Editorial

964 www.thelancet.com Vol 381 March 23, 2013

For more on thyroid cancer after the Chernobyl disaster see

http://www.who.int/ionizing_radiation/chernobyl/20110423_

FAQs_Chernobyl.pdf

For more on the health eff ects of the Fukushima disaster see

Lancet 2013; 381: 791–92 and http://www.who.int/ionizing_

radiation/pub_meet/fukushima_report/en/index.html

Thyroid cancer hit the headlines after the Chernobyl disaster: about 6000 children developed the disease after drinking milk from cows exposed to radioiodine. Now, 2 years since the Fukushima disaster, it is being discussed again. But what is less talked about is that incidence of the disease is rising generally: developed countries have seen substantial increases in the past two decades.

In The Lancet this week, a clinical Series highlights dilemmas facing clinicians and patients with diff erentiated thyroid cancer, proposes potential solutions, and summarises the latest molecular research. Donald McLeod and colleagues discuss the controversies surrounding treatment of the most common form—low-risk papillary thyroid cancer. Although the classic approach is well defi ned—thyroidectomy, radioiodine remnant ablation, and suppression of thyroid-stimulating hormone—evidence supporting the eff ectiveness of this triad in low-risk disease mostly comes from observational studies. Furthermore, guidelines produced by professional societies and other associations paint a confusing picture,

often leaving clinicians uncertain about how to proceed. Here, translational research steps into the fray.

Mingzhao Xing and colleagues draw together the latest fi ndings about molecular markers of diff erentiated thyroid cancer that could assist with diagnosis and indicate prognosis. Presence of some markers—eg, BRAF mutations—in low-risk patients could help clinicians to select the best treatment. With all the uncertainties about treatment eff ectiveness, molecular markers could enable clinicians to spare many individuals from invasive surgery and therapies that have many adverse eff ects.

Although mortality from diff erentiated thyroid cancer is low, patients deserve to receive the treatment that not only minimises chance of progression or recurrence, but also has a good balance between benefi ts and harms. Large prospective randomised studies with long follow-up are needed to elucidate the eff ectiveness of diff erent strategies. We hope that our Series will raise the profi le of the sometimes neglected clinical challenge that is thyroid cancer. The Lancet

Diff erentiated thyroid cancer: getting the complete picture

A new report card on the UK’s healthLast December saw publication of the worldwide and regional results for the Global Burden of Disease Study 2010 (GBD 2010). Now, the fi rst country report based on GBD data is published. That country is the UK, and the results suggest interesting possibilities for using the GBD to support more rational national policy making in health.

The results for the UK are mixed. Although life expec-tancy has improved, so has the average for com parable European countries. In several areas—breast cancer, ischaemic heart disease, respiratory infections, chronic obstructive pulmonary disease, the severity of its tobacco epidemic—the UK seems to be doing poorly compared with its neighbours. The UK ranking against other nations for mortality has “worsened substantially” for those aged 20–54 years.

The authors, who include several leading UK experts and policy makers, recommend specifi c initiatives to address these defi ciencies: a renewed focus on drug misuse, integrated medical care, reducing salt intake, tackling the major causes of chronic disability, and bringing more energy to the social and economic

determinants of disease, disability, and risk. The UK GBD results are an independent scientifi c report card on decades of NHS reorganisations that have often had more to do with political ideology than sound evidence. Now is an opportunity for a diff erent approach.

The provenance of the UK report is interesting to consider. The day before the GBD was launched publicly in London last December, a separate and private presen-tation of the UK GBD data was made to UK policy makers. The response was immediate and encouraging. There was strong interest in developing the presen-tation into a research paper for publication and sub-sequent review by the UK’s Department of Health. The GBD results do not by themselves off er defi nitive prescriptions for the predicaments they describe. And they do not provide a simple verdict on the performance of the UK health system. But they do off er a quantitative means to monitor measures of health and disease and to enable more rational review and discussion of health priorities. This work is an important step forward for health policy. The Lancet

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Published OnlineMarch 5, 2013

http://dx.doi.org/10.1016/S0140-6736(13)60324-4

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See Series pages 1046 and 1058