Association between screening and the thyroid cancer “epidemic” in South Korea: evidence from a nationwide studyBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5745 (Published 30 November 2016) Cite this as: BMJ 2016;355:i5745
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Turning the tide for thyroid cancer “epidemic” in South Korea
We read with great interest the commentary of Kim and Park.  We agree with their view with some reservation that the healthcare system is responsible for the thyroid cancer epidemic in Korea. As we discussed in our paper and also addressed by them, how the healthcare service was paid for was an important contributing factor for the thyroid cancer “epidemic”. After the healthcare reform in 2000, which separated the prescription and dispensing of medicines, many hospitals and practitioners in Korea promoted routine “health checkup” programs that included optional thyroid cancer screening with ultrasonography for revenue generation purposes. Once a nodule was found in the thyroid, ultrasound-guided fine needle aspiration was recommended and then thyroidectomy, according to the practice guideline. As this provider-induced demand was coupled with public perception of cancer as a fatal disease and the general belief that surgery is the best way to cure cancer, there was an “epidemic” of thyroid cancer.
As nicely elaborated in the commentary,  a “vulnerable” healthcare system could lead to overdiagnosis of thyroid cancer, as shown in an analysis of 34 OECD countries.  However, the healthcare system alone doesn’t seem to fully explain the reason why Korea had such a rapid and unprecedented increase in thyroid cancer incidence over a short time span. In our opinion, affordability and accessibility were the key components that would further explain the difference in thyroid cancer incidence among the countries with a similar healthcare system, characterized by low public health expenditure and a fee-for-service payment system. In Korea, thyroid cancer screening with ultrasonography was readily available as an inexpensive add-on to the national cancer screening program for $30 to $50.  A recent study published in the Journal,  which assessed the effects of socioeconomic status and insurance on thyroid cancer incidence in the United States, further supports the idea that affordability was an important variable for papillary thyroid cancer overdiagnosis in the United States, too.
Obviously, identifying the fundamental causes of the phenomenon is essential to find solutions for the current issue of overdiagnosis. However, will the overdiagnosis issue be solved by changing the healthcare system, either by increasing the proportion of public financing, as previously suggested,  or by changing the fee-for-service payment system to another system? The answer will be “No”. It is neither practical nor desirable to change the healthcare system for that purpose. In our opinion, the commentary seems to have put too much emphasis on the role of the healthcare system. As a result, the role of intrinsic human factors such as knowledge, belief, ethics, and fear of cancer, peer influence and sociopolitical dynamics were relatively underestimated. More importantly, without changing the healthcare system, we have already seen the tide turning.  The number of new thyroid cancer cases decreased drastically in 2014 by more than 12,000 cases (from 42,823 cases in 2013 to 30,806 cases in 2014).  Actually, the decrease in the thyroid cancer incidence for women started already in 2013, even before the activity of “Physician Coalition for Prevention for Overdiagnosis of Thyroid Cancer”,  and for men in 2014, as shown in Figure 1 [available from the corresponding author (email@example.com)]. Needless to say, however, “Physician Coalition” played an important role of its own by bringing up the overdiagnosis issue for heated discussion and debates on mass media and even in the National Assembly. In our opinion, identifying the reasons why is one thing and finding the solutions is another, especially when dealing with complicated healthcare issues like thyroid cancer overdiagnosis.
In addition, the commentary criticized the authorized institute, such as government or related quasi-governmental organization for maintaining ‘Do-Nothing policy’ on the current issue of thyroid cancer “epidemic”, to be short.  A similar sentiment was expressed by other “Physician Coalition” members.  It may be very tempting to blame the government for lack of action. However, it was not true and one should bear in mind that the responsible groups of professionals, not the government by itself, prepare the position statements and/or guidelines, based on all the available facts, after long hours of consensus-building conferences and workshops. In fact, our paper published in the Journal is the outcome of the National Epidemiologic Survey of Thyroid Cancer, which was initiated in 2010 by the Korea Central Cancer Registry to investigate the reasons for the current issue. Furthermore, the National Cancer Center Korea initiated in 2012 a pilot project to revise the national cancer screening guidelines, and in 2013 organized the Korean Committee for National Cancer Screening Guidelines. After comprehensive review of all available literatures and due public hearing process, the Thyroid Cancer Subcommittee published in April 2015 the “Korean Guideline for Thyroid Cancer Screening Recommendation”.  It concluded that “thyroid ultrasonography is not routinely recommended for healthy subjects”. Interestingly, even before the consensus recommendation was published, there was increased public awareness of the thyroid cancer overdiagnosis issue, which resulted in a dramatic decrease in thyroid cancer incidence,  as described earlier, but no change in mortality.
In conclusion, it is true that healthcare system is responsible for the thyroid cancer epidemic in Korea. However, without changing the healthcare system, concerted efforts from governmental and non-governmental organizations, and all interested parties, including alerted health care professionals, news media, and consumer groups were able to turn the tide by raising the public awareness of the thyroid cancer overdiagnosis issue. The experience with thyroid cancer screening and overdiagnosis in South Korea should serve as a cautionary and exemplary tale for the rest of the world.
