Insurance Status Is Associated with Extent of Treatment for Patients with Papillary Thyroid Carcinoma

Association of Medicaid expansion with access to thyroidectomy for benign disease at high-volume centers

BACKGROUND

Insurance-based disparities in access to thyroidectomy are well established. Patients undergoing thyroidectomy by high-volume surgeons have fewer complications and better postoperative outcomes. The aim of this study was to evaluate the association of Medicaid expansion with access to high-volume centers for thyroidectomy for benign disease.

METHODS

The Vizient Clinical Data Base was queried for adult operations for benign thyroid disease from 2010 to 2019. Centers were sorted by volume into quartiles. Difference-in-difference analysis evaluated changes in insurance populations in expansion and non-expansion states after Medicaid expansion. Odds of patients undergoing operations in the 4 volume quartiles after stratifying by insurance and Medicaid expansion status were calculated.

RESULTS

A total of 82,602 patients underwent operations at 364 centers. Expansion states increased Medicaid coverage in all volume quartiles compared to non-expansion states after Medicaid expansion (Q1, +4.87%, Q2, +5.35%, Q3, +8.57%, Q4, +4.62%, P < .002 for all). After Medicaid expansion, Medicaid patients had higher odds of undergoing operation at lower volume hospitals compared to the highest volume centers in both expansion states (Q1, ref, Q2, 1.82, Q3, 1.76, Q4, 1.67, P < .001) and non-expansion states (Q1, ref, Q2, 1.54, Q3, 2.04, Q4, 1.44, P < .001). Privately insured patients were most likely to undergo their operation at the highest volume centers in all states (E: Q1, ref, Q2, 0.78, Q3, 0.74, Q4, 0.66, P < .001; NE: Q1, ref, Q2, 0.89, Q3, 0.58, Q4, 0.85, P < .001).

CONCLUSION

Medicaid expansion increased Medicaid coverage in expansion states, but Medicaid patients in both expansion and non-expansion states were less likely to be operated on at the highest volume centers compared to privately insured patients. Persistent barriers to accessing high-volume care still exists for Medicaid patients.

Racial implications of time to surgery in disparities in thyroid cancer survival

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.

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.

Patterns in the Reporting of Aggressive Histologic Subtypes in Papillary Thyroid Cancer

INTRODUCTION

The tall cell, columnar, and diffuse sclerosing subtypes are aggressive histologic subtypes of papillary thyroid cancer (PTC) with increasing incidence, yet there is a wide variation in reporting. We aimed to identify and compare factors associated with the reporting of these aggressive subtypes (aPTC) to classic PTC (cPTC) and secondarily identify differences in outcomes.

METHODS

The National Cancer Database was utilized to identify cPTC and aPTC from 2004 to 2017. Patient and facility demographics and clinicopathologic variables were analyzed. Independent predictors of aPTC reporting were identified and a survival analysis was performed.

RESULTS

The majority of aPTC (67%) were reported by academic facilities. Compared to academic facilities, all other facility types were 1.4-2.0 times less likely to report aPTC (P < 0.05). Regional variation in reporting was noted, with more cases reported in the Middle Atlantic, despite there being more total facilities in the South Atlantic and East North Central regions. Compared to the Middle Atlantic, all other regions were 1.4-5 times less likely to report aPTC (P < 0.001). Patient characteristics including race and income were not associated with aPTC reporting. Compared to cPTC, aPTC had higher rates of aggressive features and worse 5-y overall survival (90.5% versus 94.5%, log rank P < 0.001).

CONCLUSIONS

Aggressive subtypes of PTC are associated with worse outcomes. Academic and other facilities in the Middle Atlantic were more likely to report aPTC. This suggests the need for further evaluation of environmental or geographic factors versus a need for increased awareness and more accurate diagnosis of these subtypes.

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.

Hearing the Voices of Australian Thyroid Cancer Survivors: Qualitative Thematic Analysis of Semistructured Interviews Identifies Unmet Support Needs

Background: Most thyroid cancer survivors regain their physical health-related quality of life, but psychological and social deficits persist. The nature of these detriments remains poorly understood and they are insufficiently captured by survey data alone. To address this, qualitative data exploring the breadth and depth of thyroid cancer survivors' experiences and priorities for supportive care are required. Methods: Twenty semistructured interviews were undertaken with a purposive, maximum variation sample of thyroid cancer survivors. Interviews were transcribed verbatim and coded independently by two researchers. A hybrid model of inductive and realistic codebook analysis was undertaken with themes developed. Results: Patient experiences centered around three themes: (1) impact of diagnosis and treatment, (2) thyroid cancer does not happen in isolation, and (3) role of clinicians and formalized support structures. The word "cancer" had negative connotations, but for many, the reality of their experience was more positive. Despite feeling "lucky" at the relative low-risk nature of thyroid cancer, many patients reported fatigue, weight gain, and difficulty returning to usual activities; concerns that were largely dismissed or minimized by clinicians. Few were offered any support beyond their treating doctors; where patients attempted to access formalized supportive care, little was available or appropriate. Life stage and concurrent family and social stressors greatly impacted patients' ability to cope with diagnosis and treatment. Addressing thyroid cancer in isolation felt inappropriate without appreciating the broader context of their lives. Interactions with clinicians were largely positive, particularly where information was communicated as a means of empowering patients to participate in shared decision-making and where clinicians "checked in" emotionally with patients. Information about initial treatments was largely adequate but information on longer term effects and follow-up was lacking. Many patients felt that clinicians focused on physical well-being and scan results, missing opportunities to provide psychological support. Conclusions: Thyroid cancer survivors can struggle to navigate their cancer journey, particularly with regard to psychological and social functioning. There is a need to acknowledge these impacts at the time of clinical encounters, as well as develop information resources and support structures that can be individualized to optimize holistic well-being for those in need.

