Disparities in Treatment for Differentiated Thyroid Cancer

Disparities in Diagnosis, Treatment, and Outcomes in Pediatric Thyroid Cancer

Pediatric thyroid cancer is rising with an estimated incidence of 1.4 cases per 100,000 children per year and favorable survival outcomes; however, certain vulnerable populations present with more advanced disease, have poorer disease-specific survival, and face disparities in treatment. The problem is complex and multifactorial, though common factors are race/ethnicity, language proficiency, socioeconomic status including income and insurance status, and access to care. The aim of this review is to illustrate the various disparities that impact pediatric thyroid cancer presentation, treatment differences, and outcomes, while also providing multipronged solutions that can help curb patient outcome differences.

Racial and ethnic disparities in the risk of second primary malignancies in differentiated thyroid cancer patients: a population-based study

BACKGROUND

There is limited evidence on the risks of second primary malignancies (SPMs) among patients with differentiated thyroid cancer (DTC), particularly in relation to racial disparities. We aim to examine racial and ethnic disparities in the risk and temporal patterns of SPMs among DTC survivors in the U.S.

METHODS

This retrospective cohort study, grounded in population-based data from the Surveillance, Epidemiology, and End Results (SEER) program, focused on DTC patients diagnosed between 2004 and 2015. Standardized incidence ratios (SIR) and 95% confidence intervals were employed to estimate high-risk sites for SPMs among different races. The competing risks model was applied to assess SPM risks and risk factors across racial groups, with mediation analysis conducted for selected variables.

RESULTS

Among 90,186 DTC patients, 8.3% developed SPMs. DTC survivors face a 15% higher risk of developing SPMs compared to the general population. Blacks demonstrated a significantly lower risk of SPMs, while other ethnic groups faced higher risks than Whites. Specific SPM risk factors for Whites, Blacks, and other ethnicities were receiving radiotherapy, diagnosis at a distant stage, and tumors exceeding 40 mm, respectively. Specifically, Blacks and other ethnic groups primarily encounter SPMs in the salivary glands, soft tissues, hematologic, and urinary systems, often earlier than in Whites. Conversely, Whites had a broader distribution of risk sites, with a notable risk for other endocrine tumors, manifesting 48-87 months post-diagnosis.

CONCLUSIONS

DTC patients show significant racial and ethnic disparities in high-risk sites, temporal patterns, SPM risks and risk factors. Personalized follow-up for diverse ethnic backgrounds can ameliorate disparities, enhancing SPM risk and survival outcomes.

Cancer and careers: Perspectives and experiences of patients with differentiated thyroid cancer

BackgroundAs new cases of differentiated thyroid cancer become younger and survival rates improve, young and middle-aged patients have become the main population with the disease. Therefore, most patients are in the developmental stage of work. Returning to work after cancer treatment has become common.ObjectiveTo explore the perceptions and experiences of patients with differentiated thyroid cancer about continuing to work after cancer.MethodsUsing the descriptive phenomenological research method, semi-structured in-depth interviews were conducted with 13 patients with differentiated thyroid cancer who entered the follow-up period, and the data were analyzed using the Colaizzi 7-step analysis method and managed with the help of Nvivo 11.ResultsThe themes of work experience are as follows: necessary reasons for continuing to work: survival needs, supporting family, work for recovery; negative effects of disease in work status: distressing cancer symptoms, fear of disease recurrence, difficult choice between health and future, labeling of cancer patients; support and coping: family support, social support, professional information support.ConclusionsEconomic factors play an important role in differentiated thyroid cancer survivors' choice to continue working. Patients who are currently in a work status have some distress, but to some extent, the work status facilitates survival and treatment. Multidisciplinary and individualized medical interventions, as well as employer and policy support, can help to mitigate the harm caused by cancer diagnosis and treatment and promote patients' continued work and improved quality of life.

Racial disparities in thyroid cancer outcomes: A systematic review

INTRODUCTION

Racial disparities in surgical outcomes are well described, but a paucity of literature exists examining trends in outcomes of thyroid cancer. We performed a systematic review of studies on thyroid cancer outcomes to better delineate the impact of race.

METHODS

A comprehensive search strategy was performed in several academic databases for articles on thyroid cancer and surgical outcomes in accordance with PRISMA guidelines. A total of 1771 abstracts were reviewed. Abstracts were screened by two independent reviewers with disagreements resolved by a third. Studies that were based in the United States, included single center, unique data, focused on outcomes of differentiated thyroid cancer, were performed on adults >18 years old, and reported race in their results were included. Chi square statistics with Yates correction were calculated on the compiled data. The protocol was registered on PROSPERO (CRD42022300021).