1. Kim SY, Park JH. Health system is a fundamental cause of Korea’s thyroid-cancer “epidemic”. BMJ response. Available at: http://www.bmj.com/content/355/bmj.i5745/rr
2. Lee TJ, Kim S, Cho HJ, Lee JH. The incidence of thyroid cancer is affected by the characteristics of a healthcare system. J Korean Med Sci 2012;27:1491-8.
3. Ahn HS, Kim HJ, Welch HG. Korea’s thyroid-cancer “epidemic”—screening and overdiagnosis. N Engl J Med 2014;371:1765-7.
4. Altekruse S, Das A, Cho H, et al. Do US thyroid cancer incidence rates increase with socioeconomic status among people with health insurance? An observational study using SEER population-based data. BMJ Open 2015;5:e009843. doi:10.1136/bmjopen-2015-009843
5. Ahn HS, Welch HG. South Korea’s Thyroid-Cancer “Epidemic” — Turning the Tide. N Engl J Med 2015; 373:2389-90.
6. The Korean Central Cancer Registry, National Cancer Statistics in Korea, 2014. Available at: http://ncc.re.kr/main.ncc?uri=english/sub04_Statistics
7. Lee JH, Shin SW. Overdiagnosis and screening for thyroid cancer in Korea. Lancet. 2014; 384: 1848.
8. Yi KH, Kim SY, Kim DH, et al. The Korean guideline for thyroid cancer screening. J Korean Med Assoc 2015;58:302-12.
Figure 1. Trends in incidence and mortality of thyroid cancer in South Korea, 1999-2014 [available from the corresponding author (firstname.lastname@example.org)]
Competing interests: No competing interests
Significant upward trends for thyroid cancer incidence in South Korea could be referred to an ‘epidemic of diagnosis’.1 As noted by the author, thyroid cancer ‘epidemic’ was resulted from the increasing thyroid cancer screening and access to health care services. Then, why did it increase tremendously over the last two decades in South Korea? In order to find solutions to this increase, we must identify the fundamental causes of the phenomenon.
First, similar increasing trends for incidence of thyroid cancer are found in the United States, Italy, and France, although not to the same degree.2 Especially, countries with relatively moderate to low public expenditures and further adhering to lassesz-faire health policy had higher increase in thyroid cancer incidence. In other words, when public sector’s role is relatively small, it results in higher burden of private sector such as patients and private providers. This shift leads to commercialization of the healthcare system.3 Indeed, lower pubic burden on health and higher dependency on fee-for-service system in payment mechanism were related to higher rate of thyroid cancer incidence. (figure 1: available from the author)
Second, negative effect of such vulnerable health system (characterized by moderate to low public health expenditure, a lack of gate keeper, and a high proportion of private provider), combined with low public accountability, payment mechanism based on fee-for-service scheme, and individuals’ relatively high abilities to pay is grossly exaggerated to incur a ‘Balloon effect’. A policy of low contribution and low benefits has continued since the introduction of Korea’s national health insurance system in 1989.4 The government has dominantly controlled the annual fee negotiations with health care providers. Therefore, coupled with the belief that any cancer cells should be rooted out from our body, compensation mechanism for healthcare provider’s deficit led to thyroid epidemic in Korea.
Third, appropriate information of thyroid-cancer screening was not reproduced and disseminated by authorized institute, such as government or related quasi-governmental organization. Over the last decades, they have not only remained ‘Do-Nothing policy’ on the current situation, but also distributed a vague guideline for thyroid-cancer screening, which was composed by taking opinions mainly from interest groups such as thyroid doctors, especially surgeons. However, there are some signs of hope. Recently, with activities of ‘Physician Coalition for Prevention of Overdiagnosis of Thyroid Cancer’ in 2014 and subsequent several evidences reported in medical journals,1,3 there has been a marked decrease in thyroid operations and the Korean Committee for National Cancer Screening Guideline developed the Korean Guideline for Thyroid Cancer Screening, in which thyroid untrasonography is not routinely recommended for healthy subjects.3 There need further effort to collect extensive opinions from all walks of life including patients and to deliver sufficient information.
Epidemic of thyroid cancer in Korea is just an evident example of an overdiagnosis. Widespread use of antihypertensive drug also contains many attributes of an overdignosis. This burden will eventually be led to societal burden. It is time to reorganize public accountability. Good health policy is one that making health system running well when physicians routinely perform their duty.
So Young Kim, professor
Jong Hyock Park, professor (corresponding author: email@example.com)
College of Medicine, Chungbuk National University 52 Naesudong-ro, Seowon-gu, Cheongju-si 362-763, Republic of Korea
Acknowledgement: This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (No. 2016R1A2B4011045).
1. Ahn HS, Kim HJ, Welch HG. Korea’s thyroid-cancer “epidemic” – screening and overdignosis. N Engl J Med 2014;371:1765-7.
2. Franceschi S, Vaccarella S. Thyroid cancer: an epidemic of disease or an epidemic of diagnosis? Int J Cancer 2015;136:2738-9.
3. Ahn HS. South Korea’s thyroid-Cancer “epidemic” – truning the tide. N Engl J Med 2015;373:2389-90.
4. Jeong HS. Korea's National Health Insurance-lessons from the past three decades. Health Affairs 2011;30(1):136-44.
Competing interests: No competing interests