Evidence of a positive association between malpractice climate and thyroid cancer incidence in the United States

<div><p>The incidence of thyroid cancer has risen dramatically in the past few decades. The cause of this is unclear, but several lines of evidence indicate it is largely due to overdiagnosis, the diagnosis of tumors that would have never manifest clinically if untreated. Practices leading to overdiagnosis may relate to defensive medicine. In this study, we evaluated the association between malpractice climate and incidence of thyroid, breast, prostate, colon, and lung cancer in U.S. states from 1999–2012 using publicly available government data. State-level malpractice risk was quantified as malpractice payout rate, the number of malpractice payouts per 100,000 people per state per year. Associations between state-level cancer incidence, malpractice payout rate, and several cancer risk factors were evaluated. Risk factors included several social determinants of health, including factors predicting healthcare access. States with higher malpractice payout rate had higher thyroid cancer incidence, on both univariate analysis (r = 0.51, P = 0.009, Spearman) and multivariate analysis (P<0.001, multilevel model). In contrast, state-level malpractice payout rate was not associated with incidence of any other cancer type. Malpractice climate may be a social determinant for being diagnosed with thyroid cancer. This may be a product of greater defensive medicine in states with higher malpractice risk, which leads to increased diagnostic testing of patients with thyroid nodules and potential overdiagnosis. Alternatively, malpractice risk may be a proxy for another, unmeasured risk factor.</p></div

Multivariate models for all cancer types.

<p>Multivariate models for all cancer types.</p

Thyroid cancer incidence versus malpractice payout rate.

<p>Values are average for each state from all years under study. States with higher malpractice payout rate had higher incidence of thyroid cancer (r = 0.51, <i>P</i> = 0.009, Spearman).</p

Variation in cancer incidence among states.

<p>Variation in cancer incidence among states.</p

Correlation matrix including cancer incidences, malpractice payout rate, and cancer risk factors.

<p>Correlations are represented as colored circles, blue indicating positive correlation, and red indicating negative correlation. Larger circle size and greater color intensity indicate higher correlation coefficient (see color key). Blank space indicates the correlation was not statistically significant (Spearman correlation with Bonferroni correction, <i>P</i> < 0.05 considered significant). The complete correlation matrix is presented in <b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0199862#pone.0199862.s001" target="_blank">S1 Table</a></b>.</p