Fukushima  Thyroid  Examination  Fact  Sheet:    March  2016  

 
Introduction  
 
On  October  9,  2011,  Fukushima  Prefecture  began  the  Thyroid  Ultrasound  Examination  (TUE)  on  
about  360,000  residents  who  were  age  18  or  younger  at  the  time  of  the  triple  disaster  of  the  
earthquake,  tsunami,  and  nuclear  accident  on  March  11,  2011.  As  the  exposure  to  radioactive  
iodine  dramatically  increased  the  incidence  of  pediatric  thyroid  cancer  cases  after  the  1986  
Chernobyl  nuclear  accident,  TUE  was  implemented  to  monitor  the  exposed  children  in  
Fukushima  Prefecture.  The  majority  of  Fukushima  residents  did  not  receive  stable  iodine  for  
protection  of  their  thyroid  glands.  
 
TUE  is  part  of  the  Fukushima  Health  Management  Survey  (FHMS)1,    consisting  of  Basic  Survey  
for  external  radiation  exposure  dose  for  the  first  four  post-­‐accident  months  estimated  from  
behavior  questionnaire  and  Detailed  Surveys  including  TUE,  Comprehensive  Health  Check,  
Mental  Health  and  Lifestyle  Survey,  and  Pregnancy  and  Birth  Survey.  Its  study  protocol  was  
published  in  20122.  FHMS  is  funded  by  the  central  government3  and  commissioned  by  the  
prefectural  government  to  the  prefectural-­‐run  Fukushima  Medical  University  (FMU)4.  
 
Screening  protocol  
 
TUE  consists  of  the  primary  examination  by  thyroid  ultrasound  screening  and  the  confirmatory  
examination,  if  necessary,  including  more  detailed  ultrasound  examination  and  urine/blood  
testing  and  possible  biopsy  when  needed.  The  first  round  of  TUE  was  scheduled  to  be  conducted  
from  October  9,  2011  through  March  31,  2014,  with  each  fiscal  year  from  April  to  the  following  
March  covering  residents  from  a  set  of  municipalities  grouped  according  to  the  air  dose  level  of  
radiation.    
 
The  second  round  was  scheduled  to  begin  in  April  2014,  immediately  after  the  first  round  
completed,  including  residents  who  were  born  between  April  2,  2012  and  April  1,  2013.  
However,  in  reality,  the  primary  examination  from  the  first  round  continued  another  year  
through  April  30,  2015,  concurrent  with  the  second  round  examination  scheduled  from  April  1,  
2014  through  March  31,  2015.  (FHMS  allowed  the  first  timers  to  participate  in  the  first  round  
even  though  the  second  round  was  going  on,  as  long  as  they  hadn’t  received  notification  for  the  
second  round,  in  order  to  raise  the  participation  rate  of  the  first  round  TUE.  This  effort  
increased  the  participation  rate  by  1.5%  to  the  final  participation  rate  of  81.7%).  
 
The  unique  diagnostic  categories  of  A1,  A2,  B  and  C  for  TUE  were  established  by  the  "Diagnostic  
Criteria  Inquiry  Subcommittee  of  Thyroid  Examination  Advisory  Committee,"  consisting  of  the  
following  seven  organizations:  Japan  Thyroid  Association;  Japan  Association  of  Endocrine  
Surgeons;  Japan  Association  of  Thyroid  Surgery;  The  Japan  Society  of  Ultrasonics  in  Medicine;  
The  Japan  Society  of  Sonographers;  The  Japanese  Society  for  Pediatric  Endocrinology;  and  Japan  
Association  of  Breast  and  Thyroid  Sonology.  These  diagnostic  categories  are:    
   
• A1:  no  nodules  or  cysts  found  
• A2:  nodules  ≦  5.0  mm  or  cysts  ≦  20.0  mm  
• B:  nodules  ≧  5.1  mm  or  cysts  ≧  20.1  mm  
• C:  requiring  immediate  secondary  examination  
 
(“Cysts”  in  the  TUE  are  said  to  be  colloid  cysts  with  no  malignant  potential,  as  cysts  with  solid  
components  are  classified  as  “nodules”  by  the  size  of  the  cysts  themselves.  In  other  words,  a  

 

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20.0mm  cyst  with  a  solid  component  would  be  classified  as  a  20.0mm  nodule  and  thus  placed  in  
the  B  category).  
 
There  was  one  problem:  the  lack  of  baseline  data  for  comparison.  Such  a  large-­‐scale  thyroid  
cancer  screening  in  unexposed  children  has  never  been  conducted  in  the  world.  The  FMU  
officials  determined  that  the  screening  conducted  in  the  first  3  years  after  the  Fukushima  Daiichi  
nuclear  power  plant  accident  be  considered  baselinea  on  the  premise  that  the  data  obtained  
during  this  3-­‐year  period  would  not  reflect  the  effect  of  radiation  exposure  since  the  radiation-­‐
induced  thyroid  cancer  only  began  to  appear  about  4  years  after  the  Chernobyl  accident,  
establishing  the  latency  of  radiation-­‐induced  thyroid  cancer  in  children  to  be  about  4  years.  
Thus  the  first  screening  was  named  “Initial  Screening”  and  later  renamed  “Preliminary  Baseline  
Screening.”    
 
