Study Associates Thyroid Cancer Incidence with Malpractice Culture & Payouts
Updated: Mar 29, 2019
A recent study from the Penn State Cancer Institute reported that an increasing number of medical malpractice payments now involve claims related to thyroid cancer; states with higher malpractice payouts also had higher rates of thyroid cancer. The thyroid is a gland located in the base of the neck near the “Adam's apple” that aids in managing blood pressure, heart rate, and other functions by creating hormones. As technology has progressed, thyroid cancer has become easier to detect. Fortunately, the majority of thyroid cancer cases can be effectively treated.
In 1973, there were 3.6 cases of thyroid cancer per 100,000 people. By 2014, however, the number of cases nearly quadrupled, rising to roughly 15 per 100,000 people. Unlike for breast, prostate and colon cancer, screening recommendations do not exist for thyroid cancer. Research at the University of Nebraska prior to this study had indicated that, for thyroid cancer, which rarely leads to death, most malpractice lawsuits are related to delayed diagnoses. Other research from Northwestern University, Massachusetts General Hospital and the Mayo Clinic shows that regions with higher rates of malpractice lawsuits have higher rates of unnecessary testing.
The new Penn State study examined state-level data on malpractice payouts from judgments and settlements and thyroid cancer incidence between 1999 and 2012, and also looked at other cancer risk factors, including socioeconomic status and geographic location. The study found that states with higher rates of malpractice payouts also had higher rates of thyroid cancer; the association remained even when the researchers accounted for other thyroid cancer risk factors, such as socioeconomic status; of note, wealthier people are more likely to be diagnosed with thyroid cancer, partially due to better access to health care and screening. In contrast, the study did not find a similar association between breast, prostate, colon and lung cancer rates with malpractice payout rates. For breast, prostate and colon cancer, this could be explained because screening recommendations often help to insulate physicians.
The study explained that its "findings suggest malpractice climate may be a social determinant of being diagnosed with thyroid cancer. Indeed, there are several established social determinants of cancer risk, which have complex behavioral and biological associations. For example, people with lower socioeconomic status have higher incidence of colon cancer, largely because they are more likely to be obese, smoke, and have physically inactive lifestyles, known risk factors for colon cancer. Similarly, lung cancer is more common in those with lower socioeconomic status, much of this attributable to higher rates of smoking. In contrast, men with higher socioeconomic status are more likely to be diagnosed with prostate cancer, in large part because they have greater healthcare access, which leads to more diagnostic testing (i.e. PSA screening and prostate biopsy) and thus more frequent cancer overdiagnosis. Healthcare access does not account for this entire increase in prostate cancer incidence, however, suggesting other mechanisms may be operative. Breast cancer is similar. Women with higher socioeconomic status are more likely to be diagnosed with breast cancer, partly because they have greater healthcare access (including screening mammography) and thus greater risk of overdiagnosis, and partly because they tend to have their first child later in life and fewer children overall, known biological risk factors for breast cancer. Social determinants of health are thus important in understanding cancer incidence."
Indeed, there are several established social determinants of cancer risk, which have complex behavioral and biological associations. . . . Social determinants of health are thus important in understanding cancer incidence. If malpractice climate is a social determinant of thyroid cancer risk, it may partially explain the increase in thyroid cancer incidence seen in the past several decades.
Dr. Joshua Warrick, a researcher at the Penn State College of Medicine and the Penn State Study's lead author, stated that it is difficult to determine why there has been such a massive increase in thyroid cancer incidences, but opined that a likely contributor is that more doctors are practicing “defensive medicine” by ordering more diagnostic testing. Practicing defensive medicine often involves a doctor comprehensively treating a patient and sometimes ordering diagnostic testing beyond what is required by the standard of care in an effort to ensure he is not missing any possible diagnosis or condition; as a result, the doctor may perform procedures that the patient wants or expects even if they aren't clinically necessary. For these reasons, many critics argue that defensive medicine leads to over-testing, over-treatment, and unnecessarily increased healthcare costs because physicians want to prevent bad outcomes, even if highly unlikely. Nevertheless, defensive medicine is increasingly (and often deliberately) used by providers in other areas of medicine, including obstetrics and neurosurgery, in an effort to ward off malpractice lawsuits from patients whose cancer was missed or untimely diagnosed.
According to Warrick, the study’s lead author, most of the extra cases of thyroid cancer are considered overdiagnoses by epidemiologists. “Based on what we know about thyroid cancer outcomes, had we not detected the cancers using our diagnostic tests, most of these patients would never have been bothered by them,” he said. “In most cases, surgery wasn’t necessary to prevent mortality.” Warrick further opined that malpractice payout rates related to thyroid cancer could be a proxy for cultural differences across regions and states: “It’s possible this is not cause and effect directly but rather a marker of culture."
Full study available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051569/