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Gillis A, Chen H, Wang TS, Dream S. Racial and Ethnic Disparities in the Diagnosis and Treatment of Thyroid Disease. J Clin Endocrinol Metab 2024; 109:e1336-e1344. [PMID: 37647887 PMCID: PMC10940267 DOI: 10.1210/clinem/dgad519] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/01/2023]
Abstract
CONTEXT There are differences in diagnosis, treatment, and outcomes for thyroid between racial and ethnic groups that contribute to disparities. Identifying these differences and their causes are the key to understanding and reducing disparities in presentation and outcomes in endocrine disorders. EVIDENCE ACQUISITION The present study reviews original studies identifying and exploring differences between benign and malignant thyroid diseases. A PubMed, Web of Science, and Scopus search was conducted for English-language studies using the terms "thyroid," "thyroid disease," "thyroid cancer," "race," "ethnicity," and "disparities" from inception to December 31, 2022. EVIDENCE SYNTHESIS Many racial and ethnic disparities in the diagnosis, presentation, treatment, and outcomes of thyroid disease were found. Non-White patients are more likely to have a later time to referral, to present with more advanced disease, to have more aggressive forms of thyroid cancer, and are less likely to receive the appropriate treatment than White patients. Overall and disease-specific survival rates are lower in Black and Hispanic populations when compared to White patients. CONCLUSIONS Extensive disparities exist in thyroid disease diagnosis, treatment, and outcomes that may have been overlooked. Further work is needed to identify the causes of these disparities to begin to work toward equity in the care of thyroid disease.
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Affiliation(s)
- Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53266, USA
| | - Sophie Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53266, USA
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Gillis A, Zmijewski P, Mcleod MC, Lindeman B, Fazendin J, Chen H, Bhatia S. Racial implications of time to surgery in disparities in thyroid cancer survival. Am J Surg 2024:S0002-9610(24)00063-1. [PMID: 38519403 DOI: 10.1016/j.amjsurg.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The influence of time to surgery on racial/ethnic disparities in papillary thyroid carcinoma (PTC) survival remains unstudied. MATERIALS AND METHODS The National Cancer Database (2004-2017) was queried for patients with localized PTC. Survival data was compared by time to surgery, patient demographics, and multivariable Cox regression was performed. RESULTS Of 126,708 patients included, 5% were Black, 10% Hispanic. Of all patients, 85% had no comorbidities. Non-Hispanic White (NHW) patients had a shorter median time to surgery than Black and Hispanic patients (36 vs. 43 vs. 42 days, respectively p < 0.001). In multivariable analysis, longer time to surgery (>90 days vs < 30 days) and Black race vs NHW, were associated with worse survival (HR: 1.56, (95%CI, 1.43-1.70), p < 0.001 and HR: 1.21, (1.08-1.36), p = 0.001), respectively. CONCLUSION Delaying surgery for thyroid cancer is associated with worse survival. However, independent of time to surgery and other confounders, there remains a disparity as black patients have poorer outcomes.
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Affiliation(s)
- Andrea Gillis
- University of Alabama At Birmingham, Department of General Surgery, USA.
| | - Polina Zmijewski
- University of Alabama At Birmingham, Department of General Surgery, USA
| | - M Chandler Mcleod
- University of Alabama At Birmingham, Department of General Surgery, USA
| | - Brenessa Lindeman
- University of Alabama At Birmingham, Department of General Surgery, USA
| | - Jessica Fazendin
- University of Alabama At Birmingham, Department of General Surgery, USA
| | - Herbert Chen
- University of Alabama At Birmingham, Department of General Surgery, USA
| | - S Bhatia
- University of Alabama At Birmingham, Department of General Pediatrics, USA
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Kalva S, Ginzberg SP, Passman JE, Soegaard Ballester JM, Finn CB, Fraker DL, Kelz RR, Wachtel H. Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer. Am J Surg 2024:S0002-9610(24)00070-9. [PMID: 38365554 DOI: 10.1016/j.amjsurg.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). METHODS Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity. RESULTS Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 cm were more likely in men (vs. women: OR 2.47, p < 0.001) and Hispanic patients (vs. White patients: OR 1.52, p = 0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p = 0.002; Hispanic: OR 1.44, p = 0.038) and experienced longer time to surgery (Black: HR 0.66, p < 0.001; Hispanic: HR 0.71, p < 0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p = 0.022). CONCLUSIONS Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.
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Affiliation(s)
- Saiesh Kalva
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Sara P Ginzberg
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Building, Philadelphia, PA, 19104, USA; Penn Center for Cancer Care Innovation, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk #210, Philadelphia, PA 19104, USA.
| | - Jesse E Passman
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Building, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk #210, Philadelphia, PA 19104, USA
| | - Jacqueline M Soegaard Ballester
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Building, Philadelphia, PA, 19104, USA
| | - Caitlin B Finn
- Department of Surgery, Weill Cornell Medicine, 525 E. 68th Street, New York, NY, 10065, USA
| | - Douglas L Fraker
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Building, Philadelphia, PA, 19104, USA
| | - Rachel R Kelz
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Building, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk #210, Philadelphia, PA 19104, USA
| | - Heather Wachtel
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA; Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Building, Philadelphia, PA, 19104, USA
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4
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Collins RA, McManus C, Kuo EJ, Liou R, Lee JA, Kuo JH. The impact of social determinants of health on thyroid cancer mortality and time to treatment. Surgery 2024; 175:57-64. [PMID: 37872045 DOI: 10.1016/j.surg.2023.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 04/27/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Whereas racial disparities in thyroid cancer care are well established, the role of social determinants of health is less clear. We aimed to assess the individual and cumulative impact of social determinants of health on mortality and time to treatment among patients with thyroid cancer. METHODS We collected social determinants of health data from thyroid cancer patients registered in the National Cancer Database from 2004 to 2017. We created a count variable for patients in the lowest quartile of each social determinant of health (ie, low income, low education, and no insurance). We assessed the association of social determinants of health with mortality and time to treatment and the association between cumulative social determinants of health count and time to treatment using Cox regression. RESULTS Of the 142,024 patients we identified, patients with longer time to treatment had greater mortality compared to patients treated within 90 days (90-180 days, adjusted hazard ratio 1.21 (95% confidence interval 1.13-1.29, P < .001); >180 days, adjusted hazard ratio 1.57 (95% confidence interval 1.41-1.76, (P < .001). Compared to patients with no adverse social determinants of health, patients with 1, 2, or 3 adverse social determinants of health had a 10%, 12%, and 34%, respectively, higher likelihood of longer time to treatment (1 social determinant of health, hazard ratio 0.90, 95% confidence interval 0.89-0.92, P < .001; 2 social determinants of health, hazard ratio 0.88, 95% confidence interval 0.87-0.90, P < .001; 3 social determinants of health, hazard ratio 0.66, 95% confidence interval 0.62-0.71, P < .001 for all). On subgroup analysis by race, each adverse social determinant of health was associated with an increased likelihood of a longer time to treatment for Black and Hispanic patients (P < .05). CONCLUSION A greater number of adverse social determinants of health leads to a higher likelihood of a longer time to treatment for patients with thyroid cancer, which, in turn, is associated with an increased risk for mortality.
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Affiliation(s)
- Reagan A Collins
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Catherine McManus
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Eric J Kuo
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Rachel Liou
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - James A Lee
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY.
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Zweifler RS, Medina Mora LA, Sanchez Escobar JG, Liao E, Kuriloff D, Poretsky L. Recognizing the Impact of Ethnicity: Thyroid Neoplasia in Hispanic Americans. Endocr Pract 2023; 29:1017-1019. [PMID: 37633412 DOI: 10.1016/j.eprac.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Rebecca Susan Zweifler
- Division of Endocrinology and Metabolism, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Luis Augusto Medina Mora
- Division of Endocrinology and Metabolism, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Jose Gonzalo Sanchez Escobar
- Division of Endocrinology and Metabolism, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Emilia Liao
- Division of Endocrinology and Metabolism, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Daniel Kuriloff
- Division of Otolaryngology, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Leonid Poretsky
- Division of Endocrinology and Metabolism, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York.