Thyroid  ultrasound  examination  results  
 
As  this  was  the  first  time  such  a  large-­‐scale  thyroid  ultrasound  screening  examination  was  
conducted,  each  set  of  the  results,  released  by  the  Oversight  Committee  approximately  every  3  
months  beginning  on  January  25,  2012,  caused  quite  a  stir:  the  public  was  initially  concerned  
with  any  ultrasound  findings  reported,  while  the  officials  claimed  some  of  the  findings,  such  as  
nodules  and  cysts,  were  only  detected  due  to  high  sensitivity  of  the  modern  ultrasound  
equipment  and  could  be  physiological  and  transient.    
 
The  first  report5  officially  translated  into  English,  from  the  Eighth  Oversight  Committee6  held  on  
September  11,  2012,  shows  the  rate  of  A2  at  35-­‐43%  and  B  at  0.5-­‐0.6%  for  each  screening  fiscal  
year  (FY).  Subsequent  reports  show  a  generally  increasing  tendency  for  the  proportion  of  A2  
from  FY  2011  to  FY  2013,  with  the  final  report7  of  the  first  round,  now  called  Preliminary  
Baseline  Screening,  showing  the  A2  proportion  of  36.4%  for  FY  2011,  44.6%  for  FY  2012,  and  
55.5%  for  FY  2013,  with  an  overall  average  of  47.8%.  The  vast  majority  (over  98%)  of  A2  are  
cysts.  Incidentally,  the  most  recent  February  2016  second  round  screening  results8  show  the  
average  A2  proportion  of  58.5%,  slightly  higher  than  the  first  round.  The  proportion  of  B  
increased  from  year  to  year,  at  0.5%  for  FY  2011,  0.7%  for  FY  2012,  and  0.9%  for  FY  2013,  with  
an  overall  average  of  0.8%.  The  second  round  so  far  shows  the  B  proportion  of  0.8  to  0.9%.  
 
Thyroid  cancer  cases  
 
The  first  cancer  case  was  reported  at  the  Eighth  Oversight  Committee  meeting  held  on  
September  11,  2012.  It’s  not  clearly  indicated  in  the  reported  results9  per  se,  but  the  minutes  of  
the  proceeding  (unavailable  in  English)  refer  to  “one  cancer  case  confirmed  after  biopsy  was  
conducted  in  14  individuals.”  Reporting  of  the  biopsy  results  began,  as  the  confirmatory  
examination  progressed,  at  the  Eleventh  Oversight  Committee  meeting  held  on  June  5,  2013:  
what  was  reported  included  the  number  of  cases  suspicious  for  cancer  fine-­‐needle  aspiration  
cytology  as  well  as  the  number  of  surgically  confirmed  cases.  Each  subsequent  reporting  of  the  
results  revealed  an  increasing  number  (14  to  16  more  each  time)  of  malignant  or  suspicious  

                                                                                                               
a  However,  calling  the  screening  conducted  after  exposure  “baseline”  does  not  seem  like  an  

appropriate  methodology.  This  presumes  any  thyroid  cancer  cases  detected  in  Initial  Screening  to  be  
due  to  not  radiation  effects  but  screening  effect:  detection  of  latent  thyroid  cancer  already  present  
before  the  accident  that  would  not  have  been  discovered  without  the  screening  activity.  Can  such  
presumption  hold  up?  In  general,  radiation-­‐induced  cancer  seems  to  refer  to  cancer  whose  growth  is  
initiated  due  to  exposure  to  ionizing  radiation  as  a  carcinogen.  What  if  the  growth  of  the  pre-­‐existing  
cancer  gets  promoted  due  to  radiation  exposure?  Why  would  that  not  be  considered  radiation  effect?  

 
 

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cases,  but  the  number  of  surgically  confirmed  cancer  cases  increased  at  a  slower  rate,  as  
surgeries  were  usually  scheduled  at  the  discretion  of  patients’  life  priorities.  (Final  confirmation  
of  thyroid  cancer  usually  requires  pathological  examination  of  the  tissue  from  the  resected  
thyroid  gland,  and  the  biopsy  results  normally  only  lead  to  “suspicion”  of  cancer).  
 
Officials  maintained  that  these  findings  constituted  “screening  effect,”  that  is,  widespread  
screening  of  asymptomatic  individuals  often  leads  to  discovery  of  “latent”  cancer  that  would  not  
have  been  found  if  it  weren’t  for  screening.    
 
As  the  first  round  screening  wound  down,  with  the  primary  examination  nearly  complete  and  
the  confirmatory  examination  progressing  further,  the  second  round  screening,  which  began  in  
April  2014,  started  to  show  cases  suspected  or  confirmed  of  cancer.  The  first  thyroid  
examination  report  from  the  second  round  screening10  was  released  at  the  Seventeenth  
Oversight  Committee  meeting  held  on  December  25,  201411,  showing  4  cases  suspected  of  
cancer.  Less  than  2  months  later,  on  February  12,  2015,  this  increased  to  8  cases  suspected  of  
cancer  of  which  one  was  surgically  confirmed  as  thyroid  cancer12.  Three  months  later  on  May  18,  
2015,  this  nearly  doubled  to  15  cases  suspected  of  cancer  of  which  5  were  confirmed  cancer  
cases,  and  yet  three  months  later  on  August  30,  2015,  10  more  were  added  so  there  were  25  
cases  suspected  of  cancer  including  6  cases  confirmed  as  thyroid  cancer.  November  30,  2015  
report  revealed  39  cases  suspected  of  cancer,  15  of  which  have  been  surgically  confirmed  as  
cancer.  The  most  recent  data13  released  on  February  15,  2016,  show  51  suspected  cancer  cases  
including  16  surgically  confirmed  cancer  cases.  

