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Sometimes You Should Just Say No to Surgery

The introduction of national thyroid cancer screening in South Korea led to a 15-fold increase in diagnoses and a corresponding explosion of operations—but no difference in mortality rates. This is a prime example of over-diagnosis that’s contributing to bloated health care costs.
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(Photo: XiXinXing/Shutterstock)

(Photo: XiXinXing/Shutterstock)

“When in doubt, cut it out.” This is a favorite mantra of surgeons, codified over centuries of treating the vast spectrum of diseases that can be ameliorated and cured with the knife. Surgeons love to operate; very little can match the highs of performing a successful operation that definitively takes care of a problem and helps a suffering patient. One of the keys, however, is making sure that there is actually a problem to take care of.

Thyroid cancer has been a hot topic of discussion recently, after the publication of an article by H. Gilbert Welch and colleagues in the New England Journal of Medicine exposing the epidemic of its over-diagnosis in South Korea. Since implementing a national screening program for thyroid cancer in 1999, diagnoses of the disease in South Korea increased 15-fold, which appears on the surface to be a good thing. Earlier cancer diagnosis equals more lives saved, right? However, as Welch pointed out in the NEJM article and in an accompanying op-ed in the New York Times, it’s not that straightforward.

Death rates from thyroid cancer in South Korea stayed identical to pre-screening rates, indicating that earlier diagnosis did nothing to change the natural course of the disease, and was not actually helping patients. Meanwhile, thousands more thyroid operations were being performed, with attendant risks of vocal damage, bleeding, and other potentially harmful outcomes, not to mention the expenditure of valuable health-care resources and time.

Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate.

I am a general surgeon with a practice focused on disorders of the thyroid gland and other endocrine organs, and Welch’s article and op-ed were not exactly breaking news in my community of specialists. For the past decade or so, we have been well aware of the increasingly impressive advancements of South Korean thyroid surgeons: thousands of new cases every year! Nifty minimally invasive and robotic approaches replacing traditional incisions in the neck!

When one parsed the data from these reports it was clear that the ballooning number of operations in South Korea included a high percentage of patients with microscopic cancers (typically defined as those measuring less than a centimeter in size). It has been well-established that these small tumors are present in a surprisingly high proportion of the general population, especially the elderly (as high as 35 percent in one study from Finland), and are unlikely to ever grow significantly or cause any sort of harm. In fact, there is convincing data demonstrating that it is perfectly reasonable to leave these microscopic thyroid cancers alone—without surgery.

The problem is, once you find a thyroid cancer, even a microscopic one, it is hard to do nothing. This issue is not limited to South Korea. Even without a national screening program here in the United States, I am commonly asked to evaluate patients who have been found to have a microscopic thyroid nodule on an imaging study performed for another reason: neck pain from a bulging disc, concern for carotid artery narrowing, chest CAT scan that happens to capture part of the thyroid gland. A well-meaning doctor follows up by ordering a thyroid biopsy, which reveals thyroid cancer. I end up with an anxious patient expecting—and in some cases demanding—to undergo an operation.

When I present the data regarding microscopic thyroid cancers and the favorable outcomes of simple observation without surgery, very few patients are convinced. It can be extraordinarily difficult to accept the risk of having a known cancer in one’s body, no matter how small. Doing nothing for even a speck of cancer, when a perfectly good operation could take care of it definitively, goes against so many of the ingrained tenets of modern medicine favoring action over inaction. When in doubt, cut it out.

Recommending inaction is also a struggle for the surgeon. We are not good at sitting on our hands. Even though I know the favorable outcomes of not operating on microscopic thyroid cancers, in my mind I share the same uneasiness as my patients. What if the cancer grows undetected? What if it ends up spreading or invading other organs? As in many spiraling nightmares regarding difficult treatment decisions, I always imagine what my defense would sound like in a malpractice deposition or heated courtroom cross-examination (“Doctor, what were you thinking, leaving cancer in this poor, innocent patient?”).

Surgery remains the path of least resistance. Another hidden truth: Operating for microscopic thyroid cancers is easy. It’s basically removing a normal thyroid gland. In a health care environment where surgeon compensation is directly linked to the number of operations performed, these cases are ideal: much faster and less dangerous than removing a big goiter or an invasive thyroid cancer with multiple surrounding lymph node metastases.

And yet, fighting all of these factors pushing me to recommend surgery, I try my best to convince patients with microscopic thyroid cancers that doing nothing for now is perfectly reasonable. They rarely choose this path. Perhaps Welch’s article and op-ed, and the resulting awareness of thyroid cancer over-diagnosis, will change the perspectives of clinicians and patients alike.

South Korea is currently faced with a potentially thorny public health problem. Now that they know about the phenomenon of thyroid cancer over-diagnosis, will they scale back their screening efforts? Will surgeons and patients start choosing observation over operations for small, low-risk cancers?

There’s another old adage about surgeons that applies here: Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate. Learning how and when to say no to surgery is difficult for patients and surgeons alike, but we need to get better at it if we are to make the most sensible decisions regarding thyroid cancer care. “When in doubt, leave it in” doesn’t rhyme and isn’t particularly catchy, but in the case of microscopic thyroid cancers, it is almost always the best medicine.