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INSIDE HEALTH

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Programme 9.

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TX:Ìý 28.02.17Ìý 2100-2200

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up today:Ìý Daily targets – Margaret McCartney looks at the evidence behind, and the impact of, goals like 10,000 steps, eight glasses of water, or 10 portions of fruit and veg a day.

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Thyroid cancer – the number of new cases diagnosed in the UK has tripled over the last 40 years, but are we picking up more slow growing tumours that may never have bothered people had they not been spotted on a scan done for something else?

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Clip

We know that some of these cancers can be left alone but we are not in a position today to say which of these cancers can be left alone, which will have to be removed.

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Is over diagnosis such a terrible thing?Ìý If we know we’ve got a cancer we want it dealt with.

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Porter

More on that debate later.Ìý

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But first smoking in pregnancy and news that Public Health England wants midwives to routinely screen pregnant women by measuring carbon monoxide on their breath – the gas is a marker of whether they smoke or not, and the move is backed by both NICE and the Royal College of Midwives.

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One in 10 pregnant women is still smoking at their first antenatal appointment, but there is tremendous regional variation across the country.

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Linda Bauld is Professor of Health Policy at the University of Stirling’s School of Health Sciences. ÌýLinda, what sort of impact is this having?

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Bauld

Well it’s very significant.Ìý Some work we did with the Royal College of Physicians a few years ago to pull together all the evidence suggests that smoking in pregnancy causes around 2,000 premature births, 5,000 miscarriages and unfortunately 300 perinatal deaths each year in the UK, so the baby dying prematurely.Ìý And we also know that it can contribute to poor health for the baby after it’s born.Ìý And of course the important thing we often forget is that it’s the leading cause of preventable death for the mother herself.Ìý And smoking in pregnancy’s actually a unique opportunity for women to stop smoking.

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Porter

Is it fair to assume that every pregnant woman is currently quizzed about her smoking habits as part of the routine workup that a midwife or a doctor might do?

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Bauld

Yeah I mean we certainly have made a huge amount of progress there as part of the standard questions that all women would be asked.Ìý At maternity booking early in pregnancy there is a question on smoking and the midwife is asked to ask the woman that question and completes it on a form and then that’s submitted.Ìý But the difficulty is that’s just a question that’s asked in some places and not all women, for good reasons, feel comfortable may be talking about that.

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Porter

Good reasons being what?

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Bauld

There’s a stigma around it and so I think women, certainly in one study we did in Scotland a few years ago we found that actually around one in five women who were smoking didn’t disclose her smoking status at that first maternity booking.

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Porter

Well this is where the carbon monoxide test comes in because it will detect if you’ve had a cigarette recently, it’ll pick that up.Ìý So how’s that being used at the moment?

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Bauld

Okay I mean the first thing to emphasise is that carbon monoxide screening is actually for carbon monoxide, which is a poisonous gas, women can’t see or smell it and it’s dangerous to them and the baby.Ìý So that’s what the test is for, it’s not only about smoking because that can, for example, be caused by faulty or poorly ventilated cooking or heating appliances or even car exhausts.Ìý But what we recommended in NICE guidance in 2010 and a group that I chair – The Smoking in Pregnancy Challenge Group – reiterated that in 2012, was that routine CO screening be offered in all trusts in England in particular and in other parts of the UK.Ìý But unfortunately although we have a national programme up here in Scotland it’s not universally implemented in England and there are many trusts that don’t have that always in place.Ìý And we think that’s a missed opportunity and the main reason for that is if we can accurately identify women are smoking then they can be offered support to stop.

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Porter

Just to be clear then when you’re using this test how’s it explained to the women in most situations, is it explained that this is something that we might be picking a gas up from your leaky boiler or is it – is smoking mentioned at that stage?

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Bauld

No it’s not.Ìý This is a routine test, you blow into this tube, it tests for carbon monoxide and that’s the way it’s explained.Ìý So women who are pregnant get tested for many things.Ìý Just to emphasise we actually interviewed over 50 women in a recent study and these were women who were smoking and they really didn’t have a significant problem with being asked to give that CO breath test.

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Porter

Because I can imagine a pregnant woman wanting to be tested to see whether she’s got a gas coming from her leaky boiler but if she’s a smoker she might want to keep that from you, as you said one in five people don’t admit to smoking.