 

Oversight  
Committee  
Meeting  
Session  
Number  

Meeting  date  

Data  as  of  

FNAC  cases  
suspicious  
for  cancer  
(FY2014/15)  
 

17  

12/25/14  

10/31/14  

4  
(4/0)  

18  

2/12/15  

12/31/14  

19  

5/18/15  

3/31/15  

20  

8/30/15  

6/30/15  

21  

11/30/15  

9/30/15  

22  

2/15/16  

12/31/15  

Primary  exam  
results  in  the  first  
round  (A2  can  be  
nodules  or  cysts)  

#  surgery  

#  cancer  
(Papillary  
thyroid  
cancer)  

A1x2  
A2x2  

0  

0  

8  
(8/0)  

A1x5  
A2x3  

1  

1  

15  
(15/0)  
 
25  
(25/0)  
 
39  
(38/1)  
 
51  
(45/6)  
 

A1x8  
A2x6    
Bx1  
A1x10  
A2x13  (11  cysts)  
Bx2  
A1x19  
A2x18  (13  cysts)  
Bx2  (no  FNAC)  
A1x25  
A2x22  (15  cysts)  
Bx4  (2  FNAC)  

5  

5  

6  

6  

15  

15  

16  

16  

 
At  the  58th  Annual  Meeting  of  Japan  Thyroid  Association,  held  November  5-­‐7,  2015,  in  
Fukushima  City,  Fukushima  Prefecture,  Dr.  Shunichi  Yamashita  is  said  to  have  pointed  to  
screening  effect  to  explain  the  current  increase  in  thyroid  cancer  cases.    
 
However,  an  important  fact  needs  considered:  as  seen  in  the  bottom  row  of  the  table  above,  40  
of  the  51  cases  suspected  or  confirmed  of  cancer  had  either  no  ultrasound  findings  (25  cases)  or  
only  cysts  with  no  malignant  potential  (15  cases)  in  the  first  round  screening.  This  means,  either  
some  ultrasound  findings  were  missed  in  the  first  round  screening,  or  new  lesions  appeared  
since  the  first  round  screening  and  proved  to  be  cancerous.  Fukushima  Medical  University  

 

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officials  claim  there  were  no  missed  findings,  so  these  cancers  must  have  grown  since  the  first  
round  screening.  This  means  most  of  the  cancer  cases  detected  during  the  second  round  
appeared  in  2-­‐3  years  since  the  first  round  screening,  contradicting  the  so-­‐called  “latency  of  four  
years”  that  the  officials  heavily  rely  on.  
 
The  latest  tally  
 
The  table  below  shows  the  most  recent  results  (data  as  of  December  30,  2015)  released  at  the  
Twenty-­‐First  Oversight  Committee  meeting14,15  held  on  February  15,  2016.  
 
Poorly  
Number  of  
Number  of  
Number  of  
Papillary  
differentiated  
Screening  
suspicious  
surgical  
confirmed  
thyroid  
thyroid  
FNAC  cases  
cases  
cancer  cases  
cancer  
cancer  
st
1  round  
*116  
*101  
100  
97  
3  
2nd  round  
51  
16  
16  
16  
0  
Total  
*167  
*117  
116  
113  
3  
*One  case  was  post-­‐surgically  confirmed  to  be  benign  nodule.  

 
Comparison  with  annual  incidence  in  Japan  
 
Although  it  is  not  appropriate  to  directly  compare  between  prevalence  obtained  by  screening  of  
general  population  and  incidence  based  on  clinical  diagnosis,  as  a  reference  the  2010  national  
incidence16  estimated  in  Japan  for  thyroid  cancer  in  ages  0-­‐19  was  3.3  per  million  for  both  sexes,  
1.0  per  million  for  male,  and  5.6  per  million  for  female17.    
 
Assuming  all  the  suspicious  FNAC  cases  are  to  be  confirmed  as  cancer,  excluding    the  single  case  
surgically  confirmed  to  be  benign  lesions,  the  first  round  screening  data  yields  a  prevalence  of  
333  per  million  (100  confirmed  cancer  cases  per  300,478  participants)  for  both  sexes  for  
thyroid  cancer  in  those  0-­‐18  years  old  at  the  time  of  the  accident,.    (However,  the  estimated  
incidence  significantly  increases  with  age,  as  shown  in  the  table  below,  from  1.2  per  million  for  
age  10-­‐14  to  11.2  per  million  for  age  15-­‐19,  or  even  31.1  per  million  for  age  20-­‐24,  and  about  
half  of  the  Fukushima  cases  are  over  age  18  at  diagnosis).  
 
2010  Number  of  thyroid  cancer  cases  in  Japan  by  age  and  sex  
 
                   Age  
0-­‐4  
5-­‐9  
10-­‐14  
15-­‐19  
20-­‐24  
Total  
Sex  
Male  
0  
0  
0  
12  
40  
52  
Female  
0  
0  
7  
56  
160  
223  
Both  
0  
0  
7  
68  
200  
275  
 
2010  All  (including  foreigners)  population  in  Japan  by  age  and  sex:  “All  (including  foreigners)  
population”  is  used  for  incidence  rate  calculation.  
 