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Zhang X, Wang X, Hu H, Qu H, Xu Y, Li Q. Prevalence and Trends of Thyroid Disease Among Adults, 1999-2018. Endocr Pract 2023; 29:875-880. [PMID: 37619827 DOI: 10.1016/j.eprac.2023.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/27/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Thyroid disease is a prominent endocrine disorder, yet the clinical epidemiology of this condition remains unclear. This study aims to describe the recent trends in the prevalence of thyroid disease in US adults from 1999-2018. METHODS This cross-sectional study used nationally representative data collected through the National Health and Nutrition Examination Survey (NHANES) from January 1, 1999 to December 31, 2018. Patients with thyroid disease were defined as patients who reported having a thyroid disease and were on thyroid-related treatment. Age-standardized prevalence of thyroid disease was calculated within 4-year survey periods (1999-2002, 2003-2006, 2007-2010, 2011-2014, and 2015-2018). RESULTS During the NHANES 1999-2018, a total of 57 540 participants were examined. The age-standardized prevalence of thyroid disease was 5.05% (95% CI, 4.55%-5.60%) from 2015-2018, signifying a significant increase from the 1999-2002 period (P <.0002). However, prevalent thyroid disease remained steady between 2003 and 2014. The highest prevalence of thyroid disease was observed in non-Hispanic Whites (8.1%; 95% CI, 7.3%-9.0%), individuals aged ≥60 years (15.4%; 95% CI, 13.3%-17.8%), and tended to be higher in women (7.6%; 95% CI, 6.8%-8.5%). Multiple regression analysis revealed that age, women sex, non-Hispanic White and Mexican American, body mass index, higher education and incomes were independently associated with increased risks of thyroid disease. CONCLUSION The age-standardized prevalence of thyroid disease among US adults increased from 1999-2003, remained stable between 2003 and 2014, and then saw an increase from 2014-2018, with the highest rate observed among elders, women, and non-Hispanic Whites.
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Affiliation(s)
- Xuexue Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; China Academy of Chinese Medical Sciences, Beijing, China
| | - Xujie Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; China Academy of Chinese Medical Sciences, Beijing, China
| | - Huanrong Hu
- Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Jiangxi, China; The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Hua Qu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Yuying Xu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiuyan Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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7
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Ginzberg SP, Gasior JA, Passman JE, Ballester JMS, Finn CB, Karakousis GC, Kelz RR, Wachtel H. Disparities in Presentation, Treatment, and Survival in Anaplastic Thyroid Cancer. Ann Surg Oncol 2023; 30:6788-6798. [PMID: 37474696 DOI: 10.1245/s10434-023-13945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/27/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Disparities have been previously described in the presentation, management, and outcomes of other thyroid cancer subtypes; however, it is unclear whether such disparities exist in anaplastic thyroid cancer (ATC). METHODS We identified patients with ATC from the National Cancer Database (2004-2020). The primary outcomes were receipt of surgery, chemotherapy, and radiation. The secondary outcome was 1-year survival. Multivariable logistic and Cox proportional hazards regressions were used to assess the associations between sex, race/ethnicity, and the outcomes. RESULTS Among 5359 patients included, 58% were female, and 80% were non-Hispanic white. Median tumor size was larger in males than females (6.5 vs. 6.0 cm; p < 0.001) and in patients with minority race/ethnicity than in white patients (6.5 vs. 6.0 cm; p < 0.001). After controlling for tumor size and metastatic disease, female patients were more likely to undergo surgical resection (odds ratio [OR]: 1.20; p = 0.016) but less likely to undergo chemotherapy (OR: 0.72; p < 0.001) and radiation (OR: 0.76; p < 0.001) compared with males. Additionally, patients from minority racial/ethnic backgrounds were less likely to undergo chemotherapy (OR: 0.69; p < 0.001) and radiation (OR: 0.71; p < 0.001) than white patients. Overall, unadjusted, 1-year survival was 23%, with differences in treatment receipt accounting for small but significant differences in survival between groups. CONCLUSIONS There are disparities in the presentation and treatment of ATC by sex and race/ethnicity that likely reflect differences in access to care as well as patient and provider preferences. While survival is similarly poor across groups, the changing landscape of treatments for ATC warrants efforts to address the potential for exacerbation of disparities.
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Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.
| | - Julia A Gasior
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse E Passman
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jacqueline M Soegaard Ballester
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Caitlin B Finn
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Davis S, Ullmann TM, Roman S. Disparities in Treatment for Differentiated Thyroid Cancer. Thyroid 2023; 33:287-293. [PMID: 36329677 DOI: 10.1089/thy.2022.0432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Purpose: Disparities in the diagnosis and treatment of patients with differentiated thyroid cancer (DTC) have been described. This review includes the most recent literature on existing diagnostic and treatment disparities in the United States and proposes practical clinical and policy ideas for improving the gap in the treatment of DTC. Methodology: We performed a comprehensive literature review to include key articles related to DTC and disparities of treatment, diagnosis, and outcomes for disadvantaged patient populations. Results: Vulnerable patient populations with DTC have been extensively studied, and the literature shows that clear disparities of diagnosis and treatment exist. Socioeconomically disadvantaged patients, uninsured, rural, elderly, and patients belonging to minoritized racial and ethnic groups are more likely to present with advanced disease at presentation. These same vulnerable patient populations are less likely to have access to high-volume surgeons, less likely to be treated according to guidelines, and receive less aggressive treatment (such as radioactive iodine) compared with white patients. Further, these patients experience financial toxicity more so than their counterparts. Conclusions: Disparities of care exist for certain vulnerable patient populations with DTC. Approaches to rectify these should be multipronged and involve improving access to high-volume specialists with ongoing use of telehealth consults, language concordant care, an emphasis on guideline-directed therapies, ensuring continuity of care and long-term follow-up with better community partnerships, engage diverse patients in national guideline-writing committees of prominent societies and reducing the financial burden of cancer treatments at the state and national policy level.
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Affiliation(s)
- Stephanie Davis
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Timothy M Ullmann
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sanziana Roman
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Ginzberg SP, Wachtel H. ASO Author Reflections: Achieving Equity in Thyroid Cancer Treatment-More Work Ahead. Ann Surg Oncol 2023; 30:2938-2939. [PMID: 36765004 DOI: 10.1245/s10434-023-13216-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/12/2023]
Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 4 Maloney Building, Philadelphia, PA, 19104, USA.
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 4 Maloney Building, Philadelphia, PA, 19104, USA
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Ginzberg SP, Soegaard Ballester JM, Wirtalla CJ, Morales KH, Pryma DA, Mandel SJ, Kelz RR, Wachtel H. Racial and Ethnic Disparities in Appropriate Thyroid Cancer Treatment, Before and After the Release of the 2015 American Thyroid Association Guidelines. Ann Surg Oncol 2023; 30:2928-2937. [PMID: 36749501 DOI: 10.1245/s10434-023-13158-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/12/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND The 2015 American Thyroid Association (ATA) guidelines reduced the recommended extent of therapy for low-risk thyroid cancers. Little is known about the impact of these changes on overall treatment patterns and on previously described racial/ethnic disparities in guideline-concordant care. This study aimed to assess trends in thyroid cancer care before and after release of the 2015 guidelines, with particular attention to racial/ethnic disparities. METHODS Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2018). An interrupted time series design was used to assess trends in treatment before and after the 2015 guidelines. Appropriateness of surgical and radioactive iodine (RAI) treatment was determined based on the ATA guidelines, and the likelihood of receiving guideline-concordant treatment was compared between racial/ethnic groups. RESULTS The study identified 309,367 patients (White 74%, Black 8%, Hispanic 9%, Asian 6%). Between 2010 and 2015, the adjusted probability of appropriate surgery was lower for Black (- 2.1%; p < 0.001), Hispanic (- 1.0%; p < 0.001), and Asian (- 2.1%; p < 0.001) patients than for White patients. After 2015, only Hispanic patients had a lower probability of undergoing appropriate surgical therapy (- 2.6%; p = 0.040). Similarly, between 2010 and 2015, the adjusted probability of receiving appropriate RAI therapy was lower for the Hispanic (- 3.6%; p < 0.001) and Asian (- 2.4%; p < 0.001) patients than for White patients. After 2015, the probability of appropriate RAI therapy did not differ between groups. CONCLUSIONS Between 2010 and 2015, patients from racial/ethnic minority backgrounds were less likely than White patients to receive appropriate surgical and RAI therapy for thyroid cancer. After the 2015 guidelines, racial/ethnic disparities in treatment improved.