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Bauld

Yeah that’s right but it’s not coercion because the service will contact them and if they don’t want support to stop smoking they can decline.Ìý So that’s really the point in the process at which women have a very active choice to make.Ìý But the crucial thing is we need to offer that to all women who smoke, both for their own health and for the baby.

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Porter

What do we know about the evidence behind CO monitoring?Ìý It helps us identify smokers but does it help them quit, I suppose that’s the key thing here?

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Bauld

So when we produced the NICE guidance we actually didn’t have much evidence, we just thought it would be a practical approach but fortunately since then we’ve had two really good quality studies, one in Nottingham and then one very recently, much bigger, involving over 37,000 deliveries conducted by researchers at the University of Newcastle, and they actually found that when you introduce CO screening the referral rate to stop smoking services doubled and also the chances of more women quitting by the time the baby was delivered also almost doubled in the study.Ìý And very similar findings from the Nottingham study, over twice as many women set a quit date to stop smoking, and over twice as many actually stopped smoking.Ìý So I think I see it as a pathway.Ìý And some women actually find it very difficult to stop smoking, they’re heavily nicotine dependent.Ìý And in those circumstances we think different approaches might be needed, alternative approaches or more intensive measures.Ìý And so one of the things we’ve trialled, in fact we did the world’s biggest trial of this recently in Glasgow, is financial incentives – the offer of a fairly modest voucher to good quality stop smoking service support.Ìý The value was actually up to £400 by the end of pregnancy and that was in four stages - £50 for setting a quit date, £50 at four weeks if you stop for that long, £100 at 12 weeks and £200 at the end if women managed to stay smoke free.Ìý And the findings from the study were that just over twice as many women stopped smoking in the incentive arm as did in the arm that didn’t receive the incentives, just received normal stop smoking service support.Ìý So it did look very successful.Ìý But just to emphasise the women in the trial were still smoking at around 12 weeks pregnancy, so they were finding it really difficult to stop.

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Porter

So this was quite a hard group to crack if you like.

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Bauld

Yes and I think the other thing to emphasise is it’s a less affluent group.Ìý So particularly in Glasgow but across the UK the women who were still smoking into the first or second trimester of pregnancy many of them living very difficult lives, they don’t have a good level of resources in the household, smoking for them is a way of coping and there’s plenty of research on that.Ìý And so even though I know they’re controversial these incentives added some money to the household that could be used for the baby and we track the things that women spent it on.Ìý And also in my mind to give women the confidence that they could do this and they can move away from tobacco.

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Porter

Professor Linda Bauld.

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Two other public health initiatives have hit the headlines in the last week.Ìý Inflation seems to have taken its toll on the amount of fruit and veg we should all be eating - five a day no longer suffices. We should be aiming for 10 a day, according to new research by a team from Imperial College. ÌýAnd the science behind 10,000 steps a day has also been questioned after it was revealed that the recommendation is based on just a single study done half a century ago in Japan.

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Margaret McCartney is in our Glasgow studio. ÌýMargaret, are these sort of targets helpful?

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McCartney

I can see why they’ve been produced.Ìý Obviously the government wanted to do something but when you look back at it really what is the evidence for these targets?Ìý And that’s where it gets quite interesting.Ìý So 2003 we had the launch of the five a day, but what’s interesting is in Australia they say it’s two plus five, they say you should have two serves of fruit and five serves of vegetable a day, in Denmark it’s six a day.Ìý So obviously different countries have come to quite different conclusions.Ìý And all this nutritional research is a bit questionable because it generally relies on big cohort studies asking people what they remembered and then trying to tally that up with what people had, what illnesses and diseases in the future.Ìý So it’s all a bit difficult.

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Porter

If they promote healthier eating or in the case of 10,000 steps, doing more activity, a nudge in the right direction is better than doing nowt, you might say.

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McCartney

Well what do we know, where is the evidence?Ìý Is what I would like to know and actually the evidence is a bit questionable.Ìý There was actually a study published in the Journal of the American Medical Association in 2016 that looked at the effect of giving people, who were trying to lose weight through sensible dieting, fitness trackers as well, so they were asked to give targets for their steps per day.Ìý And actually the group that were given the fitness trackers gained weight compared with the group who weren’t.Ìý So who knows what’s going on, this is certainly not a simple solution.