                   Age  
0-­‐4  
5-­‐9  
10-­‐14  
15-­‐19  
20-­‐24  
Total  
Sex  
(0-­‐19)  
Male  
2710581  
2859805  
3031943  
3109229  
3266240  
11711558  
Female  
2586167  
2725856  
2889092  
2954128  
3160193  
11155243  
Both  
5296748  
5585661  
5921035  
6063357  
6426433  
22866801  
 

 

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2010  Thyroid  cancer  incidence  rate  in  Japan  by  age  and  sex  (per  million)  
 
                   Age  
0-­‐4  
5-­‐9  
10-­‐14  
15-­‐19  
20-­‐24  
Average  for  
Sex  
0-­‐19  
Male  
0  
0  
0  
3.9  
12.2  
1.0  
Female  
0  
0  
2.4  
19.0  
50.6  
5.6  
Both  
0  
0  
1.2  
11.2  
31.1  
3.3  
 
Comparison  with  Chernobyl  and  other  parts  of  Japan  
 
As  the  only  other  major  nuclear  power  plant  accident,  the  Chernobyl  accident  is  often  used  as  a  
point  of  reference  for  many  aspects  of  the  Fukushima  accident.  Official  positions  as  to  why  
Fukushima  thyroid  cancers,  unlike  the  Chernobyl  thyroid  cancers,  are  not  considered  radiation-­‐
induced  are  roughly  summarized  in  the  following  5  points:  
 
1.
Exposure  dose  is  too  low  (less  than  100  mSv  above  which  an  increase  in  cancer  occurrence  
may  be  statistically  shown)  in  Fukushima.  
2.
Unlike  Chernobyl  where  children  kept  consuming  contaminated  food,  such  as  milk,  
internal  exposure  through  consumption  of  contaminated  milk  was  minimal  in  Japan  due  to  
regulation  of  food  distribution.  
3.
In  Fukushima,  no  children  under  age  5  at  exposure  have  so  far  been  diagnosed  with  
thyroid  cancer  and  latency  of  the  diagnosed  cases  is  too  short  (therefore  the  cancer  must  
have  already  been  present  at  the  time  of  the  accident).  
4.
Occurrence  of  ultrasound  abnormalities  and  thyroid  cancer  in  Fukushima  Prefecture  is  
comparable  to  other,  “unexposed”  areas  of  Japan.  
5.
Genetic  analyses  of  the  Fukushima  thyroid  cancers  show  a  pattern  dissimilar  to  the  
Chernobyl  radiation-­‐induced  cancer  cases18.  
 
Point  1:  Whereas  the  Chernobyl  exposure  doses,  often  directly  measured  and  swiftly  recorded  
shortly  after  the  Chernobyl  accident,  might  have  been  significantly  higher  than  the  Fukushima  
exposure  doses,  the  fact  is  that  only  1,083  direct  thyroid  measurements  were  conducted  in  
children  after  the  Fukushima  accident.  Unfortunately,  it  is  an  undeniable  fact  that  the  reliability  
of  these  measurements  is  questionable  due  to  high  background  radiation  levels.  These  simple  
thyroid  measurements  were  intended  to  be  a  quick  survey,  with  more  detailed  testing  promised  
if  needed.  However,  one  child  from  Iwaki  City  who  showed  the  highest  exposure  dose  of  35  
mSv19  never  received  any  further  monitoring:  the  reason  was  so  as  not  to  “worry  and  scare”  the  
family  and  the  community.  For  most,  the  true  exposure  dose  to  radioactive  iodine  is  not  known.  
More  detailed  diet  and  behavior  history,  even  at  least  for  those  diagnosed  with  thyroid  cancer,  
might  lead  to  a  more  accurate  dose  reconstruction,  but    it  has  not  been  done.  
 
Furthermore,  there  are  a  number  of  studies  showing  radiation  effects  at  much  lower  doses  than  
100  mSv20,  21,  22,  23,  24,  25.  
 
Regarding  point  2,  nearly  a  week  had  elapsed  since  the  accident  by  the  time  the  central  
government  established  the  provisional  regulation  values  for  food  on  March  17,  2011.  
Meanwhile,  raw  milk  collected  in  Kawamata  Town,  Fukushima  Prefecture  as  early  as  March  16,  
2011,  showed  radioactive  iodine  levels  exceeding  the  provisional  regulation  value  for  milk/milk  
products  of  300  Bq/kg26.  However,  the  testing  results  of  the  Fukushima  raw  milk  as  well  as  the  
Ibaraki  spinach  were  not  publicized  until  March  19,  201127.  In  the  post-­‐earthquake  chaos  and  
disruption  of  food  distribution,  some  might  have  consumed  untested  local  water,  milk,  leafy  
vegetables  and  other  produce  which  might  have  been  contaminated  with  high  levels  of  
radioactive  iodine.  Moreover,  even  when  contaminated  food  might  have  been  avoided,  exposure  

 

5  

via  inhalation  might  have  been  unavoidable  especially  when  there  was  no  warning  against  the  
approach  of  the  radioactive  plume.  
 
