A
Surprising Disclosure During the Ninth Session of the Ministry of the
Environment Expert Meeting
Shigenobu Nagataki appeared to be
low-keyed during the ninth session of the Expert Meeting Regarding
the Status of Health Management of Residents Following the Tokyo
Electric Fukushima Daiichi Nuclear Power Plant Accident held on
August 5th, 2014. Perhaps he was still reeling from the
aftermath of the last sessioni
ii,
held on July 16th, when he was bombarded with five
outspoken expert witnesses.
During the ninth session, Nagataki's
demeanor was hesitant yet assertive, trying to build a consensus as a
chairman. At one point he reiterated the purpose of the Expert
Meeting as the place for experts to seriously consider what is really
the best way to manage the health of those who were affected by the
disaster, as if he were trying to remind himself. He also made a few
statements suggestive of imposing a burden of responsibility on each
committee member.
However, it almost seemed as if he were
beginning to alienate some of the committee members due to the
unreasonable way he was carrying out the proceedings. He seemed in a
hurry to wrap up the dose assessment portion of the discussion, but
some of the committee members expressed objections to the dose
assessment summaryiii,
prepared by the MOE to be included in the interim report, citing too
many uncertainties regarding the dose assessment itself to draw a
hasty conclusion. This was the summary which Nagataki was working
hard to have endorsed by the committee. In particular, Toshimitsu
Honma from Japan Atomic Energy Agency (JAEA) pointed out the prepared
summary could be misleading, since it included two contradictory
statements which could not coexist scientifically: One statement was
that it was unlikely that residents were exposed to doses over 100
mSv, while the other was that the possibility of someone receiving
over 100 mSv exposure dose could not be ruled out.
In short, the table seemed to be
turned: Nagataki no longer appeared to be in control.
Another committee member, Hiromi
Ishikawa from Japan Medical Association, suggested that the committee
move onto discussions on health survey and medical measures, as he
has been told there would only be two more session scheduled. Honma
added on, stating that the completion of dose assessment and risk
assessment isn’t necessarily required for the discussion on health
survey. The Ministry of the Environment (MOE) official quickly
declared that they weren’t limited to just two more sessions. It
appeared that the entire atmosphere of the Expert Meeting shifted to
allow for more time for future discussion.
Meanwhile, the citizens’ group from
the Kanto area, comprising of concerned parents from Ibaraki
Prefecture, western Chiba Prefecture and eastern Saitama Prefecture
where hot spots can be found, submitted to the MOE Vice-Minister
Tomoko Ukishima a formal request to remove Nagataki as a chairman. In
addition, a few members of the audience, under the strict prohibition
from vocalizing any opposition, silently held up signs stating,
“We don’t need a skewed chairman” and “Do you have any
conscience?” (Incidentally, these actions possibly led to even more
strict and tightened guidelinesiv
for the audience for the next session on August 27, 2014, absolutely
prohibiting any sort of display of opinions, verbal or written, and
requiring the audience candidate to agree to such a condition when
they enter their names into a lottery selecting the actual audience.
Also during the ninth session, there
was an unexpected disclosure of crucial information from one of the
two expert witnesses, Akira Miyauchi, a thyroid, breast, and
endocrine surgeon from Kuma Hospital, a hospital in Kobe, Hyogo
Prefecture, which specializes in thyroid illnesses. First, as an
expert witness, he gave an overview of thyroid microcarcinomav.
He emphasized that the data was from adults and therefore it might
not be extrapolated to children, and that there was very little data
available for pediatric microcarcinoma of thyroid gland, in general
as well as at Kuma Hospital.
When Nagataki askedvi
if an early detection of small thyroid cancer would mean
hemithyroidectomy, where only a half of the thyroid gland is removed,
preserving some thyroid function and eliminating the need for
administration of thyroid hormone, Miyauchi stated,”Papillary
thyroid cancers tend to occur in multiples. Therefore, even though
the thyroid cancer might be discovered when small, it might still be
necessary to conduct a total thyroidectomy [meaning the removal of
the entire thyroid gland]. Removing smaller (3 to 9 mm) cancers would
significantly increase the number of total thyroidectomies performed.