RESULTS

Twelve studies met inclusion criteria with data on 7,221patients. Among the included studies, our study consists of 67 ​% White patients, 22 ​% Black patients, 7 ​% Hispanic patients, and 3 ​% Asian patients. Extrathyroidal extension was observed in 8.4 ​% (n ​= ​13) of White patients. In comparison to White patients, Black (18.4 ​%, n ​= ​21, p ​= ​0.024) and Hispanic patients (28.3 ​%, n ​= ​30, p ​< ​0.001) had a higher incidence of extrathyroidal extension, while a similar incidence was observed in Asian patients (14.0 ​%, n ​= ​8, p ​= ​0.336). Compared to White patients (22.2 ​%, n ​= ​34), Black (12.4 ​%, n ​= ​13, p ​= ​0.065), Hispanic (16.0 ​%, n ​= ​15, p ​= ​0.301), and Asian (18.4 ​%, n ​= ​9, p ​= ​0.709) patients had a similar incidence of T1a stage. White patients had 10.1 ​% (n ​= ​54) recurrence rates, and Black (13.5 ​%, n ​= ​7, p ​= ​0.595), Hispanic (10.5 ​%, n ​= ​2, p ​= ​1.000), and Asian (11.1 ​%, n ​= ​3, p ​= ​1.000) patients had similar recurrence rates.

CONCLUSIONS

Race is seldom reported in outcomes on studies of thyroid cancer. From our analysis we conclude that non-White patients may have a higher risk of more advanced local disease at presentation. More data with granular detail on race is necessary to better understand racial disparities in thyroid cancer outcomes and how to alleviate them.

Racial-Ethnic Comparison of Treatment for Papillary Thyroid Cancer in the Military Health System

PURPOSE

We aimed to compare Asian or Pacific Islander, Black, Hispanic, and non-Hispanic White patients in treatment for papillary thyroid cancer (PTC) in the equal access Military Health System to better understand racial-ethnic cancer health disparities observed in the United States.

METHODS

We used the MilCanEpi database to identify a cohort of men and women aged 18 or older who were diagnosed with PTC between 1998 and 2014. Low- or high-risk status was assigned using tumor size and lymph node involvement. Treatment with surgery (e.g., thyroidectomy) overall and treatment by risk status [active surveillance (low-risk) or adjuvant radioactive iodine (RAI) (high-risk)] was compared between racial-ethnic groups using multivariable logistic regression and expressed as adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

RESULTS

The study included 598 Asian, 553 Black, 340 Hispanic, and 2958 non-Hispanic White patients with PTC. Asian (AOR = 1.21, 95% CI 0.98, 1.49), Black (AOR = 1.07, 95% CI 0.87, 1.32), and Hispanic (AOR = 0.92, 95% CI 0.71, 1.19) patients were as likely as White patients to receive surgery. By risk status, there were no significant racial-ethnic differences in receipt of active surveillance or thyroidectomy for low-risk PTC or in thyroidectomy or total thyroidectomy with adjuvant RAI for high-risk PTC.

CONCLUSIONS

In the Military Health System, where patients have equal access to care, there were no overall racial-ethnic differences in surgical treatment for PTC. As American Thyroid Association guidelines evolve to include more conservative treatment, further research is warranted to understand potential disparities in active surveillance and surgical management in U.S. healthcare settings.

Relaxin-2 is a novel biomarker for differentiated thyroid carcinoma in humans

Relaxin's role in differentiated thyroid cancer (DTC) has been suggested but its characterization in a large clinical sample remains limited. We performed immunohistochemistry for relaxin-2 (RLN2), CD68 (total macrophages), CD163 (M2 macrophages) on tissue microarrays from 181 subjects with non-distant metastatic DTC, and 185 subjects with benign thyroid tissue. Mean pixels/area for each marker was compared between tumor and adjacent tissue via paired-t test and between DTC and benign subjects via t-test assuming unequal variances. RNA qPCR was performed for expression of RLN2, RLN1, and RXFP1 in cell lines. Amongst 181 cases, the mean age was 46 years, 75 % were females. Tumoral tissue amongst the DTC cases demonstrated higher mean expression of RLN2 (53.04 vs. 9.79; p < 0.0001) compared to tumor-adjacent tissue. DTC tissue also demonstrated higher mean expression of CD68 (14.46 vs. 4.79; p < 0.0001), and CD163 (23.13 vs. -0.73; p < 0.0001) than benign thyroid. These markers did not differ between tumor-adjacent and benign thyroid tissue groups; and amongst cases, did not differ by demographic or clinicopathologic features. RLN1 and RXFP1 expression was detected in a minority of the cell lines, while RLN2 was expressed by 6/7 cell lines. In conclusion, widespread RLN2 expression in DTC tissue and most cell lines demonstrates that RLN2 acts in a paracrine manner, and that RLN1 and RXFP1 are probably not involved in thyroid cancer cell signaling. RLN2 is a biomarker for thyroid carcinogenesis, being associated with but not secreted by immunosuppressive macrophages. These findings will guide further investigations for therapeutic avenues against thyroid cancer.