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Porter

Unintended consequences striking yet again.

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McCartney

Well absolutely and I think for some people 5,000 steps might be a fantastic achievement and for other people 10,000 steps would literally be a walk in the park, they’d be doing far more than that anyway.Ìý So I’d really suggest that the one size fits all solution is not one that human beings ascribe to.

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Porter

Well as someone who’s married to a kidney specialist I need to ask you this one.Ìý I mean the other message you sometimes see is drinking eight glasses of water a day – what do you think of that?

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McCartney

This is something that’s been consistently debunked over the last 20 years.Ìý It seems to have come from a paper from 1945 from the US Food and Nutrition Board that recommended two and a half litres a water a day but they qualified that in a later sentence by saying that this fluid is mostly contained within foods.Ìý But unfortunately it seems to have seeped in to the consciousness, particularly of bottled water manufacturers, who will very often say to people you need to drink more, we’re not drinking enough.Ìý I think the big problem is with all these kind of messages is that it’s trying to simplify what is very complicated into something that is very readily advertisable.

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Porter

Thank you Margaret.

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And there are links to the 10 portions, and the 10,000 steps coverage on the Inside Health page of the Radio 4 website.

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As cancers go, cancer of the thyroid gland in the neck is comparatively rare, but it’s on the increase. ÌýLast year there were just over 3,000 cases diagnosed across the UK – two thirds of whom were women over the age of 30. ÌýBut there is growing concern that increased use of imaging techniques like CT scans are picking up small, slow growing tumours that would otherwise have gone undetected and never posed a threat to life. ÌýAnd that, in some cases, the resulting over treatment may be doing more harm than good. ÌýBut which cases?

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Kate Newbold is Consultant Clinical Oncologist at the Royal Marsden Hospital in London.

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Newbold

Well the incidence of thyroid cancer’s really increasing and what we’re noticing is that from the 1970s we’d see about five cases per 100,000, in 2009-2010 we were seeing almost 15 cases per 100,000.

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Porter

Take me back to the ‘70s, how would a typical case of thyroid cancer have presented?

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Newbold

So at that stage it would probably be a patient would have noticed a lump in the neck and the most common for men is if when they’re shaving they suddenly realise that they’ve noticed a lump in the neck, for ladies maybe looking at photographs or when they’re applying their makeup.Ìý The nature of thyroid cancer is it’s incredibly slow growing and when you get the diagnosis they’ll look back at family photographs and say actually the lump was there but because it has grown so slowly it’s not been noticed.

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Porter

Who gets thyroid cancer and do we know why?

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Newbold

We don’t know all the causes for thyroid cancer yet.Ìý One definite cause is exposure to radiation, so we know that patients who have been treated, for example, for childhood cancers with radiotherapy are at risk of developing thyroid cancer.Ìý We know that patients who have been exposed to nuclear accidents.Ìý But in the majority we don’t know what the cause is.

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Porter

So what’s a typical presentation today then, somebody that you might see in your clinic, how is it first picked up?

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Newbold

So still lumps in neck are the most common way of presenting but increasingly now, compared to my colleagues sort of 10-20 years ago, we’ll have patients sent to us from other doctors who have done a scan of the neck.Ìý So, for example, a lot of the stroke investigations where patients have their carotid arteries in the neck ultra-sounded they will also say oh and actually we’ve seen a nodule in the thyroid, please could you see and investigate.Ìý So we’re seeing a lot more of what we call incidental findings.Ìý So the whole sort of picture of thyroid cancer’s changing to the degree that we’ve got a lot of early stage tumours which probably are not going to affect a person’s life expectancy but they’ve been detected.

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Porter

Is there a concern amongst specialist, like yourselves, and surgeons, your colleagues that you work with, that we are over-treating some thyroid cancers?

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Newbold

I think that has definitely been the concern amongst the thyroid cancer doctors’ community.

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Balasubramanian

My name is Saba Balasubramanian, I’m a consultant endocrine surgeon and I work in Sheffield.Ìý There are no increases in exposure to any of the risk factors that cause thyroid cancer, that we know of, and therefore there has been speculation for quite some time on whether we’re simply picking up more and more cancers, including these very slow growing dormant cancers that patients would have otherwise lived with.