To be honest with you, even though the complication rate might be
low, an increased number of total thyroidectomies would inevitably
lead to some cases of permanent hypoparathyroidism. Therefore, I
don’t think it is a good idea to operate on every case. “
Fukushima Medical University Vice
President Masafumi Abe chimed in to defend the validity of thyroid
cancer cases which have been operated on so far. “Fukushima Medical
University has been conducting thyroid ultrasound examination, and so
far there are a total of 90 confirmed or suspected malignant cases.
Of these, 51 had surgeries and 50 were confirmed to be cancer,
including microcarcinoma smaller than 10 mm. Our facility is only
operating on cases which are deemed high risk.”
Miyauchi followed, “To supplement
what was just stated, I am also a member of the Diagnostic Criteria
Inquiry Subcommittee of the Thyroid Examination Expert Committee. The
day before yesterday I attended the subcommittee meeting where the
information about the surgical cases at Fukushima Medical University
was presented. According to the presentation, at least over 70% of
the cases had conditions which would be ordinarily considered
appropriate for surgery, based on our current standard of care, such
as the tumor size over 1 cm, the presence of lymph node metastases,
or some aggressive cases with distant metastases. Regarding the
remaining 30%, Dr. Suzuki explained that those cases were operated on
as they were what we consider high risk, such as being near the
recurrent laryngeal nerve or contacting the trachea.”
This statement by Miyauchi immediately
caught everyone's attention, especially in the social stream timeline
for the Ustream channel for OurPlanet-TVvii,
where the Internet audience was writing in comments while watching
the Expert Meeting in real time. Details regarding the Diagnostic
Criteria Inquiry Subcommittee, established on September 18, 2011,
have been sketchy. Its existence was mentioned during the fourth
session of the Prefectural Oversight Committee Meetings for Fukushima
Health Management Surveyviii.
It was established to bring consistency to examinations on evacuees
residing outside Fukushima Prefecture, and composed of thyroid
specialists, endocrine and thyroid surgeons, pediatric
endocrinologists, and ultrasound specialists. What is known up to
this point was that the subcommittee consisted of the following seven
organizations:
- Japan Thyroid Associationix
- Japan Association of Endocrine Surgeonsx
- Japan Society of Thyroid Surgeryxi
- The Japan Society of Ultrasonics in Medicinexii
- The Japan Society of Sonographers xiii
- The Japanese Society for Pediatric Endocrinologyxiv
- The Japan Association of Breast and Thyroid Sonologyxv
However, no record could be found, at
least on the Internet, regarding the proceedings of the “Diagnostic
Criteria Inquiry Subcommittee.” A freelance journalist, Ryuichi
Kino, tweeted that the document obtained through information
disclosure was heavily redacted, with the names of the subcommittee
members blacked out.
Miyauchi’s self-admittance that he
was a subcommittee member, therefore, was a pleasant surprise. He was
disclosing information that was not readily provided by Shinichi
Suzuki, a thyroid surgeon at FMU in charge of the thyroid
examination, at the third session of the Thyroid Examination
Assessment Subcommittee, held on June 10, 2014, when Kenji Shibuya,
an epidemiologist and a public health specialist from the University
of Tokyo, raised a possibility of over-diagnosis and over-treatmentxvi.
At the time, all Suzuki would admit, defending the decision to
operate, was that some cases had lymph node metastases or hoarseness
[which indicates the involvement of the recurrent laryngeal nerve].
Suzuki would not give the percentage of the cases which actually had
lymph node metastases or hoarseness. He even said he wasn’t the one
who decided not to reveal the information.
Miyauchi’s revelation essentially
validated the surgeries performed at FMU so far, dispelling the
criticism that the screening was harmful and not really warranted.
Then, quite curiously, Nagataki started
off the question and answer session by presenting a hypothetical
situation to Miyauchi, saying, “For instance, if we conduct a
screening, some cancers would always be discovered. If we continue on
with the screening and remove all the cancers we find even though
some may not have risks [of becoming aggressive] because there is a
sense of security in simply removing anything that might remotely be
dangerous, ultimately one in ten or one in one hundred children in
Fukushima might end up getting their thyroid glands removed. Some
might say that would be acceptable as long as it brought a sense of
security. What do you think about such an idea?”
