甲状腺癌的过度诊疗与精准规避策略——基于循证医学与风险分层模型的整合分析

Overdiagnosis and Overtreatment of Thyroid Cancer and Precision Mitigation Strategies—An Integrated Analysis Based on Evidence-Based Medicine and Risk Stratification Models

摘要: 背景：甲状腺癌尤其是乳头状甲状腺癌(Papillary Thyroid Carcinoma, PTC)全球发病率在过去30年间显著激增。根据GLOBOCAN 2022数据，2022年全球新发甲状腺癌病例约82.12万例，年龄标准化发病率(ASIR)持续上升，但同期死亡率保持相对稳定(约4.75万例，年龄标准化死亡率约0.5/10万)，这一“流行病学悖论”强烈提示过度诊断(overdiagnosis)和过度治疗(overtreatment)已成为重大公共卫生问题。大量检出的微小癌(直径 ≤ 1 cm的甲状腺微小乳头状癌，PTMC)多为惰性肿瘤，一生中不会引起临床症状或威胁生命，却因传统“诊断即手术”模式导致不必要的手术、放射性碘治疗及终身激素替代，带来手术并发症(如喉返神经损伤、甲状旁腺功能减退)、心理负担、就业歧视和巨额医疗支出。近年来，中国作为发病率增长最快的国家之一，这一问题尤为突出，城市地区PTMC检出率已超过50%。目的：本综述系统分析甲状腺癌过度诊疗的驱动因素，评价现行规避策略(如主动监测)的有效性、安全性与局限性，并探讨分子标志物、影像组学及人工智能等新型工具在风险分层中的应用价值，最终提出整合多维度参数(临床–病理–分子–影像–患者偏好)的精准决策路径，以实现从经验驱动向数据驱动的转变。结论：甲状腺癌过度诊疗是多因素驱动的系统性问题。通过多层次风险分层，可有效区分惰性肿瘤与真正高风险病例，推动诊疗模式从“一刀切”向“个体化、精准化”转变。未来需加强本土化证据积累、完善医保政策、优化多学科协作(MDT)并提升医患共同决策能力，以实现患者获益最大化和医疗资源合理分配。

Abstract: Background: The global incidence of thyroid cancer, particularly papillary thyroid carcinoma (PTC), has risen markedly over the past three decades. According to GLOBOCAN 2022 data, there were approximately 821,200 new cases of thyroid cancer worldwide in 2022, with a persistent increase in the age-standardized incidence rate (ASIR). In contrast, the mortality rate remained relatively stable during the same period (about 47,500 deaths, with an age-standardized mortality rate of approximately 0.5 per 100,000 population). This “epidemiological paradox” strongly indicates that overdiagnosis and overtreatment have emerged as critical public health problems. The vast majority of detected microcarcinomas, namely papillary thyroid microcarcinoma (PTMC, defined as tumors with a diameter ≤ 1 cm), are indolent neoplasms that do not cause clinical symptoms or threaten life throughout a patient’s lifetime. However, the traditional “diagnosis-equals-surgery” model has led to unnecessary surgeries, radioactive iodine therapy and lifelong hormone replacement, resulting in surgical complications (e.g., recurrent laryngeal nerve injury, hypoparathyroidism), psychological distress, employment discrimination and substantial medical expenses. In recent years, as one of the countries with the fastest-growing thyroid cancer incidence, China has been confronted with an especially severe situation: the detection rate of PTMC in urban regions has exceeded 50%. Objective: This review systematically analyzes the driving factors underlying the overdiagnosis and overtreatment of thyroid cancer, evaluates the efficacy, safety and limitations of current mitigation strategies (e.g., active surveillance), and explores the application value of novel tools including molecular markers, radiomics and artificial intelligence in risk stratification. Ultimately, it proposes a precise decision-making pathway integrating multi-dimensional parameters (clinical, pathological, molecular, imaging and patient preferences), aiming to realize the transformation from experience-driven to data-driven clinical practice. Conclusion: Overdiagnosis and overtreatment of thyroid cancer are systemic issues driven by multiple factors. Multi-level risk stratification can effectively distinguish indolent tumors from genuinely high-risk cases, facilitating the shift of the diagnosis and treatment paradigm from a “one-size-fits-all” model to individualized and precise management. Future efforts are required to strengthen the accumulation of localized evidence, improve medical insurance policies, optimize multidisciplinary team (MDT) collaboration and enhance the capability of physician-patient shared decision-making, so as to maximize patient benefits and achieve the rational allocation of medical resources.