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Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.
| | | | | | - Knashawn H Morales
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel A Pryma
- Division of Nuclear Medicine, Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Susan J Mandel
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
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11
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Racial/ethnic disparities in thyroid cancer in California, 1999-2017. Am J Surg 2023; 225:298-303. [PMID: 36208959 DOI: 10.1016/j.amjsurg.2022.09.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/26/2022] [Accepted: 09/20/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Recent studies examining treatment disparities in thyroid cancer care found that appropriate use of surgery and radioactive iodine may be improving over time. METHODS California Cancer Registry and California Office of Statewide Health Planning and Development data was evaluated for the effect of race on overall and disease-specific survival for thyroid cancer in California (1999-2017). Reoperation data was also examined. We hypothesized treatment and outcome disparities would persist between Black and white patients. RESULTS Black patients with thyroid cancer had worse overall survival than white patients (p < 0.01). No difference was found in disease-specific survival between Black and white patients after adjusting for SES and health insurance status. Black patients underwent reoperation less frequently (1.4%) (HR = 0.70 [CI, 0.50-0.99], p < 0.05) than white patients (2.0%). CONCLUSIONS SES and insurance type are drivers of disparities in thyroid cancer survival in Black patients. Addressing social determinants of health or healthcare access are paramount to addressing disparities in thyroid cancer between Black and white patients.
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12
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Ullmann TM, Papaleontiou M, Sosa JA. Current Controversies in Low-Risk Differentiated Thyroid Cancer: Reducing Overtreatment in an Era of Overdiagnosis. J Clin Endocrinol Metab 2023; 108:271-280. [PMID: 36327392 PMCID: PMC10091361 DOI: 10.1210/clinem/dgac646] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT Low-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy. EVIDENCE ACQUISITION This mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed. EVIDENCE SYNTHESIS Recommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad. CONCLUSION Clinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.
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Affiliation(s)
- Timothy M Ullmann
- Division of General Surgery, Department of Surgery, Albany Medical College, 50 New Scotland Ave., MC-193, Albany, NY 12208, USA
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Bldg. 16, Rm 453S, Ann Arbor, MI 48109, USA
| | - Julie Ann Sosa
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Ave. Ste. S320, Box 0104, San Francisco, CA 94143, USA
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Moon PK, Qian ZJ, Noel JE, Orloff LA, Seeley H, Hartman GE, Josephs S, Meister KD. Sociodemographic Disparities in the Diagnostic Management of Pediatric Thyroid Nodules. JAMA Otolaryngol Head Neck Surg 2022; 148:2797390. [PMID: 36227590 PMCID: PMC9562096 DOI: 10.1001/jamaoto.2022.3167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/23/2022] [Indexed: 11/14/2022]
Abstract
Importance Thyroid cancer is the most common pediatric endocrine malignant neoplasm. Disparities in the workup of thyroid nodules may be significantly associated with thyroid cancer outcomes. Objective To determine the association of sociodemographic factors with the odds of receiving a biopsy, timeliness of the procedure, and risk of nodule malignancy. Design, Setting, and Participants This was a retrospective cross-sectional study using insurance claims data from the Optum Clinformatics Data Mart database. The study cohort comprised pediatric patients diagnosed with single thyroid nodules between 2003 and 2020. Data analysis was performed from January 1, 2003, to June 30, 2020. Main Outcomes and Measures Multivariable logistic regression models were used to identify demographic variables associated with biopsy and nodule malignant neoplasm. A multivariable linear regression model was used to assess the time between thyroid nodule diagnosis and biopsy. Results Of 11 643 children (median [IQR] age at diagnosis or procedure, 15 [12-17] years; 8549 [73.2%] were female and 3126 [26.8%] were male) diagnosed with single thyroid nodules, 2117 (18.2%) received a biopsy. Among the patients who received a biopsy, 304 (14.4%) were found to have a malignant nodule. Greater parental education was associated with a shorter diagnosis-to-biopsy interval (mean difference, -7.24 days; 95% CI, -13.75 to -0.73). Older age at nodule diagnosis (odds ratio [OR], 1.11; 95% CI, 1.09-1.13) and female gender (OR, 1.25; 95% CI, 1.11-1.40) were associated with increased odds of receiving a biopsy, while Black/African American (OR, 0.80; 95% CI, 0.65-0.99) and Hispanic (OR, 0.84; 95% CI, 0.72-0.99) patients had lower odds of receiving a biopsy compared with White patients. Finally, female gender (OR, 1.08; 95% CI, 0.80-1.47) was not associated with lower odds of nodule malignant neoplasm. Conclusions and Relevance Findings of this cross-sectional study highlight disparities in the diagnostic management of pediatric thyroid nodules. These results call for future work to ensure equitable access to thyroid care for all children.
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Affiliation(s)
- Peter K. Moon
- School of Medicine, Stanford University, Stanford, California
| | - Z. Jason Qian
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
| | - Julia E. Noel
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
| | - Lisa A. Orloff
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
| | - Hilary Seeley
- Department of Pediatrics–Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Gary E. Hartman
- Department of Surgery–Pediatric Surgery, Stanford University, Stanford, California
| | - Shellie Josephs
- Department of Radiology–Pediatric Radiology, Stanford University, Stanford, California
| | - Kara D. Meister
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California
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Moon PK, Chakoma T, Ma Y, Megwalu UC. Thyroid Cancer Incidence, Clinical Presentation, and Survival Among Native Hawaiian and Other Pacific Islanders. Otolaryngol Head Neck Surg 2022:1945998221118538. [PMID: 35943808 DOI: 10.1177/01945998221118538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the incidence, clinical presentation, and survival in Native Hawaiian and other Pacific Islander (NHPI) patients with well-differentiated thyroid cancer. STUDY DESIGN This population-based incidence analysis and retrospective cohort study utilized data from the Surveillance, Epidemiology, and End Results database. SETTING Incidence analysis included patients diagnosed between 1990 and 2014, while the cohort to study clinical presentation and survival comprised patients diagnosed between 2004 and 2015. METHODS Incidence rates and trends were compared among NHPI, Asian, and non-Hispanic White (NHW) populations. Clinical presentation was assessed via multivariable logistic regression. Survival was assessed per Cox regression. RESULTS Recent incidence trends (2009-2014) show that the rate of increase remained consistent among NHPI patients (annual percentage change, 3.67%; 95% CI, 2.66%-4.69%), while it slowed in the NHW population and plateaued among Asians as compared with previous years. NHPI patients were more likely to present with distant metastasis than NHW patients (odds ratio, 3.37; 95% CI, 1.97-5.36) and Asian patients (odds ratio, 1.82; 95% CI, 1.05-2.97). NHPI race was also associated with advanced T stage and nodal metastasis as compared with the NHW race. Survival outcomes were similar among NHPI, NHW, and Asian patients. CONCLUSION Well-differentiated thyroid cancer incidence has increased at a higher rate for the NHPI population as opposed to the NHW and Asian populations in recent years. NHPI patients are more likely to present with advanced disease when compared with NHW and Asian patients. These results highlight the importance of disaggregating the often-combined Asian/Pacific Islander group in epidemiologic studies.