Factors influencing TSH suppression efficacy in postoperative papillary thyroid carcinoma patients: a retrospective cohort study

OBJECTIVES

While surgery plays a crucial role in treating papillary thyroid carcinoma (PTC), the potential effects of subsequent TSH suppression therapy on prognosis should not be overlooked. This study aims to investigate the factors that influence postoperative TSH suppression therapy in patients with PTC.

METHODS

This study was a retrospective cohort study conducted at our hospital. It included 268 patients who underwent surgery and were pathologically diagnosed with PTC between February 2019 and February 2021. The selected patients received postoperative TSH suppression therapy. Based on the TSH level measured 12 months after surgery, the patients were divided into two groups: TSH level conforming group (n = 80) and non-conforming group (n = 188). We then compared the general clinical data, clinicopathological characteristics, preoperative laboratory test indicators, postoperative levothyroxine sodium tablet dosage, follow-up frequency, and thyroid function-related indicators between the two groups of patients. The correlation between the observed indicators and the success of TSH suppression therapy was further analyzed, leading to the identification of influencing factors for TSH suppression therapy.

RESULTS

There were no statistically significant differences in general clinical data and clinicopathological characteristics between the two groups of patients (P > 0.05). The proportion of patients with preoperative TSH ≥ 2.0 mU/L was higher in the non-conforming group compared to the TSH level conforming group (P < 0.05), and the ROC curve analysis indicated that the area under the curve for the preoperative TSH index was 0.610 (P < 0.05). The proportion of patients in the TSH level conforming group who took oral levothyroxine sodium tablets at a dose of ≥ 1.4 µg/kg·d after surgery was higher (P < 0.05). The postoperative levels of FT3 and FT4 were higher in the TSH level conforming group (P < 0.05). The results of binary logistic regression analysis indicated that factors "Postoperative TSH level ≥ 2 mU/L", "Levothyroxine sodium tablet dose<1.4 µg/kg·d", and "Combined with Hashimoto thyroiditis" were significantly associated with an elevated risk of postoperative TSH levels failing to reach the target (P < 0.05).

CONCLUSION

Optimal thyroid function in patients with PTC post-surgery is best achieved when adjusting the dose of levothyroxine sodium in a timely manner to reach the target TSH level during follow-up visits.

Social Determinants of Health and Disparities in Thyroid Care

BACKGROUND

There have been documented racial and ethnic disparities in the care and clinical outcomes of patients with thyroid disease.

CONTEXT

Key to improving disparities in thyroid care is understanding the context for racial and ethnic disparities, which includes acknowledging and addressing social determinants of health. Thyroid disease diagnosis, treatment, and survivorship care are impacted by patient- and system-level factors, including socioeconomic status and economic stability, language, education, health literacy, and health care systems and health policy. The relationship between these factors and downstream clinical outcomes is intricate and complex, underscoring the need for a multifaceted approach to mitigate these disparities.

CONCLUSION

Understanding the factors that contribute to disparities in thyroid disease is critically important. There is a need for future targeted and multilevel interventions to address these disparities, while considering societal, health care, clinician, and patient perspectives.

The impact of social determinants of health on thyroid cancer mortality and time to treatment

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.

Disparities in access to high-volume parathyroid surgeons in the United States: A call to action

BACKGROUND

Parathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States.

METHODS

We used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care.

RESULTS

We identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P < .001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P < .001).

CONCLUSION

Older adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients.

Parathyroidectomy outcomes for Asians in the United States: Implications for resident surgical education

Introduction

Outcomes for Asian patients in the United States are often overlooked in the surgical literature. Surgical education includes little emphasis on reporting outcomes for Asian patients in the United States. Our null hypothesis (H0) is that there is no difference in surgical complications following parathyroid surgery between Asians and all other ethnicities in the United States. Our alternate hypothesis (H1) is that Asians have more incidences of certain complications (possibly due to culture and language barriers).

Methods

Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for parathyroidectomy and patient race. Complications within 30 days of surgery were extracted.

Results

Among, White, Black, Asian, Pacific Islanders, Native Americans, and Hispanic patients of the United States the Asians (p = 0.018) and Blacks (p = 0.003) had increased operative time for parathyroid surgery compared to other groups. Hispanics had the most surgical complications (p = 0.025). Blacks had statistically significant longer hospital stay (p < 0.0001).

Discussion/conclusion

United States Asian patient data is not typically analyzed separately for complications. We found that in the United States Asians have increased operative time for parathyroidectomy. Future studies of healthcare inequities should include analysis of data for Asian surgical data in the United States as this may help prevent future surgical complications.