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Porter

In the last 18 months or so I can think of at least two of my patients who’ve been in having investigations, one for a stroke, one for something else where they’ve picked up and said oh by the way can you please refer this patient because he’s got nodules…

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Balasubramanian

They found a lump yeah.

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Porter

And you must see quite a few of those in your clinic?

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Balasubramanian

Lots and lots of patients, it’s becoming a regular feature, in every clinic there’s one or two patients where a lump has been picked up entirely incidentally.

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Porter

Well listeners now will say well that’s good isn’t it, I mean picking these cancers up early makes them easier for people like you to treat?

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Balasubramanian

Yeah that is the obvious response from many of our patients.Ìý The problem is that with thyroid tumours a lot of us have thyroid tumours, so there has been a very recent review of autopsy studies, studies which have looked at the thyroid gland in patients who have died of other reasons and surprisingly these studies have shown that around 10% of us in the population have a focus of thyroid cancer within the thyroid gland that we’ve not had any problem from, not had any symptoms and people have died of other reasons and these autopsy studies have picked that up.Ìý And that particular number, the 10% or so, has not changed over the last 60, 70 years. ÌýSo we know from these autopsy studies that the true incidence hasn’t changed over the last how many decades that there’s been data but the clinically detected cancer has sky rocketed, we now think that that is primarily due to the increased use of scanning.

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Porter

But can you, as a surgeon, or your oncologist colleagues not look at the scan, do a biopsy and decide which of these cancers need treatment or not?

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Balasubramanian

It is difficult.Ìý Scans alone it is difficult to say which of these lumps that have been detected incidentally have potential to grow.Ìý Biopsies also in thyroid disease are quite difficult, so when we do a biopsy of the thyroid gland we usually do not get a straightforward black and white yes or no answer as to whether this is thyroid cancer or not.

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Newbold

We are getting better at trying to work out the character or how a particular thyroid nodule is going to behave.Ìý Increasingly we’re going to be using molecular markers, so looking at mutations within the DNA of these cells that we might take out on a needle aspiration from the nodule.Ìý So we’re moving towards improving that but we haven’t got definitive answers straightaway, so we have to use a combinations of things.Ìý And actually the only thing at the moment that will definitely tell us is if we remove that nodule from the thyroid gland which often means removing half of the thyroid gland initially to get that answer.

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Porter

And looking at those incidental findings – a nodule that’s picked up, or a number of nodules that are picked up – when they come to a clinic like you what are the chances that that’s something serious?

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Newbold

It’s still much more likely that it is a non-cancerous or benign nodule than it is a cancer.

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Balasubramanian

What we get from the pathologist is an estimate of cancer risk with these lumps.Ìý And as you know if you say to a patient that there is a 5%, 10%, or 25% risk of cancer the usual response is going to be I’d rather have it out.Ìý So that leads to a lot more surgery and it leads to complications from surgery.Ìý And when you in hindsight think that this was done for a lump that probably would not have caused the patient any harm then you get the idea of how much overtreatment is a problem.

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Porter

Where are the patient groups in this?Ìý I mean what’s their attitude been?

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Balasubramanian

So the patient groups are a little bit concerned about the reporting of over-diagnosis in the medical literature, that this could lead them down into a scenario where we dismiss patients with thyroid lumps, some of them potentially cancerous, and not take them seriously.

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Farnell

I’m Kate Farnell, I’m the CEO of the Butterfly Thyroid Cancer Trust in Newcastle-upon-Tyne.Ìý I’m also the thyroid cancer patient advisor at the Freeman Hospital in Newcastle.Ìý Perhaps more importantly I’m a thyroid cancer survivor of 17 years now.Ìý When patients are hearing that their cancer perhaps is being tagged with a label of over-diagnosis they’re not happy about it.Ìý They feel that alright, okay, it may have been an incidental finding, I may have been having a scan for something else, what they always say is how would you feel, would you care that it was incidental?Ìý No you wouldn’t.Ìý You would be pleased that it had been found at a stage where it could be successfully treated and hopefully you could get a cure.Ìý Now that said, there are people who will have the most common types of this cancer and they won’t survive it.Ìý Patients also hear that if we lived to a grand old age and we had to undergo an examination after death a lot of patients would, a lot of us, would have had a thyroid cancer that hasn’t done us any harm, we didn’t know it was there and it didn’t progress.Ìý But do you as a person want to take that risk?Ìý And is over-diagnosis such a terrible thing?Ìý If you ask any of my patients, they knew I was doing this today and they said – Kate, please get the patient perspective over – and that is if we know we’ve got a cancer we want it dealt with.