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Affiliation(s)
- Peter K Moon
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Tatenda Chakoma
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Yifei Ma
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Uchechukwu C Megwalu
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
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Santamaria-Barria JA, Graff-Baker AN, Chang SC, Khader A, Scholer AJ, Garland-Kledzik M, Goldfarb M. Disparities in the impact of the AJCC 8th edition staging system on differentiated thyroid cancer outcomes. Head Neck 2022; 44:2129-2141. [PMID: 35766292 DOI: 10.1002/hed.27122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/15/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The impact of AJCC8 among self-reported racial/ethnic groups on differentiated thyroid cancer (DTC) outcomes is unknown. METHODS Multivariate-regression evaluated the association between AJCC7 to AJCC8 stage change and race/ethnicity in patients with DTC in the NCDB. Cox-proportional-regression evaluated whether AJCC7 to AJCC8 stage change affects overall survival (OS) differently based on reported race/ethnicity. RESULTS After adjusting for confounders, Hispanics and Asian-Pacific-Islanders (APIs) were 27% and 12% less likely to be down-staged compared to white-non-Hispanics (WNHs) (p < 0.001); black-non-Hispanics (BNHs) had no significant down-staging difference. Down-staged patients had an increased risk of death compared to patients with unchanged staging, regardless of race/ethnicity. However, based on two-way interaction, the magnitude of this negative change on survival from down-staging was only different between WNHs (HR = 2.64) and BNHs (HR = 1.77), (p = 0.04). CONCLUSIONS Outcome disparities persist among self-reported racial/ethnic groups with AJCC8. Down-staged patients across all racial/ethnic groups had decreased survival compared to those with unchanged stage, with the least impact in BNHs.
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Affiliation(s)
- Juan A Santamaria-Barria
- Department of Surgical Oncology, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | | | - Shu-Ching Chang
- Medical Data Research Center, Providence St. Joseph Health, Portland, Oregon, USA
| | - Adam Khader
- Department of Surgical Oncology, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Anthony J Scholer
- Department of Surgical Oncology, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Mary Garland-Kledzik
- Department of Surgical Oncology, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Melanie Goldfarb
- Department of Surgical Oncology, Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
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Abstract
Thyroid disease affects an estimated 20 million Americans, with 1 in 8 women developing a thyroid disorder during her lifetime. Although most patients with thyroid cancer have a good prognosis and effective treatments for benign thyroid disease are available, disparities exist in thyroid care and result in worse outcomes for racial and ethnic minorities. Inequities in the diagnosis and treatment of thyroid disease are due to the complex interplay of systems-, physician-, and patient-level factors. Thus, innovative strategies that take an ecological approach to addressing racial disparities are needed to achieve equitable care for all patients with thyroid disease.
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Affiliation(s)
- Debbie W Chen
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106, USA.
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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17
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Asamoah EO, Caraballo G, Castro MR. Identifying and Addressing Health Disparities in Thyroid Cancer Care. J Clin Endocrinol Metab 2022; 107:e2190-e2191. [PMID: 34871424 PMCID: PMC9016455 DOI: 10.1210/clinem/dgab875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Ernest O Asamoah
- Diabetes & Endocrinology Care, Community Health Network, Indianapolis, Indiana 46256, USA
| | - Graciela Caraballo
- George Washington University, School of Medicine and Health Sciences, Washington, DC 20037, USA
| | - M Regina Castro
- Mayo Clinic College of Medicine, Division of Endocrinology and Metabolism, Rochester, Minnesota 55905, USA
- Correspondence: M. Regina Castro, MD, Mayo Clinic College of Medicine, Division of Endocrinology and Metabolism, 200 First St SW, Rochester, MN 55905, USA.
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18
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Clinical Factors Predictive of Lymph Node Metastasis in Thyroid Cancer Patients: A Multivariate Analysis. J Am Coll Surg 2022; 234:691-700. [PMID: 35290290 DOI: 10.1097/xcs.0000000000000107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Early-stage thyroid cancers have excellent survival. However, lymph node metastases (LNM) confer a worse prognosis and are not always known preoperatively. Therefore, investigation on the clinical and histological factors predictive of LNM in thyroid cancers was conducted to tailor the extent of surgery and radioactive iodine therapy. STUDY DESIGN Multivariate logistic regressions were performed based on retrospective data from thyroid cancer patients seen between 2013 and 2020 at a single institution. RESULTS Among 913 patients, mean age was 49.4 years, 76.5% were female, 58.3% were White, 21.2% were Black, and 27.9% had LNM. In the multivariate analyses in which the outcome was LNM, White (odds ratio [OR] 1.74, 95% CI 0.98 to 3.15, p = 0.064) and Hispanic patients (OR 2.36, 95% CI 0.97 to 5.77, p = 0.059) trended toward higher risk of LNM compared to Black patients, whereas age (OR 0.98, 95% CI 0.97 to 1.00, p = 0.008) showed protective effect. Tumor size (OR 1.04, 95% CI 1.01 to 1.07, p = 0.007), extrathyroidal extension (OR 2.46, 95% CI 1.53 to 3.97, p < 0.001), lymphovascular invasion (OR 6.30, 95% CI 3.68 to 11.14, p < 0.001), and multifocality (OR 1.47, 95% CI 1.01 to 2.12, p = 0.042) were associated with higher risk of LNM. In another model with outcome as >5 LNM, tumor size (OR 1.07, 95% CI 1.03 to 1.11, p = 0.001), age (OR 0.95, 95% CI 0.93 to 0.97, p < 0.001), extrathyroidal extension (OR 3.20, 95% CI 1.83 to 5.61, p < 0.001), and lymphovascular invasion (OR 6.82, 95% CI 3.87 to 12.17, p < 0.001) remained significant predictors. CONCLUSION Our analyses demonstrated and confirmed that age, tumor size, extrathyroidal extension, and lymphovascular invasion are independent predictors of significant LNM, thereby conferring higher risk of recurrence. Risk of LNM based on these patient characteristics should be considered when planning an operative approach.
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Radhakrishnan A, Reyes-Gastelum D, Abrahamse P, Gay B, Hawley ST, Wallner LP, Chen DW, Hamilton AS, Ward KC, Haymart MR. Physician Specialties Involved in Thyroid Cancer Diagnosis and Treatment: Implications for Improving Health Care Disparities. J Clin Endocrinol Metab 2022; 107:e1096-e1105. [PMID: 34718629 PMCID: PMC8852205 DOI: 10.1210/clinem/dgab781] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 02/07/2023]
Abstract
CONTEXT Little is known about provider specialties involved in thyroid cancer diagnosis and management. OBJECTIVE Characterize providers involved in diagnosing and treating thyroid cancer. DESIGN/SETTING/PARTICIPANTS We surveyed patients with differentiated thyroid cancer from the Georgia and Los Angeles County Surveillance, Epidemiology and End Results registries (N = 2632, 63% response rate). Patients identified their primary care physicians (PCPs), who were also surveyed (N = 162, 56% response rate). MAIN OUTCOME MEASURES (1) Patient-reported provider involvement (endocrinologist, surgeon, PCP) at diagnosis and treatment; (2) PCP-reported involvement (more vs less) and comfort (more vs less) with discussing diagnosis and treatment. RESULTS Among thyroid cancer patients, 40.6% reported being informed of their diagnosis by their surgeon, 37.9% by their endocrinologist, and 13.5% by their PCP. Patients reported discussing their treatment with their surgeon (71.7%), endocrinologist (69.6%), and PCP (33.3%). Physician specialty involvement in diagnosis and treatment varied by patient race/ethnicity and age. For example, Hispanic patients (vs non-Hispanic White) were more likely to report their PCP informed them of their diagnosis (odds ratio [OR]: 1.68; 95% CI, 1.24-2.27). Patients ≥65 years (vs <45 years) were more likely to discuss treatment with their PCP (OR: 1.59; 95% CI, 1.22-2.08). Although 74% of PCPs reported discussing their patients' diagnosis and 62% their treatment, only 66% and 48%, respectively, were comfortable doing so. CONCLUSIONS PCPs were involved in thyroid cancer diagnosis and treatment, and their involvement was greater among older patients and patients of minority race/ethnicity. This suggests an opportunity to leverage PCP involvement in thyroid cancer management to improve health and quality of care outcomes for vulnerable patients.
