Young people's perspectives of thyroid cancer screening and its harms after the nuclear accident in Fukushima Prefecture: a questionnaire survey indicating opt-out screening strategy of the thyroid examination as an ethical issue

Abstract

Background: Overdiagnosis of thyroid cancer has become a major global medical issue. Ultrasound-based thyroid cancer screening has promoted overdiagnosis, and recently international recommendations state that it should not be conducted, even after a nuclear accident. The Fukushima thyroid cancer screening program was initiated in 2011 as a health policy after the nuclear accident. The risk of radiation-induced thyroid cancer was unlikely given the low radiation levels, but the thyroid cancer screening program has continued at 2-year intervals with a relatively high participation rate and is now in its fifth round. It is therefore crucial to clarify whether those targeted for screening understand the disadvantages of screening, and to identify factors that influenced their decision to participate.

Methods: We conducted an anonymous mail-based questionnaire among young people from Fukushima Prefecture (subjects) and a neighboring prefecture that was not targeted for screening (non-subjects). We asked them about the significance of the thyroid cancer screening in Fukushima Prefecture, their reasons for accepting or refusing screening, their perception of the harms of screening, and their opinions on thyroid examination at school. We compared the results of the questionnaire between subjects and non-subjects and between examinees (who were screened) and non-examinees (who declined screening).

Results: Only 16.5% of respondents were aware of the harms associated with thyroid cancer screening, with most perceiving that the benefits outweighed the harms. Comparison of subjects' and non-subjects' responses showed there were no significant differences between the two groups. Among subjects, there were also no differences in responses between examinees and non-examinees. The most common reason for participation in screening was that the screening was conducted in schools and perceived as obligatory.

Conclusions: These results highlighted a serious ethical issue in that school-based screening leads to making young people think that it is mandatory screening in an opt-out and default setting manner, with a lack of knowledge about the disadvantages of screening. Based on the autonomy of the subjects and the ethical principle of the post-disaster, surveys after a nuclear disaster should be conducted in an opt-in style without an opt-out style such as school-based screening.

Keywords: Decision-making; Nuclear accident; Overdiagnosis; Screening; Thyroid cancer.

Fig. 1

Impact of the school-based thyroid examination. The percentage of “Yes” responses are shown for the following items related to the recognition of a school-based examination. i) 80% of participants perceived the examination was a good thing. ii) 78% of participants considered the school-based examination was somewhat mandatary. iii) 70% of participants said that their preference not to have the examination was not respected. iv) About half of the participants felt there was something wrong with those who did not have the examination. The remaining percentages for each item show responses of “no”, “no opinion”, or “no answer”

Fig. 2

Decision-making process and potential influencing factors for young subjects of the thyroid ultrasound examination in Fukushima Prefecture. There were several potential factors that influenced whether the subjects took the thyroid ultrasound examination after the nuclear accident. The "✖" indicates factors that were not found to be affected by this study