Access Denied: Disparities in Thyroid Cancer Clinical Trials

Evaluating Diversity in Thyroid Cancer Clinical Trials: Application of the Clinical Diversity Rating Framework

BACKGROUND

Despite progress in recruiting representative patient samples for clinical trials, disparities persist. This study quantifies the representation of historically marginalized groups-female patients, members of racial/ethnic minority groups, and older patients-in thyroid cancer clinical trials and proposes strategies for improving their participation.

METHODS

We performed a systematic review and meta-analysis of thyroid cancer treatment studies conducted in the United States and published between January 2018 and December 2023, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Studies were sourced from EMBASE and PubMed. Independent and duplicate screening and data extraction were conducted to ensure accuracy. Extracted data included trial interventions, clinical phases, sample sizes, demographic characteristics of participants, and funding sources. Studies were evaluated using the Clinical Trial Diversity Rating framework to assess the inclusion rates of diverse participant groups compared to their prevalence rates for thyroid cancer.

RESULTS

We found that US-based clinical trials for thyroid cancer frequently underrepresented female and non-white individuals. In over half of studies, male participants outnumbered female participants. Reporting of race and ethnicity information was inadequate, with 9/13 studies failing to provide any demographic breakdown. Among the four studies that did report race and ethnicity data, none achieved adequate representation of minority patients. Additionally, there was a notable lack of reporting on participant age bands, despite the relatively high incidence of thyroid cancer in adults aged 60 and above.

CONCLUSIONS

Our findings highlight the persistent underrepresentation of women, non-white racial/ethnic groups, and older adults in thyroid cancer trials. Urgent efforts are needed to address these disparities, particularly given the increasing rates of thyroid cancer among women and the healthcare access disparities in marginalized communities.

The Relationship Between Hospital Safety-Net Burden on Outcomes for High-Volume Thyroid Cancer Surgeons

Background: Higher center and surgeon volume correspond to better outcomes for patients with thyroid cancer. This study aims to investigate how a hospital's safety-net burden, the proportion of a hospital's patients who are insured by state Medicaid plans or are uninsured, influences the outcomes of high-volume (HV) surgeons. Methods: We performed a retrospective cohort study of all patients who underwent surgery for thyroid cancer in California from 1999 to 2017. We stratified treating facilities by the proportion of Medicaid-type and indigent payors into safety-net burden quartiles. We compared the perioperative and oncologic outcomes of HV surgeons (annual case volume ≥10) for patients undergoing total thyroidectomy across safety-net burden quartiles. A mixed-effects regression model controlled for surgeon random effects and fixed effects of patient and tumor characteristics. Results: Our sample comprised 42,347 patients (78% female, median age 50), of whom 13,848 (32%) were treated by HV surgeons (n = 276). Compared to patients of lower-volume surgeons, patients of HV surgeons were more likely to be White, from the upper quartiles of socioeconomic status and well insured (all p < 0.001). HV surgeons in each hospital's safety-net burden quartile displayed similar case number distributions. Compared to patients treated by HV surgeons at Q1 (lowest safety-net burden) hospitals, those treated by HV surgeons at Q4 (highest safety-net burden) hospitals had higher absolute risks of endocrine complications (+7%, p = 0.007), airway complications (+6%, p = 0.004), disease-specific mortality (+1.3%, p = 0.046), and all-cause mortality during the study period (+3%, p = 0.046) in multivariable analysis. Conclusion: The performance of HV thyroid cancer surgeons differs by a hospital's safety-net burden, with patients treated at high safety-net burden hospitals experiencing higher rates of operative complications, disease-specific mortality, and all-cause mortality. Having a HV surgeon alone may be insufficient to provide optimal short- and long-term outcomes for patients with thyroid cancer.

Worse survival and higher rates of relapse in U.S. Armenians with papillary thyroid cancer

Objectives

Papillary thyroid cancer (PTC) is the most frequent subtype of thyroid cancer with overall favorable survival. Currently, little is known about the PTC experience within the United States (U.S.) Armenians. We performed the first study comparing clinicopathologic variables and clinical outcomes of U.S. Armenian PTC patients to a matched control group of non-Armenians.

Methods

We performed a single-center, retrospective, case-control study of adult Armenian PTC patients who received care at COH from 2005 to 2022. Armenian ethnicity was determined by surnames ending in "-ian" and "-yan". We report and compare clinicopathologic presentation and disease outcomes with a gender- and age-matched control non-Armenian population.

Results

Fifty-eight Armenian patients comprised our study cohort. Positive margin status (p = .038), angioinvasion (p = .006), and extrathyroidal extension (p = .014) were more prevalent in the Armenian population. Higher rates of both persistent disease and death due to disease were seen in the Armenians regardless of age groupings. Multivariable analysis revealed significant impact of Armenian status on outcomes. Calculated 5- and 10- year disease-specific survival rates in the Armenian cohort were 88% and 73.2%, respectively, compared with 100% and 94.6% in the non-Armenian group (p < .002). The 5- and 10- year progression-free survival was worse in the Armenian group at 61.8% and 50.1%, respectively, compared with 87.5% and 87.5% in the non-Armenian group (p < .001).

