The discussion of the value of thyroid ultrasounds has wider
importance. The broader question highlighted in the responses to this
article is not only “What to do”, but also "When is enough enough?". In
our current system once an aspect of an individual is measured and
categorized as ‘abnormal’, even when it is not, it becomes very difficult
to ignore.
There are an increasing number of examples where the availability of
testing and suggestion of risk of disease simply increase the diagnosis of
the condition, rather then offering any prospect of relief of dys-ease.
The consequent cascade of further testing and treatment with the attendant
risks of side effects, increased anxiety and medicalisation of a
previously well individual, is thus triggered. With the increase in PSA
testing the diagnosis of prostate cancer rose, with no indication yet of
improvement in mortality or morbidity. Similarly, with the advent of
ultrasound scanning the diagnosis of thyroid cancer more than doubled in
the USA from 1973 to 2002 with no change in mortality. (1)
The problem is clear and is one that needs to be thought through. It
includes screening for risk factors and “predisease”, which seems to have
few limits. Once an abnormal ‘number’ is measured, or imaging finding
detected, we find it almost impossible not to investigate it further. If
such incidental findings were not investigated what would the harm benefit
ratio be? It is likely that more suffering is caused by unwarranted
investigation than rare cases of serious disease detected. PSA testing,
thyroid ultrasounds, lipid tests and bone density scans should not be
performed in populations where the individuals do not stand to benefit
from treatment in real terms – terms other than correcting their
‘numbers’, or reassuring the physician that everything possible has been
done. Diagnosis itself is not a benefit in the absence of symptoms.
1. Davies L, Welch HG. Increasing Incidence of Thyroid Cancer in the
United States, 1973-2002. JAMA. 2006 May 10, 2006;295(18):2164-7.
Competing interests:
None declared
Competing interests:
No competing interests
27 April 2009
Dee Mangin
associate professor
Ben Hudson, senior lecturer
Dept of Public Health and General Practice, University of Otago, Christchurch
Rapid Response:
Limits to medicine
The discussion of the value of thyroid ultrasounds has wider
importance. The broader question highlighted in the responses to this
article is not only “What to do”, but also "When is enough enough?". In
our current system once an aspect of an individual is measured and
categorized as ‘abnormal’, even when it is not, it becomes very difficult
to ignore.
There are an increasing number of examples where the availability of
testing and suggestion of risk of disease simply increase the diagnosis of
the condition, rather then offering any prospect of relief of dys-ease.
The consequent cascade of further testing and treatment with the attendant
risks of side effects, increased anxiety and medicalisation of a
previously well individual, is thus triggered. With the increase in PSA
testing the diagnosis of prostate cancer rose, with no indication yet of
improvement in mortality or morbidity. Similarly, with the advent of
ultrasound scanning the diagnosis of thyroid cancer more than doubled in
the USA from 1973 to 2002 with no change in mortality. (1)
The problem is clear and is one that needs to be thought through. It
includes screening for risk factors and “predisease”, which seems to have
few limits. Once an abnormal ‘number’ is measured, or imaging finding
detected, we find it almost impossible not to investigate it further. If
such incidental findings were not investigated what would the harm benefit
ratio be? It is likely that more suffering is caused by unwarranted
investigation than rare cases of serious disease detected. PSA testing,
thyroid ultrasounds, lipid tests and bone density scans should not be
performed in populations where the individuals do not stand to benefit
from treatment in real terms – terms other than correcting their
‘numbers’, or reassuring the physician that everything possible has been
done. Diagnosis itself is not a benefit in the absence of symptoms.
1. Davies L, Welch HG. Increasing Incidence of Thyroid Cancer in the
United States, 1973-2002. JAMA. 2006 May 10, 2006;295(18):2164-7.
Competing interests:
None declared
Competing interests: No competing interests