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Affiliation(s)
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Brittany Gay
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Debbie W Chen
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, GA 30322, USA
| | - Megan R Haymart
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
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20
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The impact of race and ethnicity on thyroid nodules, malignancy risk, and surgical management commentary on "Comparing the rate and extent of malignancy in surgically excised thyroid nodules across race and ethnicity". Am J Surg 2021; 223:615-616. [PMID: 34657720 DOI: 10.1016/j.amjsurg.2021.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022]
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21
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Jackson Levin N, Zhang A, Reyes-Gastelum D, Chen DW, Hamilton AS, Zebrack B, Haymart MR. Change in worry over time among Hispanic women with thyroid cancer. J Cancer Surviv 2021; 16:844-852. [PMID: 34633638 DOI: 10.1007/s11764-021-01078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study is to assess change in worry over time in Hispanic women with thyroid cancer. METHODS Worry about recurrence, quality of life, family at risk, death, and harm from treatments was assessed in 273 Hispanic women with thyroid cancer diagnosed in 2014-2015. Subjects were recruited from Surveillance, Epidemiology, and End Results (SEER) Los Angeles. Participants were surveyed at two points in time (time 1: 2017-2018 and time 2: 2019). Multivariable logistic regression was used to determine correlates with high worry (somewhat, quite a bit, very much) versus low worry (not at all, a little) at time 2. RESULTS For the five worry items, 20.1-39.6% had high worry at both time 1 and time 2. An additional 7.6-13.4% had low worry at time 1 that became high worry at time 2. In multivariable logistic regression controlling for age, recurrence status, education level, and number of complications or side effects symptoms, younger age (20-39) as compared to older (40-79) was associated with high worry about thyroid cancer recurrence (OR 2.16, 95% CI 1.12-4.17). History of recurrent or persistent disease was associated with high worry about harms from treatment (OR 2.94, 95% CI 1.29-6.67). Greater number of complications or side effects of symptoms was associated with more worry across all five items. CONCLUSIONS Some Hispanic women with thyroid cancer have persistently high worry, with young adult Hispanic women vulnerable to worry about recurrence. IMPLICATIONS FOR CANCER SURVIVORS Hispanic women with thyroid cancer may benefit from targeted psychosocial support during survivorship, with interventions informed by patient and cancer characteristics.
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Affiliation(s)
- Nina Jackson Levin
- School of Social Work and Department of Anthropology, University of Michigan, 1080 S. University Ave, Room B660, Ann Arbor, MI, 48109, USA
| | - Anao Zhang
- School of Social Work, University of Michigan, 1080 S. University, Room 3704, Ann Arbor, MI, 48109, USA
| | - David Reyes-Gastelum
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Bldg. 16, 400S-20, MI, 48109, Ann Arbor, USA
| | - Debbie W Chen
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Domino's Farms (Lobby C, Suite 1300), 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI, 48106, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto St., SSB318E, MC9239, Los Angeles, CA, 90089-9239, USA
| | - Bradley Zebrack
- School of Social Work, University of Michigan, 1080 S. University, Room 2778, Ann Arbor, MI, 48109, USA
| | - Megan R Haymart
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Bldg 16, Rm 408E, Ann Arbor, MI, 48109, USA.
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22
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Insurance type is associated with appropriate use of surgical and adjuvant care for differentiated thyroid carcinoma. Surgery 2021; 171:140-146. [PMID: 34600741 DOI: 10.1016/j.surg.2021.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/26/2021] [Accepted: 07/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND We aimed to characterize the association between differentiated thyroid cancer (DTC) patient insurance status and appropriateness of therapy (AOT) regarding extent of thyroidectomy and radioactive iodine (RAI) treatment. METHODS The National Cancer Database was queried for DTC patients diagnosed between 2010 and 2016. Adjusted odds ratios (AOR) for AOT, as defined by the American Thyroid Association guidelines, and hazard ratios (HR) for overall survival (OS) were calculated. A difference-in-differences (DD) analysis examined the association of Medicaid expansion with outcomes for low-income patients aged <65. RESULTS A total of 224,500 patients were included. Medicaid and uninsured patients were at increased risk of undergoing inappropriate therapy, including inappropriate lobectomy (Medicaid 1.36, 95% confidence interval [CI]: 1.21-1.54; uninsured 1.30, 95% CI: 1.05-1.60), and under-treatment with RAI (Medicaid 1.20, 95% CI: 1.14-1.26; uninsured 1.44, 95% CI: 1.33-1.55). Inappropriate lobectomy (HR 2.0, 95% CI: 1.7-2.3, P < .001) and under-treatment with RAI (HR 2.3, 95% CI: 2.2-2.5, P < .001) were independently associated with decreased survival, while appropriate surgical resection (HR 0.3, 95% CI: 0.3-0.3, P < .001) was associated with improved odds of survival; the model controlled for all relevant clinico-pathologic variables. No difference in AOT was observed in Medicaid expansion versus non-expansion states with respect to surgery or adjuvant RAI therapy. CONCLUSION Medicaid and uninsured patients are at significantly increased odds of receiving inappropriate treatment for DTC; both groups are at a survival disadvantage compared with Medicare and those privately insured.
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Zheng H, Lai V, Lu J, Kang JK, Felger EA, Carroll NM, Burman KD, Wartofsky L, Rosen JE. Comparing the rate and extent of malignancy in surgically excised thyroid nodules across race and ethnicity. Am J Surg 2021; 223:617-623. [PMID: 34600740 DOI: 10.1016/j.amjsurg.2021.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/23/2021] [Accepted: 09/22/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Few studies have compared the features of thyroid cancer among races and ethnicities. We hypothesized that race and ethnicity may influence the frequency and features of thyroid malignancy in thyroid nodules. METHOD This was a retrospective chart review of patients between 2013 and 2020 who underwent thyroidectomy. RESULTS In the analysis of 2737 patients, thyroid cancer was less prevalent among Blacks (24.0% vs Whites 52.1%, Hispanics 58.7%, Asians 71.7%, and Others 57.9%, p < 0.001). Thyroid cancer in Blacks was less likely to have extrathyroidal extension (9.7% vs Whites 18.6%, Hispanics 25.8%, Asians 18.2%, and Others 17.8%, p = 0.01), overall nodal involvement (12.4% vs Whites 31.1%, Hispanics 37.5%, Asians 36.3%, and Others 30.1%, p < 0.01), and lateral neck metastasis (4.4% vs Whites 10.8%, Hispanics 6.3%, Asians 13.2%, and Others 9.6%, p = 0.02). CONCLUSIONS Race and ethnicity may play important roles in the risk of malignancy as well as in the extent of thyroid cancer.
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Affiliation(s)
- Hui Zheng
- MedStar-Washington Hospital Center, Division of Endocrine Surgery, 110 Irving St NW, Washington, DC, 20010, USA; MedStar-Georgetown University Hospital, Department of Surgery, 3800 Reservoir Rd NW, Washington, DC, 20007, USA.
| | - Victoria Lai
- MedStar-Washington Hospital Center, Division of Endocrine Surgery, 110 Irving St NW, Washington, DC, 20010, USA
| | - Jana Lu
- Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, DC, 20007, USA
| | - Jin K Kang
- MedStar-Washington Hospital Center, Division of Endocrine Surgery, 110 Irving St NW, Washington, DC, 20010, USA; MedStar-Georgetown University Hospital, Department of Surgery, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
| | - Erin A Felger
- MedStar-Washington Hospital Center, Division of Endocrine Surgery, 110 Irving St NW, Washington, DC, 20010, USA
| | - Nancy M Carroll
- MedStar-Washington Hospital Center, Division of Endocrine Surgery, 110 Irving St NW, Washington, DC, 20010, USA
| | - Kenneth D Burman
- MedStar-Washington Hospital Center, Section of Endocrinology, 110 Irving St NW, Washington DC, 20010, USA
| | - Leonard Wartofsky
- MedStar Health Research Institute, Thyroid Cancer Unit, 100 Irving St NW, Washington, DC, 20010, USA
| | - Jennifer E Rosen
- MedStar-Washington Hospital Center, Division of Endocrine Surgery, 110 Irving St NW, Washington, DC, 20010, USA
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24
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Haymart MR. Progress and Challenges in Thyroid Cancer Management. Endocr Pract 2021; 27:1260-1263. [PMID: 34562612 DOI: 10.1016/j.eprac.2021.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 12/19/2022]
Abstract
The state of thyroid cancer in 2021 is reviewed including the prevalence of thyroid cancer, vulnerable patient groups such as women and young adults, and known and hypothesized risk factors for thyroid cancer. Understanding the overdiagnosis and overtreatment of thyroid cancer and recent efforts to reduce harms secondary to overdiagnosis and overtreatment are addressed with optimism that future work will continue to evaluate and improve the care of patients with thyroid cancer.
