Can computed tomography scanning in adults lead to an increased risk of thyroid cancer? A nationwide nested case–control study

Objective: To evaluate the association between computed tomography (CT) scanning and newly diagnosed thyroid cancer cases in relation to the confounding effect of the healthcare utilization rate. Methods: This nested case–control study used the Korean National Health Insurance Service-National Sample Cohort 2002–2015: 3557 adult thyroid cancer cases were matched to 17,785 controls by age, sex, and diagnosis date. Odds ratios (ORs) were estimated for thyroid cancer associated with cumulative exposure to CT scanning > 3 years before cancer diagnosis. Changes in estimated ORs with and without adjustment for outpatient visit frequency were investigated. Results: ORs for newly diagnosed thyroid cancer increased according to the higher number of total CT scans and thyroid-exposing CT scans (CT scans of the head, neck, or chest compartment; OR and 95% confidence interval [CI], 1.09 [1.03–1.16] and 1.28 [1.05–1.57], respectively). ORs for thyroid cancer increased according to higher outpatient visit frequency. The association between thyroid cancer incidence and CT scans became insignificant when outpatient visit frequency was adjusted in the models (OR [95% CI], 1.03 [0.97–1.10]: total CT scans, 1.14 [0.93–1.41]: thyroid-exposing CT scans). Subgroup analyses stratified by age, sex, and history of other malignancies did not reveal independent associations between CT scanning and thyroid cancer. Conclusions: The high incidence of thyroid cancer in adults exposed to ionizing radiation during CT scanning can be largely explained by the confounding effect of the healthcare utilization rate. These effects should be considered to avoid overestimation of the CT scanning–associated risk of thyroid cancer. Key Points: • Studies indicate that diagnostic imaging using low-ionizing radiation may increase risks for thyroid cancer in adults. • Our findings suggest that the risk for radiation-induced thyroid cancer following CT scanning in adults may have been overestimated in observational studies due to medical surveillance–related biases.