As  for  point  3,  in  Chernobyl,  official  stance  is  that  children  younger  than  5  at  exposure  began  to  
be  diagnosed  with  thyroid  cancer  beginning  in  1990,  the  fourth  year  after  the  accident.  So  far  in  
Fukushima,  at  4  years  after  the  accident,  no  cancer  case  has  been  seen  in  children  age  5  or  
younger  at  exposure.  However,  TUE  is  still  ongoing  for  the  year  4,  with  the  announcement  of  the  
results  lagging  about  2  months  behind  the  date  those  results  are  actually  confirmed.  No  cancer  
case  has  been  found  in  children  age  5  or  younger  at  exposure  in  the  evacuated  municipalities  in  
the  20-­‐30  km  zones,  but  a  municipality  such  as  Iwaki  City,  located  in  the  southern  part  of  
Fukushima  Prefecture,  south  of  the  Fukushima  Daiichi  NPP,  is  still  undergoing  the  second  round  
TUE.  Iwaki  City  is  a  place  where  unsuspecting  residents  went  about  their  post-­‐earthquake  days,  
taking  care  of  necessities,  lining  up  outside  for  water  rations,  and  waiting  outside  stores  for  their  
turns  to  go  inside  to  purchase  needed  goods,  often  with  children  in  tow,  totally  unaware  of  the  
radioactive  plume  permeating  through  their  city  when  the  wind  turned  south.  Those  residents  
do  not  know  how  much  radiation  they  were  exposed  to  from  breathing  in  the  contaminated  air  
when  the  plume  came.  Lack  of  post-­‐accident  precipitation  in  Iwaki  City,  unlike  in  Iitate  Village,  
means  the  lack  of  surface  deposition  of  radioactive  substances:  the  radiation  testing  of  the  soil  
does  not  reflect  the  degree  of  the  early  exposure  doses  sustained  by  residents.  
 
Point  4  refers  to  the  so-­‐called  control  study28,  29  in  Yamanashi,  Nagasaki  and  Aomori  Prefectures  
(a.k.a.  the  3-­‐prefecture  study)    in  which  the  sample  size  is  much  smaller  (4,365  vs.  360,000  in  
Fukushima),  and  the  age  distribution  and  gender  proportion  are  different  from  the  Fukushima  
study.  Although  widely  (and  almost  too  eagerly)  referred  to  as  a  control  study,  it  may  not  really  
be  an  appropriate  comparison  study  due  to  the  degree  of  uncertainty  stemming  from  a  large  
variance  from  the  small  sample  size:  a  single  case  of  thyroid  cancer  diagnosed  in  the  3-­‐
prefecture  study  makes  a  point  estimate  of  229  per  1  million  (95%  CI:  6  to  1,276  per  million).  
 
Genetic  analyses  mentioned  in  Point  5  do  not  constitute  a  definite  proof  of  radiogenicity  and  can  
be  influenced  by  other  factors.  As  a  matter  of  fact,  no  clear  and  convenient  “fingerprint”  exists  
that  can  discern  radiation  effects  at  this  time,  although  more  research  is  underway30.  
 
Surgical  and  pathological  features    
 
Even  though  TUE  is  funded  by  the  central  government  (and  administered  by  the  prefectural  
government),  once  the  participant  progresses  into  the  confirmatory  examination  and  needs  a  
closer  clinical  follow-­‐up,  biopsy  and/or  surgery,  the  case  becomes  part  of  regular  medical  care  
under  the  national  health  care  system.  Because  biopsy  and  cancer  cases  are  no  longer  
considered  part  of  TUE,  clinical  details,  such  as  presence/absence  of  symptoms,  family  history,  
and  pathological  and  molecular  genetic  findings  of  thyroid  cancer  cases  are  not  openly  shared  
for  protection  of  patient  privacy.    
 
The  only  information  reported  at  quarterly  Oversight  Committee  meetings  include  age  and  sex  
distribution,  tumor  diameter  range,  and  the  types  of  thyroid  cancer  (Two  types-­‐-­‐    papillary  
thyroid  cancer  and  poorly  differentiated  thyroid  cancer—have  been  reported  so  far).  During  
committee  proceedings  and  post-­‐committee  press  conferences,  questions  regarding  symptoms  
are  often  asked  by  other  committee  members  or  journalists.  The  answer  has  been  consistently,  
“No  symptoms.”  
 
In  addition,  there  have  been  two  reports  on  surgical  and  pathological  features  of  thyroid  cancer  
cases  operated  at  FMU.  The  first  was  released  in  November  201431  at  the  4th  Thyroid  
Examination  Evaluation  Subcommittee  meeting.  The  second  report  was  released  in  August  

 

6  

201532  at  the  20th  Oversight  Committee  meeting.  Both  reports  were  prepared  in  response  to  
doubts  about  over  treatment  and  complaints  about  lack  of  clinical  data  release  from  the  
committee  members.      
 
Furthermore,  some  data  have  been  presented  at  domestic  academic  meetings  without  being  
released  to  the  prefecture.  Abstracts  available  online  are  usually  in  Japanese,  but  they  have  been  
unofficially  translated,  along  with  the  two  reports  mentioned  above33,  34,  35.    
 
