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 hadnt 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

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. Its 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?

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 werent 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

8
(8/0)

A1x5
A2x3

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)

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

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

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

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 cancerhave 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

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

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.

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 UNSCEARs 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. UNSCEARs 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 Japans 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


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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