Conclusion

Armenian PTC patients displayed more aggressive disease than non-Armenians. In addition, Armenian PTC patients had higher incidence of disease relapse and worse clinical outcomes.

Level of Evidence

5.

The Multi-Institutional Medullary Thyroid Cancer Collaborative Registry: Can a Rare Tumor Registry Accurately Represent the Real-World Patient Population?

Background: Large population-based registries, such as the Surveillance, Epidemiology and End Results (SEER) Registry, help in the study of rare tumors, including medullary thyroid cancer (MTC), but lack data to understand the natural history of the disease. The Medullary Thyroid Cancer Collaborative Registry (MTCCoRe) is an exhaustive multi-institutional collection of demographic, clinical, and pathological data. To determine the extent to which MTCCoRe represents the real-world MTC population, we compared the characteristics of patients enrolled in MTCCoRe with patients enrolled in population-based cancer registries. Methods: Comparison of demographic and clinical characteristics of MTC patients who were enrolled in MTCCoRe, Texas Cancer Registry (TCR), California Cancer Registry (CCR), and SEER between 1995 and 2018. Results: A total of 1416 patients were identified in MTCCoRe, 329 in TCR, 2105 in CCR, and 3820 in SEER. Percentages of patients 20-54 years in MTCCoRe were 58.0%, 50.2% in TCR, 47.2% in CCR, and 44.8% in SEER (p < 0.0001). About half of the patients were female (55.9% in MTCCoRe, 61.4% in TCR, 59% in CCR, and 57.5% in SEER (p = 0.3). Percentages of Hispanic and Black patients differed among cohorts (10.1% and 3.8% for MTCCoRe, 23.7% and 8.2% for TCR, 24.8% and 4.9% in CCR, and 15.9% and 8.2% for SEER, respectively; p < 0.001). MTCCoRe patients presented with more advanced T and N classifications than patients in the other registries (MTCCoRe, 28.6% T3-4 and 49.4% N1; TCR, 12.7% and 32.2%; CCR, 18.6% and 32.4%; and SEER, 24% and 37.8%; p < 0.0001). Prevalence of M1 disease was 10% in MTCCoRe, 11.9% in TCR, 14.1% in CCR, and 9.5% in SEER (p < 0.0001). In the MTCCoRe, 11.4% underwent systemic therapy (compared with 0.3% in TCR and 5.6% in CCR). Conclusions: The clinicodemographic profile of patients with MTC enrolled in a multi-institutional registry differs from those enrolled in population-based databases, with lower proportions of Hispanic and Black patients but additive data on treatment modalities. Moving forward, MTCCoRe and other registry and clinical trial enrollment efforts should intentionally include underrepresented groups via community engagement techniques, patient stakeholder involvement, and inclusion of languages other than English in study materials to yield more generalizable results and conclusions.

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.

Real-World Use of Systemic Therapies for the Treatment of Advanced Thyroid Cancers

OBJECTIVE

In the last decade, new systemic treatment options have been made available for patients with advanced thyroid cancer. However, little is known about the real-world utilization of these systemic therapies.

METHODS

We used Optum's de-identified Clinformatics® Data Mart Database to characterize trends in the use of 15 systemic therapies that are available for the treatment of advanced thyroid cancer between 2013 and 2021. Joinpoint regression was used to calculate annual percentage changes in the use of systemic therapy by patients' race/ethnicity. The sequence of therapies was determined by the date of prescription claims.

RESULTS

Between 2013 and 2021, the annual number of patients treated for advanced thyroid cancer with systemic therapy increased from 45 patients in 2013 to 114 patients in 2021 (N of total cohort = 885). Most patients were female (54.7%) and non-Hispanic White (62.1%). Between 2013 and 2021, there was a significant decrease in the proportion of non-Hispanic White patients treated for advanced thyroid cancer with systemic therapy (annual percentage change -3.9%, 95% confidence intervals, -6.0% to -1.8%). Since its approval by the US Food and Drug Administration (FDA) in 2015, lenvatinib remains the most frequently prescribed first-line therapy for the treatment of radioiodine-refractory thyroid cancer (48.8% of patients between 2017 and 2021). Between 2017 and 2021, most patients (79.7%) were initiated on 1 of the 10 FDA-approved agents and 81.7% received only a first-line therapy.

CONCLUSIONS

Between 2013 and 2021, the use of systemic treatment options for advanced thyroid cancer increased significantly, largely driven by the prescription of lenvatinib following its approval by the FDA in 2015, with an increasing trend for use in non-White patients.