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Affiliation(s)
- Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
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25
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Greenberg JA, Thiesmeyer JW, Ullmann TM, Egan CE, Valle Reyes F, Moore MD, Ivanov NA, Laird AM, Finnerty BM, Zarnegar R, Fahey TJ, Beninato T. Association of the Affordable Care Act with access to highest-volume centers for patients with thyroid cancer. Surgery 2021; 171:132-139. [PMID: 34489109 DOI: 10.1016/j.surg.2021.04.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/02/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear. METHODS The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile. RESULTS In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001). CONCLUSIONS Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.
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Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/JacquesGreenbe2
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/JessicaThiesme1
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/TUllmannMD
| | - Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/CaitlinEgan18
| | | | - Maureen D Moore
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/maureenmooremd
| | - Nikolay A Ivanov
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/n_a_ivanov
| | - Amanda M Laird
- Department of Surgery Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. https://twitter.com/amlaird
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/FinnertyMD
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/RasaZarnegarMD
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/tjf3endosurg
| | - Toni Beninato
- Department of Surgery Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
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Megwalu UC, Ma Y, Osazuwa‐Peters N, Orloff LA. Clinical presentation and survival outcomes of well-differentiated thyroid cancer in Filipinos. Cancer Med 2021; 10:5964-5973. [PMID: 34288520 PMCID: PMC8419748 DOI: 10.1002/cam4.4149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Background Filipinos have higher recurrence rates compared to other racial/ethnic groups, which might suggest a higher propensity for aggressive disease. The goal of this study was to perform a population‐based analysis of disease extent at diagnosis and survival outcomes in Filipino patients with well‐differentiated thyroid cancer relative to other racial/ethnic groups. Methods The study cohort comprised adult patients with well‐differentiated thyroid cancer diagnosed between 2004 and 2015, identified in the California Cancer Registry. Rates of extrathyroidal extension, nodal metastasis, and distant metastasis were compared between Filipinos, Non‐Filipino Asians, and Non‐Asians using multilevel logistic regression models. Survival outcomes were compared using Cox regression models, utilizing a sequential modeling approach. Results Filipino ethnicity was associated with extrathyroidal extension (OR 1.35, 95% CI 1.11–1.63) compared with non‐Asians and non‐Filipino Asians. Filipino ethnicity was also associated with nodal metastasis (OR 1.32, 95% CI 1.18–1.46), and with worse OS (Hazard Ratio [HR] 1.45, 95% CI 1.20–1.75) and DSS (HR 1.51, 95% CI 1.12–2.04). After adjusting for demographic and clinical factors, Filipino ethnicity was no longer associated with OS (HR 1.03, 95% CI 0.84–1.25) or DSS (HR 0.93, 95% CI 0.68–1.28). Conclusion Filipino patients with thyroid cancer are more likely to present with locoregionally advanced disease compared with non‐Filipino Asians and non‐Asians. Furthermore, Filipino patients have worse survival outcomes compared with non‐Filipino Asians and non‐Asians. However, this appears to be driven by the higher rates of locoregionally advanced disease in Filipino patients.
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Affiliation(s)
- Uchechukwu C. Megwalu
- Department of Otolaryngology—Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Yifei Ma
- Department of Otolaryngology—Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Nosayaba Osazuwa‐Peters
- Department of Head and Neck Surgery and Communication SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Lisa A. Orloff
- Department of Otolaryngology—Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
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Megwalu UC, Ma Y. Racial/Ethnic Disparities in Use of High-Quality Hospitals Among Thyroid Cancer Patients. Cancer Invest 2021; 39:482-488. [PMID: 34077307 DOI: 10.1080/07357907.2021.1938108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study examined racial/ethnic differences in the use of high-quality hospitals among thyroid cancer patients. The study included adult patients diagnosed between 2004 and 2015 identified in the California Cancer Registry linked with hospital discharge records. Hospital quality was defined using a composite thyroid cancer-specific hospital quality score. Black (risk ratio [RR] 0.75, 95% CI 0.70-0.80), Hispanic (RR 0.73, 95% CI 0.71-0.75), and Asian/Pacific Islander patients (RR 0.86, 95% CI 0.84-0.89) were less likely to be treated in high-quality hospitals than non-Hispanic White patients. This disparity persisted after adjusting for insurance status and socioeconomic status.
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Affiliation(s)
- Uchechukwu C Megwalu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Yifei Ma
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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Crepeau PK, Kulkarni K, Martucci J, Lai V. Comparing surgical thoroughness and recurrence in thyroid cancer patients across race/ethnicity. Surgery 2021; 170:1099-1104. [PMID: 34127303 DOI: 10.1016/j.surg.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/05/2021] [Accepted: 05/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND For patients with differentiated thyroid cancer who will receive postoperative radioactive iodine, thyroid remnant uptake can be calculated and may point to the thoroughness of the surgical resection. In the United States, outcome disparities exist among ethnic/racial minorities with differentiated thyroid cancer. Data about surgical thoroughness and recurrence rates across races/ethnicities do not exist. This study compared the amount of thyroid remnant uptake and cancer recurrence rates across race/ethnicity. METHODS This was a retrospective analysis of adult patients with differentiated thyroid cancer who had postoperative radioactive iodine in 2017 and 2018 and were followed to 2020. We collected thyroid bed remnant uptake from postoperative radioactive iodine scans and analyzed it as a ratio of percent of uptake to dose of radioactive iodine received to control for varying radioactive iodine doses. Thyroid remnant, uptake to dose of radioactive iodine received, and recurrence were evaluated across race/ethnicity. RESULTS Of 218 patients: 61% were White, 21% Black, 11% Asian, and 7% Hispanic; 72% were female. Seventy-one percent of patients had their surgery done by a high-volume surgeon, although volume data were not available for all. In White, Black, Asian, and Hispanic patients, median uptake was 0.68%, 0.44%, 1.5%, and 0.8%, respectively (P = .13). We did not observe differences in median uptake to dose of radioactive iodine received across groups (P = .41). Recurrence rate was 17.0% among White patients, 16.7% among Black patients, 17.6% among Asian patients, and 16.7% among Hispanic patients (P = 1.00). CONCLUSION We did not observe differences across race/ethnicity in surgical thoroughness or rate of recurrence. These findings suggest that disparities may be mitigated when ethnic/racial minorities have similar access to quality surgical care.
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Affiliation(s)
- Philip K Crepeau
- Department of Surgery, MedStar Georgetown University/Washington Hospital Center, Washington, DC
| | - Kanchan Kulkarni
- Department of Nuclear Medicine, MedStar Washington Hospital Center, Washington, DC
| | | | - Victoria Lai
- Department of Surgery, MedStar Georgetown University/Washington Hospital Center, Washington, DC.
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29
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Wallner LP, Banerjee M, Reyes-Gastelum D, Hamilton AS, Ward KC, Lubitz C, Hawley ST, Haymart MR. Multilevel Factors Associated With More Intensive Use of Radioactive Iodine for Low-Risk Thyroid Cancer. J Clin Endocrinol Metab 2021; 106:e2402-e2412. [PMID: 33687063 PMCID: PMC8118575 DOI: 10.1210/clinem/dgab139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Indexed: 12/28/2022]
Abstract
CONTEXT The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs. OBJECTIVE To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer. METHODS This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer. RESULTS Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67). CONCLUSIONS Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.