Miyauchi quickly said, as if
reprimanding Nagataki, “I think the numbers you just gave are
rather extreme.”
Then Miyauchi continued, “As I
mentioned earlier, I am a member of the Diagnostic Criteria Inquiry
Subcommittee of the Fukushima Thyroid Examination Expert Committee,
so I am quite familiar with why the thyroid screening is being
conducted in Fukushima Prefecture. As we know that pediatric thyroid
cancer notably increased after the Chernobyl accident, and most
members of the general public are aware of it and worried whether
thyroid cancers would also increase in Fukushima. Given such a
concern, for one thing, a scientific assessment had to be carried out
to see if there would actually be an increase. The other thing is to
monitor the health of the residents. I understand both of these
issues are rather difficult issues. Based on these conditions, as
mentioned earlier, what should be done is to do everything according
to certain criteria; to conduct an examination according to a certain
criterion, to read the ultrasound image according to a certain
criterion, to decide whether or not to conduct fine needle aspiration
biopsy according to a certain criterion, and so on. This is what is
happening in Fukushima Prefecture. For instance, our hospital has
examined Fukushima residents who moved to the Kansai area, at the
request of FMU. The ultrasound examination data is not assessed by
us. Instead, it is sent to FMU to be read according to a certain
criterion. If the fine needle aspiration biopsy is needed, we will
conduct the biopsy based on instructions from FMU and send the
specimen to FMU. So my understanding is that they are making an
effort to maintain a certain standard in every way possible.”
Mass screening is almost always
accompanied by a possibility of over-diagnosis and over-treatment. In
case of thyroid cancer, surgery is not risk-free. In the previous
sessions of the MOE Expert Meeting, pros and cons of cancer
screenings were discussed, especially in relation to adult cancer
screenings, given the fact the residents had concerns regarding their
health after having been exposed to the radioactive releases from
FDNPP. Gen Suzuki suggested the exposure dose was too low to warrant
the screening. The consensus of the seventh session of the MOE
Expert Meeting, citing the low exposure doses, appeared to be on the
passive side in regards to offering health checkups, including cancer
screenings, to the Fukushima residents outside of the evacuation zone
as well as the residents of neighboring prefectures.
There even appeared to be movements,
both by a certain group of citizens and citizen scientists on Twitter
and by some experts, like the University of Tokyo researchers, to do
away with the thyroid ultrasound examination of those who were 18 or
younger at the time of the accident, claiming over-diagnosis and
over-treatment.
However, the biggest issue was that
Fukushima Medical University lacked transparency to disclose
information necessary for the outside experts to properly evaluate
the situation.
Miyauchi’s statement at least
validates the way Fukushima Medical University is handling surgical
cases. However, his statement also raises a concern that there are so
many thyroid cancers which are considered high risk. After all,
Shunichi Yamashita and Shinichi Suzuki kept saying that these cancers
were considered latent cancers which would not be discoverable until
much later in life. The reality is that these are clinically obvious
cancers, and the question would be why there are so many such cases.
The government and Fukushima Medical University have maintained that
the thyroid abnormality rates, such as nodules, cysts, and even
cancer, do not differ between Fukushima Prefecture and the rest of
the nation (citing the MOE study in Yamanashi, Aomori and Nagano
Prefecturesxvii),
in an attempt to dispel any relationship between the thyroid
abnormalities and radiation exposure.
On August 24, 2014, the sixteenth
session of the Assessment Committee for the Fukushima Prefecture
Health Survey is to be held. It is expected that the full report of
the first round (FY2011-2013) of the thyroid ultrasound examination
will be released, along with some of the result from the second round
which has already begun.
We must keep close tabs on how the
number of thyroid cancer cases might change from the first to the
second round. If it's truly a screening effect, the second round
should not yield as many thyroid cancers. Meanwhile, FMU needs to be
more transparent, sharing some crucial information with the medical
and scientific communities, of course, with a full consideration to
preserve patient confidentiality. Suzuki mentioned that FMU was
accumulating all sorts of data from the thyroid examination,
including the radiation exposure data, so that studies could be
published. He said that was the way FMU was trying to fulfill its
social responsibility. However, their social responsibility really
should rest on the residents first, not so much the publication of
scientific paper.
References
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