DÄ internationalArchive16/2014Too Much Diagnostic Evaluation and Therapy
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Wienhold and colleagues’ key message in the article (1) on the management of thyroid nodules in Germany—that scintigraphy and surgery are used too often in Germany, whereas fine-needle aspiration cytology (FNAC) is used too rarely—is true and correct.

It is also correct that the upper billing limit for sonography and the low reimbursement for FNAC are contributing factors in this setting. The assumption that the indication for surgery is often defined by using scintigraphy is (in many cases) reality in Germany. As long as thyroid problems indicate scintigraphy almost as a reflex, and as long as the scintigraphic finding of a “cold nodule” triggers the association of “suspected malignancy” in doctors as well as patients, this kind of over-treatment is not going to change. Attractive reimbursement for thyroid nodules, irritating scintigraphic findings, and the “German Angst” ascribed to us by general opinion worldwide, provoke unnecessary surgical procedures.

In conclusion: since most thyroid disorders and functional impairments can be diagnosed conclusively by the patient’s medical history, a small number of laboratory parameters, qualified color Doppler ultrasound, and, if required, elastography and FNAC, this will have to become the diagnostic standard (2). Revised guidelines should clearly state that scintigraphy (which entails all the risks associated with radiation) should not be used as the primary investigative option, and not for diagnosing malignancy, in hyperthyroidism, Graves’ disease, and in order to determine autonomy in nodules with a volume (measured by ultrasound) of <1 mL and avascular nodules of <2 mL. Applying all these standards will result in scintigraphy rates below 10%, as was recently shown in an occupational thyroid screening conducted by myself, which included some 1000 participants.

The authors’ comments regarding calcitonin measurement in non-surgically treated patients—not performed as often as it should—are problematic (1). For reasons of space, I refer readers to an excellent critical overview (3). Calcitonin is highly sensitive for the purpose of detecting C cell carcinomas (how many were detected in the 25 600 patients insured with the statutory sickness funds?), but its specificity is irritatingly low (2, 3). Preanalytic laboratory problems, many false-positive findings, and cost (one calcitonin measurement accounts for about half the quarterly budget for one patient) may explain doctors’ reticence in this context. Rather than demanding improved dissemination of calcitonin screening, the guideline should, conversely, be adapted to the reality of clinical practice and the development of sonography.

DOI: 10.3238/arztebl.2014.0287a

Prof. Dr. med. Bernd Braun

Reutlingen, Prof.B.Braun@gmx.de

Conflict of interest statement

The author declares that no conflict of interest exists.

1.
Wienhold R, Scholz M, Adler JB, Günster C, Paschke R: The management of thyroid nodules—a retrospective analysis of health insurance data. Dtsch Arztebl Int 2013; 110(49): 827–34. VOLLTEXT
2.
Braun B. Schilddrüse und Nebenschilddrüsen. In: Braun B, Günther R, Schwerk WB (eds.): Ultraschalldiagnostik – Lehrbuch und Atlas. Heidelberg, München, Landsberg: ecomed MEDIZIN 2010; III-3.1: 1–238.
3.
Ross DS, Cooper DS, Mulder JE: Diagnostic approach to and treatment of
thyroid nodules. Serum calcitonin concentration. www.uptodate.com/store
(Last accessed on 25 September 2013).
1.Wienhold R, Scholz M, Adler JB, Günster C, Paschke R: The management of thyroid nodules—a retrospective analysis of health insurance data. Dtsch Arztebl Int 2013; 110(49): 827–34. VOLLTEXT
2.Braun B. Schilddrüse und Nebenschilddrüsen. In: Braun B, Günther R, Schwerk WB (eds.): Ultraschalldiagnostik – Lehrbuch und Atlas. Heidelberg, München, Landsberg: ecomed MEDIZIN 2010; III-3.1: 1–238.
3.Ross DS, Cooper DS, Mulder JE: Diagnostic approach to and treatment of
thyroid nodules. Serum calcitonin concentration. www.uptodate.com/store
(Last accessed on 25 September 2013).

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