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.