Pieces  of  information  from  different  sources  are  summarized:  
As  of  March  31,  2015,  pre-­‐surgical  diagnosis  revealed  that  33  of  96  surgically  confirmed  thyroid  
cancer  cases  had  a  diameter  of  10  mm  or  smaller.  (Surgical  treatment  of  papillary  thyroid  cancer  
10  mm  or  smaller,  called  papillary  thyroid  microcarcinoma  or  PTMC,  is  controversial  in  adults).  
8  cases  had  nodal/distant  metastasis  or  mild  extrathyroidal  extension.  22  of  remaining  25  had  
proximity  to  vital  organs  such  as  trachea  or  recurrent  laryngeal  nerve  or  cancer  cells  extending  
beyond  the  capsular  covering  of  thyroid  gland.  In  other  words,  excluding  3  cases  which  
underwent  surgeries  against  recommendations  of  non-­‐surgical  observation,  30  PTMC  cases  had  
indications  for  surgery.  Post-­‐surgically,  there  were  42  PTMC  including  14  with  mild  
extrathyroidal  extension  and  8  with  no  nodal/distant  metastasis  or  extrathyroidal  extension.  
Overall,  39%  had  mild  extrathyroidal  extension  and  74%  had  nodal  metastasis.  
 
Below  are  excerpts  from  translation  of  abstracts  for  presentation  at  the  27th  Annual  Congress  of  
the  Japan  Association  of  Endocrine  Surgeons36.    The  number  of  cases  described  differs  among  
them  since  each  study  looked  at  dataset  at  various  points  of  time:  
 
“(…)  here  were  84  cases  (96.6%)  of  papillary  thyroid  cancer  amongst  87  surgical  cases  of  pediatric  
and  adolescent  thyroid  cancer  at  the  end  of  2014.  They  included  3  cases  of  follicular  variants  and  4  
cases  of  cribriform-­‐morular  type.  The  solid  variant,  seen  in  high  frequency  after  the  Chernobyl  
accident,  is  classified  as  poorly  differentiated  thyroid  cancer  in  the  Sixth  Edition  of  Thyroid  Cancer  
Management  Guideline.”  
 
“(…)  65  surgical  cases  of  pediatric  and  adolescent  papillary  thyroid  cancer:  22  males  and  43  
females;  average  age  17.4  years;  59  cases  of  classic  subtype,  2  cases  of  follicular  variant,  and  4  
cases  of  cribriform-­‐morular  type.  “  
 
“Surgical  methods  included  total  thyroidectomy  in  6  cases  (8%)  and  hemithyroidectomy  in  73  
cases  (92%).  Lymph  node  dissection  was  conducted  in  all  cases,  with  82%  limited  to  the  central  
compartment  and  18%  including  the  central  and  lateral  compartments.  Post-­‐operative  
pathological  diagnosis  revealed  17  cases  (22%)  with  tumor  diameter  ≤  10  mm,  and  44%  with  
extrathyroidal  extension,  pEx1*,  and  75%  with  lymph  node  metastasis.”  
 
Although  some  information  can  be  sought  out  which  provide  bits  and  pieces  of  information,  
without  having  exact  and  comprehensive  details  of  each  cancer  case,  such  as  age,  sex,  
municipality  of  residence  at  the  time  of  the  accident,  size  and  location  of  tumor,  a  state  of  
nodal/distant  metastasis,  and  a  degree  of  invasiveness,  it  is  difficult  to  conduct  a  further  analysis.  
Lack  of  sufficient  exposure  dose  information  is  hailed  as  one  of  the  main  reasons  for  not  being  
able  to  conduct  a  dose-­‐response  analysis.  In  that  respect,  even  a  general  idea  of  where  the  
patient  was  when  the  radioactive  plume  came  might  give  a  clue  to  the  dose  range.    
 
Release  and  Analysis  of  data  
 
FMU  and  Fukushima  Prefecture  have  not  conducted  their  own  epidemiological  analysis  of  the  
thyroid  cancer  data.  Nor  have  they  released  all  the  available  data  to  make  a  complete  third-­‐party  

 

7  

analysis  possible.  FMU  has  even  prioritized  presentations  of  previously  withheld  information  at  
academic  conferences.  Some  journalists  have  repeatedly  requested,  in  vain,  the  release  of  
information  that  might  offer  a  clue  to  any  relationship  of  specific  cancer  cases  with  the  place  of  
residence  as  a  surrogate  for  exposure  doses.  Data  released  do  include  the  gender  and  age  
distributions  and  the  place  of  residence,  without  possibility  to  cross-­‐reference:  only  the  total  
number  of  cases  is  available  on  the  municipality-­‐basis,  with  no  way  of  knowing  the  gender  
and/or  age  of  specific  cases.  Clinical  details  of  each  case  are  said  to  be  beyond  the  scope  of  the  
Oversight  Committee,  since  the  confirmatory  examination  transitions  some  cases  (biopsy  and  
beyond)  from  the  government-­‐paid  screening  by  the  TUE  team  to  the  regular  medical  care  by  
specialists  through  the  national  health  insurance  incurring  self-­‐pay  costs.  At  this  level,  the  
privacy  wall  is  reinforced,  and  information  from  individual  cases  is  not  necessarily  collected  
centrally  by  the  prefecture.  
 
In  October  2015,  the  first  epidemiological  analysis37  of  the  publicly  available  thyroid  cancer  data  
(the  first  round  screening  data  as  of  December  31,  2014)  was  published  by  Tsuda  et  al.  in  the  
online,  ahead-­‐of-­‐print  edition  of  Epidemiology,  the  official,  peer-­‐reviewed  journal  of  the  
International  Society  for  Environmental  Epidemiology.  The  study  by  Tsuda  et  al.  found  a  
regional  variability  of  the  prevalence  within  Fukushima  Prefecture  as  well  as  increased  
incidence  rate  ratios  in  most  of  Fukushima  Prefecture  compared  to  the  national  incidence  rate.    
Despite  the  claim  by  the  authors  that  the  study  used  standard  epidemiological  methods  based  
on  the  concept  of  the  discipline  of  modern  epidemiology,  it  created  quite  a  controversy.  There  
have  been  criticisms  from  within  and  outside  Japan38,  39,  40,  41,  42,  43,  44.  A  counterargument  by  
Tsuda  et  al.  has  also  been  published45.  
 
