in guidelines for thyroid ultrasound reporting and management of detected thyroid tumours is an important step. However, current Australian data suggest at best a plateauing of the overdiagnosis of thyroid cancer. The problem is complex; with multiple pathways to thyroid cancer overdiagnosis,1 all these pathways may need to be addressed if we are to reduce the current three in four rate of thyroid cancer overdiagnosis (nearly all of which currently end in thyroidectomy).2 While active surveillance is now an option according to guidelines, clinicians may find it difficult to recommend it in practice.3 We also agree that the public needs clear messages, but these may not necessarily be simple. First, the public has been oversold on screening and needs a balanced message that includes “earlier is not necessarily better” to avoid overenthusiasm for screening that does more harm than good.4 In this way, patients and doctors can share decisions about whether the potential benefits of doing a test outweigh potential harms, taking into account individual disease risk, personal preferences, and values. Second, conversations about watchful waiting will be made easier by public awareness that not all cancers behave the same — ranging from the dormant overdiagnosed cases to aggressive life‐threatening cancer. One element of this is changing the terms we use, especially for low risk and low grade lesions.5,6 This communication will not be simple and requires rigorous scientific work on different ways to label, frame and provide information about the consequences of different options for both the initial test and subsequent treatment.
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- 1. Rahman ST, McLeod DSA, Pandeya N, et al. Understanding pathways to the diagnosis of thyroid cancer: are there ways we can reduce over‐diagnosis? Thyroid 2019; 29: 341–348.
- 2. Furuya‐Kanamori L, Sedrakyan A, Onitilo AA, et al. Differentiated thyroid cancer: millions spent with no tangible gain? Endocr Relat Cancer 2018; 25: 51–57.
- 3. Nickel B, Brito JP, Barratt A, et al. Clinicians’ views on management and terminology for papillary thyroid microcarcinoma: a qualitative study. Thyroid 2017; 27: 661–671.
- 4. Evans I, Thornton H, Chalmers I, Glasziou P. Earlier is not necessarily better. In: Evans I, Thornton H, Chalmers I, Glasziou P. Testing treatments: Better research for better healthcare. Pinter and Martin, 2013: https://en.testingtreatments.org/book/4-earlier-not-necessarily-better/ (viewed Mar 2020).
- 5. Nickel B, Barratt A, McGeechan K, et al. Effect of a change in papillary thyroid cancer terminology on anxiety levels and treatment preferences: a randomized crossover trial. JAMA Otolaryngol Head Neck Surg 2018; 144: 867–874.
- 6. Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–e242.
We received funding from the Australian National Health and Medical Research Council: Fellowship 1080042, Centres of Research Excellence grant 1104136 (Creating sustainable health care: ensuring new diagnostics avoid harms, improve outcomes and direct resources wisely), program grant 1113532 (Using healthcare wisely: reducing inappropriate use of tests and treatments), and grant 9100002 (Partnership Centre for Health System Sustainability).
No relevant disclosures.