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Affiliation(s)
- Lauren P Wallner
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
| | | | - Ann S Hamilton
- Keck School of Medicine, University of Southern California, Department of Preventive Medicine, Los Angeles, CA, USA
| | - Kevin C Ward
- Emory University, Department of Epidemiology, Atlanta, GA, USA
| | - Carrie Lubitz
- Massachusetts General Hospital, Department of Surgery, Boston, MA, USA
| | - Sarah T Hawley
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Departments of Health Management and Policy and Health Behavior and Education, Ann Arbor, MI, USA
| | - Megan R Haymart
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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30
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Maduka RC, Gibson CE, Chiu AS, Jean RA, Wills-Johnson N, Azar SA, Oliveira K, Ahuja V. Racial disparities in surgical outcomes for benign thyroid disease. Am J Surg 2020; 220:1219-1224. [DOI: 10.1016/j.amjsurg.2020.06.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/22/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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Abstract
Until recently, thyroid cancer was one of the most rapidly increasing cancers in the United States. Disparities exist in many aspects of thyroid cancer care as a result of the multifactorial interplay of systemic, patient, and physician factors. To better understand the management of thyroid cancer in populations at risk for health disparities and subsequently implement changes that will lead to health equity for all patients with thyroid cancer, health services research with innovative approaches is necessary.
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Affiliation(s)
- Debbie W. Chen
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan R. Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Mallick R, Xie R, Kirklin JK, Chen H, Balentine CJ. Race and Gender Disparities in Access to Parathyroidectomy: A Need to Change Processes for Diagnosis and Referral to Surgeons. Ann Surg Oncol 2020; 28:476-483. [PMID: 32542566 DOI: 10.1245/s10434-020-08707-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hyperparathyroidism substantially impairs quality of life, and effective treatment depends on timely referral to surgeons. We hypothesized that there would be race and gender disparities in the time from initial diagnosis of hyperparathyroidism to treatment with parathyroidectomy. METHODS We reviewed administrative data on 2289 patients with hypercalcemia (calcium > 10.5 mg/dL) and abnormal parathyroid hormone levels who were seen at a tertiary referral center from 2011 to 2016. We used two-phase parametric hazard modeling to identify predictors of time from index abnormal calcium until parathyroidectomy. RESULTS The median age of our cohort was 63 years, and 1685 (74%) were women. Of the total patients, 1301 (57%) were Caucasian, and 946 (41%) were African-American. Only 490 (21%) patients underwent parathyroidectomy. Among patients undergoing surgery, time from index high calcium to surgical treatment was longest for African-American men, who waited a median of 13.6 months (interquartile range IQR 2-28), compared with 2.9 months (IQR 1-8) for Caucasian males (p < 0.05). African-American women waited a median of 6.7 months (IQR 2-16) versus 3.5 months (IQR 2-14) for Caucasian women (p < 0.05). At 1 year after the index abnormal calcium, only 6% of black men underwent surgery compared with 20% of white males (p < 0.05). Similarly, 13% of black women underwent surgery versus 20% of white women (p < 0.05). These differences remained significant after adjusting for age, calcium levels, insurance, and comorbidities. CONCLUSIONS African-Americans face substantial delays in access to parathyroidectomy after diagnosis with hyperparathyroidism that could impair quality of life and increase health care costs. We must improve systems of diagnosis and referral to ensure timely treatment of hyperparathyroidism.
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Affiliation(s)
- Reema Mallick
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rongbing Xie
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA.,Kirklin Institute for Research in Surgical Outcomes, University of Alabama-Birmingham, Birmingham, AL, USA
| | - James K Kirklin
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA.,Kirklin Institute for Research in Surgical Outcomes, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Courtney J Balentine
- North Texas VA Health Care System, Dallas, TX, USA. .,Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Chen DW, Reyes-Gastelum D, Wallner LP, Papaleontiou M, Hamilton AS, Ward KC, Hawley ST, Zikmund-Fisher BJ, Haymart MR. Disparities in risk perception of thyroid cancer recurrence and death. Cancer 2020; 126:1512-1521. [PMID: 31869452 PMCID: PMC7178109 DOI: 10.1002/cncr.32670] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/17/2019] [Accepted: 11/26/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND To the authors' knowledge, studies regarding risk perception among survivors of thyroid cancer are scarce. METHODS The authors surveyed patients who were diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County (2632 patients; 63% response rate). The analytic cohort was defined by a ≤5% risk of disease recurrence and mortality (1597 patients). Patients estimated their recurrence and mortality risks separately (increments of 10% and endpoints of ≤5% and ≥95%). Both outcomes were dichotomized between reasonably accurate estimates (risk perception of ≤5% or 10%) versus overestimation (risk perception of ≥20%). Multivariable logistic regression was used to identify factors associated with risk overestimation, and the relationships between overestimation and both worry and quality of life were evaluated. RESULTS In the current study sample, 24.7% of patients overestimated their recurrence risk and 12.5% overestimated their mortality risk. A lower educational level was associated with overestimating disease recurrence (≤high school diploma: odds ratio [OR], 1.64 [95% CI, 1.16-2.31]; and some college: OR, 1.36 [95% CI, 1.02-1.81]) and mortality (≤high school diploma: OR, 1.86 [95% CI, 1.18-2.93]) risk compared with those attaining at least a college degree. Hispanic ethnicity was found to be associated with overestimating recurrence risk (OR, 1.44, 95% CI 1.02-2.03) compared with their white counterparts. Worry about recurrence and death was found to be greater among patients who overestimated versus those who had a reasonably accurate estimate of their risk of disease recurrence and mortality, respectively (P < .001). Patients who overestimated mortality risk also reported a decreased physical quality of life (mean T score, 43.1; 95% CI, 41.6-44.7) compared with the general population. CONCLUSIONS Less educated patients and Hispanic patients were more likely to report inaccurate risk perceptions, which were associated with worry and a decreased quality of life.
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Affiliation(s)
- Debbie W. Chen
- Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI, United States
| | - David Reyes-Gastelum
- Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI, United States
| | - Lauren P. Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Maria Papaleontiou
- Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI, United States
| | - Ann S. Hamilton
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kevin C. Ward
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brian J. Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
- Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Megan R. Haymart
- Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI, United States
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Saeed NA, Kelly JR, Deshpande HA, Bhatia AK, Burtness BA, Judson BL, Mehra S, Edwards HA, Yarbrough WG, Peter PR, Holt EH, Decker RH, Husain ZA, Park HS. Adjuvant external beam radiotherapy for surgically resected, nonmetastatic anaplastic thyroid cancer. Head Neck 2020; 42:1031-1044. [PMID: 32011055 DOI: 10.1002/hed.26086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 01/02/2020] [Accepted: 01/10/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND EBRT in resected, nonmetastatic anaplastic thyroid cancer (ATC) remains undefined. We evaluated patterns/outcomes with EBRT and chemotherapy in this setting. METHODS This retrospective analysis included patients identified from the National Cancer Database with nonmetastatic ATC from 2004 to 2014 who underwent non-palliative resection. RESULTS Our analysis included 496 patients, including 375 who underwent adjuvant EBRT (among whom 198 received concurrent chemotherapy). The median age was 68 years. On MVA, EBRT was associated with sex (OR 0.5, 95% CI 0.3-0.8, P = .002) and income (OR 2.2, 95% CI 1.4-3.3, P < .001). EBRT was associated with longer OS on UVA (12.3 vs 9.1 months, P = .004) and MVA (HR 0.7 [CI 0.6-0.9], P = .004). Concurrent chemoradiation was associated with longer OS on UVA (14.0 vs 9.1 months, P = .003) and MVA (HR 0.6 [CI 0.5-0.8], P < .001). CONCLUSION Adjuvant EBRT is associated with longer OS in resected, nonmetastatic ATC, with additional improved survival with concurrent chemotherapy.