A  group  of  researchers  from  the  National  Cancer  Center  recently  published  their  analysis46  and  
showed  the  observed/expected  ratio  of  thyroid  cancer  prevalence  to  be  as  much  as  30.8.  
However,  they  attribute  this  increase  to  overdiagnosis.  
 
Jacob  et  al.  (2014)47  estimated  the  prevalence  of  the  first  round  screening  and  then  determined  
the  screening  factor  for  the  subsequent  screenings.  However,  a  careful  consideration  of  the  
studies  cited  by  Jacob  et  al.  reveals  that  data  used  in  estimation  was  derived  from  the  data  
obtained  12  to  14  years  post-­‐Chernobyl,  unlike  the  first  several  years  post-­‐Fukushima,  and  
involved  other  factors  potentially  leading  to  large  uncertainties.  
 
Potential  issues  
 
Publicly  available  TUE  data  is  limited,  and  the  official  English  translation  that  is  eventually  
provided  may  not  include  the  entire  data.  Additional  information  might  be  extracted  during  the  
Oversight  Committee  meeting  or  the  subsequent  press  conference,  but  the  official  minutes,  only  
available  in  Japanese,  do  not  include  the  press  conference  material.  Information  presented  at  
domestic  academic  meetings  may  be  available  online,  but  often  only  in  Japanese.  All  these  make  
it  difficult  for  non-­‐Japanese  speakers  to  obtain  thorough  information.  
 
Given  the  fact  that  the  second  round  has  not  completed,  some  say  it  is  too  premature  to  draw  
any  definite  conclusion  from  the  data.  Ideally,  unbiased,  collaboratory  effort  amongst  clinicians  
and  researchers  to  integrate  all  the  available  information  might  lead  to  a  more  effective  and  
congruent  analytical  process  that  could  be  useful  towards  policy  making  to  benefit  the  public.  
Such  information  might  include  the  exposure  dose  (with  a  more  comprehensive  effort  to  
conduct  dose  reconstruction),  the  TUE  results,  and  clinical  data  such  as  surgical  and  pathological  
details.  Rather,  in  reality,  various  parties  are  presenting  and  defending  their  own  claims  with  
little  interdisciplinary  crossover,  reflecting  vertical  divisions  permeating  the  Japanese  society.      
 

 

8  

What  to  think  of  all  this  
 
Radiation  epidemiologists  and  others  think  that  it  is  premature  to  determine  if  the  thyroid  
cancer  cases  detected  in  Fukushima  children  are  due  to  the  radiation  exposure  from  the  
Fukushima  Daiichi  nuclear  power  plant  accident,  as  the  conventionally  accepted  latency  for  
childhood  thyroid  cancer  is  about  5  years.    
 
One  of  UNSCEAR’s  conclusions  from  the  2013  report48,  “No  discernible  increases  in  future  
cancer  rates,”  is  upheld  in  the  2015  White  Paper49,  as  presented  at  the  February  9-­‐10,  2016  
Public  Dialogues  held  in  Fukushima  Prefecture50.  Meanwhile  the  second  round  screening  is  
identifying  more  cancer  cases  than  can  be  explained  by  screening  effect  which  should  not  play  a  
large  role  due  to  harvest  effect  of  most  latent  cancers  having  been  “harvested”  in  the  first  round.  
At  the  aforementioned  Public  Dialogues,  UNSCEAR  officials  cited  screening  effect  as  an  
explanation  for  the  thyroid  cancer  cases.  UNSCEAR’s  2015  White  Paper  only  included  update  
information  from  October  2012  to  December  2014,  and  the  second  round  screening  results  
were  not  considered.  
 
On  January  22,  2016,  the  International  Society  for  Environmental  Epidemiology  sent  an  open  
letter  to  the  Japanese  government51  expressing  their  concern  about  a  “12-­‐fold  higher  risk  of  
developing  thyroid  cancer  among  residents  of  Fukushima”  compared  to  the  Japan’s  annual  
incidence,  as  demonstrated  in  the  study  by  Tsuda  et  al.  ISEE  called  for  the  need  to  develop  
scientific  studies  of  health  risks  from  the  accident  and  offered  to  the  government  of  Japan  its  
expertise  as  an  independent  international  professional  organization  of  environmental  
epidemiologists.  To  date,  the  Japanese  government  is  yet  to  acknowledge  the  ISEE  letter52.  
 
With  the  report  of  thyroid  cancer  cases  outside  Fukushima  Prefecture53,  it  is  critical  for  the  
public  health  sector  to  be  ready  for  what  might  be  coming.  Assistance  from  independent  bodies  
of  experts  would  seem  wise  and  desirable.  

