Rogers Wendy A, Craig Wendy L, Entwistle Vikki A
Bioethics. 2017 Oct;31(8):590-598. doi: 10.1111/bioe.12383.
Current practices of identifying and treating small indolent thyroid cancers constitute an important but in some ways unusual form of overdiagnosis. Overdiagnosis refers to diagnoses that generally harm rather than benefit patients, primarily because the diagnosed condition is not a harmful form of disease. Patients who are overdiagnosed with thyroid cancer are harmed by the psycho-social impact of a cancer diagnosis, as well as treatment interventions such partial or total thyroidectomy, lifelong thyroid replacement hormone, monitoring, surgical complications and other side effects. These harms seem to outweigh any putative benefit of knowing about a cancer that would not have caused problems if left undiscovered. In addition to harms to patients, thyroid cancer overdiagnosis leads to significant opportunity costs at a societal level, due to costs of diagnosis and treatment. Unlike many other overdiagnosed cancers, accurate risk stratification is possible with thyroid cancer. At the individual patient level, use of this risk information might support informed choice and/or shared decision-making, as mandated by clinical ethics frameworks. And this approach might, to some extent, help to reduce rates of diagnosis and intervention. In practice, however, it is unlikely to stem the rising incidence and associated harms and costs of overdiagnosed thyroid cancer, especially in situations where health professionals have conflicts of interest. We argue in this article that thyroid cancer overdiagnosis may be usefully understood as a public health problem, and that some public health approaches will be readily justifiable and are more likely to be effective in minimising its harms.
目前识别和治疗微小惰性甲状腺癌的做法构成了过度诊断这一重要但在某些方面不寻常的形式。过度诊断是指那些通常对患者有害而非有益的诊断，主要是因为所诊断出的病情并非有害的疾病形式。被过度诊断为甲状腺癌的患者会受到癌症诊断带来的心理社会影响，以及诸如部分或全甲状腺切除术、终身甲状腺替代激素治疗、监测、手术并发症和其他副作用等治疗干预措施的伤害。这些危害似乎超过了知晓一种即使不被发现也不会引发问题的癌症所带来的任何假定益处。除了对患者造成伤害外，甲状腺癌的过度诊断在社会层面还会因诊断和治疗成本导致巨大的机会成本。与许多其他被过度诊断的癌症不同，甲状腺癌能够进行准确的风险分层。在个体患者层面，使用这些风险信息可能有助于支持明智的选择和/或共同决策，这是临床伦理框架所要求的。而且这种方法在一定程度上可能有助于降低诊断和干预率。然而，在实际操作中，它不太可能阻止过度诊断的甲状腺癌发病率的上升以及相关危害和成本，尤其是在卫生专业人员存在利益冲突的情况下。我们在本文中认为，甲状腺癌过度诊断可被有效地理解为一个公共卫生问题，并且一些公共卫生方法将很容易被证明是合理的，而且更有可能有效地减少其危害。