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Balasubramanian

If it is cancer the primary treatment is surgery.Ìý It is a very commonly performed operation, it is tricky because there are a number of very important structures around the thyroid gland that the surgeon would try actively to avoid bruising or damage to but despite the best efforts a significant proportion of people do have complications.Ìý The operation could affect their voice because of bruising or damage to the nerves that are on the back of the thyroid up towards the voice box.Ìý Another complication is damage to the parathyroid glands, these are small glands, most of us have four of them, two on either side of the thyroid gland, and they are usually stuck to the back of the thyroid and have to be separated from the thyroid gland, so these parathyroid glands get bruised or damaged then your blood calcium levels will drop and you get a number of symptoms from a low calcium problem.Ìý Usually this is temporary but between 5 and 10% of patients who have all of their thyroid gland removed have a long term low calcium problem.Ìý So surgery is the mainstay of treatment, surgery is the primary treatment and some patients after surgery need radioactive iodine to reduce the risk of the tumour coming back.

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Porter

So the patient has a cancer, sees the surgeon – you – you remove the entire gland, the idea of giving the radioactive iodine is to pick up any thyroid tissue that might be left behind?

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Balasubramanian

Correct, so after the entire gland has been removed, or in other words a total thyroidectomy has been performed, the radioactive iodine, when given orally, gets preferentially taken up the thyroid gland along with the thyroid cancer and it helps to mop up any microscopic tiny remnants of thyroid or thyroid cancer that is left behind either in the neck or if there is cancer that has spread to other parts of the body, which I must say is very uncommon in thyroid cancer, then the iodine will be effective against those cancer cells that have spread outside.Ìý Some radioiodine is also taken up by the salivary glands, the glands around your face and below your jaw, that produce saliva and that is why some patients get a dry mouth or sometimes some discomfort and hot feeling around the neck but these effects are only transient, only for a few days if that.

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Porter

It sounds a bit scary, the concept of having radioactive stuff concentrated in your neck, it’s a kind of smart bomb that picks cells, kills them and hopefully doesn’t cause any collateral damage while it’s doing it.

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Balasubramanian

That is correct, that is correct which is why radioiodine is considered to be a very safe and effective treatment.Ìý It is very different to radiotherapy, which is used in the treatment of lots of other cancers, which is associated with lots of side effects.

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Newbold

And the third treatment is the treatment with the thyroxine replacement, which we tend to give at a slightly higher dose in patients with thyroid cancer and that can cause increased risk of osteoporosis – thinning of the bones – or irregular heartbeats.

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Porter

If a patient does have thyroid cancer generally, as an overview, what’s the prognosis like these days?

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Newbold

So the prognosis is very good.Ìý So in the majority of thyroid cancers this will be a treatable and a curable cancer with cure rates in the high 90s.

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Porter

Clinical oncologist Kate Newbold.Ìý And if you’d like more information on thyroid cancer and the Butterfly Thyroid Cancer Trust there are links on the Inside Health page of the Radio 4 website.

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Now, to floss or not to floss? ÌýThat is the question Carl Heneghan, Professor of Evidence Based Medicine at the University of Oxford, and our resident sceptic Dr Margaret McCartney are discussing in this week’s episode of our series on uncertainty. ÌýFlossing has fallen out of favour in some quarters recently despite being long-promoted as one of the foundations of good dental care.Ìý Margaret McCartney was certainly told she should do it.