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Affiliation(s)
- Nadia A Saeed
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Jacqueline R Kelly
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Hari A Deshpande
- Department of Internal Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Aarti K Bhatia
- Department of Internal Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Barbara A Burtness
- Department of Internal Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin L Judson
- Department of Otolaryngology-Head & Neck Surgery, Boston University School of Medicine, Boston
| | - Saral Mehra
- Department of Otolaryngology-Head & Neck Surgery, Boston University School of Medicine, Boston
| | - Heather A Edwards
- Department of Otolaryngology-Head & Neck Surgery, Boston University School of Medicine, Boston
| | - Wendell G Yarbrough
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Patricia R Peter
- Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth H Holt
- Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Zain A Husain
- Department of Radiation Oncology, University of Toronto, Stewart Building, Toronto, Ontario, Canada
| | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
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Moten AS, Zhao H, Intenzo CM, Willis AI. Disparity in the use of adjuvant radioactive iodine ablation among high-risk papillary thyroid cancer patients. Eur J Surg Oncol 2019; 45:2090-2095. [DOI: 10.1016/j.ejso.2019.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/20/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022] Open
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36
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Racial and Socioeconomic Disparities in Access and Utilization of Adrenal Metastasectomy. World J Surg 2019; 44:163-170. [DOI: 10.1007/s00268-019-05204-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ramirez AG, Schneider EB, Mehaffey JH, Zeiger MA, Hanks JB, Smith PW. Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity. Am Surg 2019. [DOI: 10.1177/000313481908500934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time–related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients’ home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1–107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.
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Affiliation(s)
- Adriana G. Ramirez
- From the Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Eric B. Schneider
- From the Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - J. Hunter Mehaffey
- From the Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Martha A. Zeiger
- From the Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - John B. Hanks
- From the Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Philip W. Smith
- From the Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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Adequacy of Lymph Node Yield for Papillary Thyroid Cancer: An Analysis of 23,131 Patients. J Surg Res 2019; 244:566-573. [PMID: 31352235 DOI: 10.1016/j.jss.2019.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/31/2019] [Accepted: 06/07/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Threshold numbers for defining adequacy of lymph node (LN) yield have been determined for evaluation of occult nodal disease during papillary thyroid cancer (PTC) surgery. This study assesses the prevalence of adequate LN yield and estimates its association with patient clinicopathologic characteristics. MATERIALS AND METHODS Adult patients with cN1 pT1b or pT2 and cN0 or cN1 pT3 M0 PTC ≥1 cm who received surgery with ≥1 LN resected were identified from the National Cancer Database, 2004-2015. Adequate yield was defined as removing ≥6, 9, and 18 LNs for pT1b, pT2, and pT3 stages, respectively, based on recently published literature. Univariable and multivariable logistic regression were used to determine factors associated with adequate yield. RESULTS A total of 23,131 patients were included; 7544 (32.6%) had adequate LN yield. Rate of adequate yield increased from 19.9% to 36.6% over time. After adjustment, patients at academic facilities were more likely to have adequate yield than those at community centers [OR 1.94 (95% CI 1.55-2.41), P < 0.001]. Patients with more advanced tumors were less likely to have adequate yield (pT1b: 75.9% versus pT2: 64.5% versus pT3: 24.6% adequate LN yield, P < 0.001). Patients with adequate LN yield were 0.89 times likely to receive radioactive iodine compared with those with inadequate yield [OR 0.98 (95% CI 0.81-0.98), P = 0.02]. CONCLUSIONS The rate of adequate LN yield has increased over time, but only a minority of lymphadenectomies performed for PTC can be defined as adequate. Disparities still exist based on patient and facility characteristics; patients with more advanced tumors appear less likely to have adequate LN yield.
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39
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The overuse of radioactive iodine in low-risk papillary thyroid cancer patients. Surg Oncol 2019; 29:184-189. [DOI: 10.1016/j.suronc.2019.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/23/2019] [Accepted: 05/18/2019] [Indexed: 11/20/2022]
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James BC, Timsina L, Graham R, Angelos P, Haggstrom DA. Changes in total thyroidectomy versus thyroid lobectomy for papillary thyroid cancer during the past 15 years. Surgery 2019; 166:41-47. [PMID: 30904172 DOI: 10.1016/j.surg.2019.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/19/2018] [Accepted: 01/08/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND The incidence of papillary thyroid cancer has increased substantially during the past 15 years, which is likely related to an increased detection of small, nonlethal cancers. Studies have shown that patients may have a similar prognosis when undergoing less aggressive surgical intervention, such as thyroid lobectomy. The objective of this study is to determine whether surgical treatment patterns for papillary thyroid cancer have changed during the past 15 years. METHODS We performed a retrospective cohort study evaluating changes in the incidence and proportion of total thyroidectomy versus thyroid lobectomy for histologically confirmed papillary thyroid cancers, using the National Cancer Institute Surveillance, Epidemiology, and End Results cancer registries between 2000 and 2014. RESULTS During the study period, 44,537 patients underwent surgical treatment for papillary thyroid cancer, of which 77% were female and 81.3% were white. The incidence of papillary thyroid cancer more than doubled: from 6.2 (5.9-6.5) to 13.0 (12.5-13.4) per 100,000. The proportion of total thyroidectomy among all papillary cases increased from 78.16% in 2000 to 85.67% in 2014, and the proportion of thyroid lobectomy dropped from 16.62% to 11.41%. When stratified by tumor size, we observed a sustained and increasing gap in the proportions of total thyroidectomy and thyroid lobectomy. CONCLUSION The incidence of total thyroidectomy has not decreased despite recommendations encouraging consideration of lobectomy for patients with small papillary thyroid cancers. Although these findings could be attributed to the lag between scientific evidence and clinical practice, further work is warranted to explore any additional patient and provider factors that may explain this lack of change.
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Affiliation(s)
- Benjamin C James
- Section of Endocrine Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Lava Timsina
- Indiana University School of Medicine, Department of Surgery, Indianapolis
| | - Ryan Graham
- Indiana University School of Medicine, Indianapolis
| | - Peter Angelos
- Section of Endocrine Surgery, Department of Surgery, University of Chicago, IL
| | - David A Haggstrom
- Indiana University School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis; Center for Health Information and Communication, US Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN
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Iwata AJ, Bhan A, Lahiri S, Williams AM, Burmeister C, Chang SS, Singer MC. INCIDENTAL THYROID NODULES: RACE/ETHNICITY DISPARITIES AND OUTCOMES. Endocr Pract 2018; 24:941-947. [PMID: 30084685 DOI: 10.4158/ep-2018-0173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Black patients have a significantly lower incidence of well-differentiated thyroid cancer (WDTC) compared to all other race/ethnic groups, while white patients appear to be at greater risk. This study examines incidental thyroid nodules (ITNs) to assess whether racial disparities in WDTC arise from a differential discovery of ITNs-perhaps due to socioeconomic disparities-or reflect true differences in thyroid cancer rates. METHODS A retrospective review was performed of all patients who underwent fine-needle aspiration (FNA) of thyroid nodules by our academic medical center's endocrinology division between January 2006 and December 2010. Medical records were reviewed to identify whether the biopsied thyroid nodule was discovered incidentally through nonthyroid-related imaging or identified by palpation. RESULTS FNAs were performed on 1,369 total thyroid nodules in 1,141 study patients; 547 (48%) were classified as white, and 593 (52%) were classified as nonwhite. Among this cohort, 36.6% of patients underwent biopsy for an ITN. White patients were 1.6 times more likely to have undergone a biopsy for a nodule that was incidentally identified compared to nonwhites ( P<.0001). Indicators of socioeconomic status (SES) did not have a significant association with ITNs. Within the ITN cohort, 4.9% of nonwhite patients were found to have a thyroid malignancy compared to 12.9% of white patients ( P<.01). CONCLUSION The higher incidence of thyroid cancer in white patients appears to be not only due to diagnostic bias, but also to a true difference in cancer prevalence. ABBREVIATIONS FNA = fine-needle aspiration; ITN = incidental thyroid nodule; SEER = Surveillance Epidemiology and End Results; SES = socioeconomic status; WDTC = well-differentiated thyroid cancer.
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Otolaryngology-Related Disorders in Underserved Populations, Otolaryngology Training and Workforce Considerations in North America. Otolaryngol Clin North Am 2018; 51:685-695. [DOI: 10.1016/j.otc.2018.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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