 

 
                                                                                                               

Yuri  Hiranuma,  D.O.    
Portland,  Oregon,  USA  
yurihrnm@gmail.com  

1  http://fmu-­‐global.jp/fukushima-­‐health-­‐management-­‐survey/  
2  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798631/  
3  http://www.env.go.jp/chemi/rhm/support.html  
4  http://clearinghouse.main.jp/wp/?p=738  
5  http://fmu-­‐global.jp/?wpdmdl=37  
6  http://fmu-­‐global.jp/survey/proceedings-­‐of-­‐the-­‐8th-­‐prefectural-­‐oversight-­‐committee-­‐meeting-­‐for-­‐

fukushima-­‐health-­‐management-­‐survey/  
7  http://fmu-­‐global.jp/?wpdmdl=1222  
8  http://fmu-­‐global.jp/?wpdmdl=1563  
9  http://fmu-­‐global.jp/?wpdmdl=37  
10  http://fmu-­‐global.jp/?wpdmdl=158  
11  http://fmu-­‐global.jp/survey/proceedings-­‐of-­‐the-­‐17th-­‐prefectural-­‐oversight-­‐committee-­‐meeting-­‐
for-­‐fukushima-­‐health-­‐management-­‐survey/  
12  http://fmu-­‐global.jp/?wpdmdl=170  
13  http://fmu-­‐global.jp/?wpdmdl=1563  
14  Ibid.  
15  http://fukushimavoice-­‐eng2.blogspot.com/2016/02/fukushima-­‐thyroid-­‐examination-­‐
february.html  
16  http://ganjoho.jp/en/professional/statistics/table_download.html  

 

9  

                                                                                                                                                                                                                                                                                                                                         
17  Ibid.  

18  http://www.nature.com/articles/srep16976  
19  http://www.bioone.org/doi/10.1667/RR13351.1  
20  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2009418/  
21  http://www.bmj.com/content/331/7508/77  
22  http://ehp.niehs.nih.gov/1408548/  
23  http://www.bmj.com/content/346/bmj.f2360  
24  http://www.thelancet.com/journals/lanhae/article/PIIS2352-­‐3026%2815%2900094-­‐0/fulltext  
25  http://www.bmj.com/content/351/bmj.h5359  

26  http://www.maff.go.jp/j/kanbo/joho/saigai/seisan_kensa/pdf/2011_3g.pdf  
27  http://www3.nhk.or.jp/news/genpatsu-­‐fukushima/20110319/2010_s_shokuhin_taiou.html  
28  http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083220  
29  http://www.nature.com/articles/srep09046  
30  http://link.springer.com/article/10.1007/s00259-­‐015-­‐3303-­‐3  

31  https://www.pref.fukushima.lg.jp/uploaded/attachment/90997.pdf  
32  https://www.pref.fukushima.lg.jp/uploaded/attachment/129308.pdf  
33  http://fukushimavoice-­‐eng2.blogspot.com/2014/11/details-­‐of-­‐fukushima-­‐thyroid-­‐cancer.html  
34  http://fukushimavoice-­‐eng2.blogspot.com/2015/06/2015-­‐update-­‐details-­‐of-­‐fukushima.html  
35  http://fukushimavoice-­‐eng2.blogspot.com/2015/09/surgical-­‐and-­‐pathological-­‐details-­‐of.html  
36  http://fukushimavoice-­‐eng2.blogspot.com/2015/08/3-­‐thyroid-­‐cancer-­‐cases-­‐diagnosed-­‐in.html  
37  http://journals.lww.com/epidem/pages/default.aspx  

38http://journals.lww.com/epidem/Citation/publishahead/Re___Thyroid_Cancer_Among_Young_Peo
ple_in.99055.aspx  
39http://journals.lww.com/epidem/Citation/publishahead/Re___Thyroid_Cancer_Among_Young_Peo
ple_in.99056.aspx  
40http://journals.lww.com/epidem/Citation/publishahead/Re___Thyroid_Cancer_Among_Young_Peo
ple_in.99058.aspx  
41http://journals.lww.com/epidem/Citation/publishahead/Re__Thyroid_Cancer_Among_Young_Peop
le_in.99064.aspx  
42http://journals.lww.com/epidem/Citation/publishahead/Re___Thyroid_Cancer_Among_Young_Peo
ple_in.99065.aspx  
43http://journals.lww.com/epidem/Citation/publishahead/Re___Thyroid_Cancer_Among_Young_Peo
ple_in.99066.aspx  
44http://journals.lww.com/epidem/Citation/publishahead/Re__Thyroid_Cancer_among_Young_Peop
le_in.99063.aspx  
45http://journals.lww.com/epidem/Citation/publishahead/Response_to_the_Commentary_by_Profes
sor_Davis_and.99060.aspx  
46  https://jjco.oxfordjournals.org/content/early/2016/01/10/jjco.hyv191.full  
47  http://link.springer.com/article/10.1007/S00411-­‐013-­‐0508-­‐3#/page-­‐1  
48  http://www.unscear.org/unscear/en/publications/2013_1.html  
49  http://www.unscear.org/unscear/en/publications/Fukushima_WP2015.html  
50  http://www.unis.unvienna.org/unis/en/pressrels/2016/unisma129.html  
51  http://www.iseepi.org/documents/Fukushimaletter.pdf  
52  http://www.isee-­‐europe.com/blog/open-­‐discussion-­‐on-­‐isees-­‐letter-­‐to-­‐the-­‐authorities-­‐in-­‐japan-­‐
concerning-­‐the-­‐paper-­‐by-­‐tsuda-­‐et-­‐al-­‐2015  
53  http://fukushimavoice-­‐eng2.blogspot.com/2015/08/3-­‐thyroid-­‐cancer-­‐cases-­‐diagnosed-­‐in.html  
 

 

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