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McCartney

Yeah and certainly every time I’ve been to the dentist as an adult, I remember my dentist saying to me – Keep flossing at least once if not twice a day, good for your health, cuts down the amount of plague that you have, gets rid of any food debris, will help prevent cavities and the need for filings.Ìý But actually the evidence has never been in support of flossing.Ìý And there was kind of outrage in the press in August/September 2016 when it became apparent that the recommendation to floss everyday had been quietly dropped by the US Federal Government and they had been recommending flossing since 1979 and suddenly that recommendation went away.Ìý But actually when you go back and look at the data there’s very little data indeed that says it’s any good at all, in fact there’s only been studies published in just over a thousand people, when you consider that flossing’s been recommended to millions of people, those studies would seem really particularly inadequate.Ìý And I think this is an example of the subject not being studied well enough as opposed to the science telling us that flossing doesn’t work.

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Porter

Carl, you would hope that for something to become established in health law, public health agencies are telling people to floss, parents are telling their children to floss, that it would be based on rock solid evidence.

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Heneghan

Well it’s interesting.Ìý In America if you make a statement like that at the Federal Government level it has to be backed up by scientific evidence.Ìý And what Margaret’s talking about is the American Press Association, not researchers, who criticised the guidelines.Ìý That’s what led to all of these claims being removed in America.Ìý But I think you have to be pragmatic here.Ìý There are not the trials to show that actually flossing can make a difference to your caries, can make to longstanding tooth problems. ÌýHowever, when I floss, which I do on occasion, it still gets rid of that little piece of gunk in my teeth and actually I quite like that and that’s helpful for me.Ìý So there’s a balance between having advice that says you must do something every day, dogmatic advice and being pragmatic in the world as opposed to you must do this.

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McCartney

Oh I would love to see really good trials on this though, I would absolutely love to get a big trial happening in the UK where you could randomise yourself into being really diligent about flossing and getting reminders versus not really bothering much at all.Ìý And I suspect for most people they’re probably in that category.Ìý And it be really good to get better data on this.Ìý So I can understand the pragmatism Carl’s talking about but really it would be entirely possible to get a trial done and find out once and for all what the recommendation should be.

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Heneghan

Well there’s an interesting point, I think this is a big market, it’s like $2 billion sales, so often myth and uncertainty is better for sales.Ìý But it’s interesting there have been trials of other products, so for instance Listerine, because they thought floss was so good, said we did a trial of Listerine against flossing and what happened is they said, in a big advert, they did this in the Superbowl actually and said Listerine is as good as flossing and that was a major marketing campaign.Ìý Interestingly though the company who made the flossing then actually sued the people who made the Listerine for false advertising.Ìý So you get in this situation where there’s huge disparities about many of these products and how to understand their uncertainty.

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McCartney

And I do think that expert advice has got a place to try and help to fill in the gaps, where you’ve got unavoidable uncertainties.Ìý But my point is that some uncertainties are avoidable, in other words we could find out better what the science is in this area and then make a higher quality recommendation to people for the future.

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Heneghan

I think Margaret’s point’s really important there.Ìý There is a point which you should definitely do something, is you need just as robust evidence to say you should definitely not do something that’s shown to be harmful.Ìý What we hear is in the middle where you have to be more pragmatic and say right now we’re not certain about what the advice should be for you.Ìý So you can then individualise it.

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Porter

If you don’t like flossing and you don’t find it helpful it’s probably okay to stop is what you’re saying?

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Heneghan

Yes.

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McCartney

Or we don’t have the evidence.Ìý We don’t know, that’s the thing.

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Porter

So Carl you’re a flosser I guess?

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Heneghan

Well I’m an intermittent flosser but I’m certainly not somebody who flosses every day.

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Porter

Margaret, what about you?

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McCartney

No, I have the stuff there and I look at it guiltily and when I’m not too tired and I remember then sometimes I do but you know I just wish there was a better trial because then I would do, probably, what the trial says.Ìý But I’ve got an electric toothbrush and a healthy guilt complex.

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Porter

Margaret McCartney and Carl Heneghan. ÌýAnd there are more details on the flossing advice on our website.

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Just time to tell you about next week when we debate the opt in/opt out approaches to organ donation. ÌýShould the rest of the UK follow Wales and assume, unless we state otherwise, that we are happy for our organs to be used after death?

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And talking of death, I will be quizzing a pathologist about what happens to our bodies when we die – covering everything from rigor mortis to the characteristic smell, as well as busting a few myths propagated by crime writers.

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ENDS