Insurance-Based Disparities in Guideline-Concordant Thyroid Cancer Care in the Era of De-escalation

INTRODUCTION

Prior studies have demonstrated insurance-based disparities in the treatment of well-differentiated thyroid cancer. However, it remains unclear whether these disparities have persisted in the era of the 2015 American Thyroid Association (ATA) management guidelines. The goal of this study was to assess whether insurance type is associated with the receipt of guideline-concordant and timely thyroid cancer treatment in a modern cohort.

METHODS

Patients diagnosed with well-differentiated thyroid cancer between 2016 and 2019 were identified from the National Cancer Database. Appropriateness of surgical and radioactive iodine treatment (RAI) was determined based on the 2015 ATA guidelines. Multivariable logistic regression and Cox proportional hazard regression analyses, stratified at age 65, were used to evaluate the associations between insurance type and appropriateness and timeliness of the treatment.

RESULTS

125,827 patients were included (private = 71%, Medicare = 19%, Medicaid = 10%). Compared to privately insured patients, patients with Medicaid more frequently presented with tumors >4 cm in size (11% versus 8%, P < 0.001) and regional metastases (29% versus 27%, P < 0.001). However, patients with Medicaid were also less likely to undergo appropriate surgical treatment (odds ratio 0.69, P < 0.001), less likely to undergo surgery within 90 d of diagnosis (hazard ratio 0.80, P < 0.001), and more likely to be undertreated with RAI (odds ratio 1.29, P < 0.001). There were no differences in the likelihood of guideline-concordant surgical or medical treatment by insurance type in patients ≥65 y old.

CONCLUSIONS

In the era of the 2015 ATA guidelines, patients with Medicaid remain less likely to receive guideline-concordant, timely surgery and more likely to be undertreated with RAI compared to privately insured patients.

Barriers and facilitators to surgical access in underinsured and immigrant populations

BACKGROUND

Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations.

METHODS

A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies.

RESULTS

Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors.

CONCLUSIONS

Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.

Thyroid cancer

The past 5-10 years have brought in a new era in the care of patients with thyroid cancer, with the introduction of transformative diagnostic and management options. Several international ultrasound-based thyroid nodule risk stratification systems have been developed with the goal of reducing unnecessary biopsies. Less invasive alternatives to surgery for low-risk thyroid cancer, such as active surveillance and minimally invasive interventions, are being explored. New systemic therapies are now available for patients with advanced thyroid cancer. However, in the setting of these advances, disparities exist in the diagnosis and management of thyroid cancer. As new management options are becoming available for thyroid cancer, it is essential to support population-based studies and randomised clinical trials that will inform evidence-based clinical practice guidelines on the management of thyroid cancer, and to include diverse patient populations in research to better understand and subsequently address existing barriers to equitable thyroid cancer care.

Association of Medicaid expansion of the Affordable Care Act with operations for benign endocrine surgical disease

•Background: The Affordable Care Act's Medicaid expansion increased insurance coverage and access to care for endocrine cancers, though impact on benign endocrine disease is unknown. •Methods: Patients undergoing operations for benign thyroid, parathyroid, and adrenal disease were collected from the Vizient® Clinical Data Base from 2009 to 2016 and grouped by state Medicaid expansion status in January 2014. Insurance coverage was analyzed by difference-in-differences analysis, and logistic regression evaluated odds of operation by insurance status. •Results: 134,242 patients were included. Medicaid coverage in expansion states increased for all operations (Adj-DD 5.78%, p < 0.001) with decreases in uninsured and private insurance. Medicaid patients had increased odds of undergoing thyroid operations (OR 1.56, p < 0.001) and decreased odds of parathyroid (OR 0.68, p < 0.001) or adrenal operations (OR 0.70, p < 0.001) versus private insurance. •Conclusion: Medicaid expansion increased insurance coverage for benign endocrine disease, however, barriers remain for Medicaid patients with parathyroid and adrenal disease.

Disparities in Treatment for Differentiated Thyroid Cancer

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.

Current Controversies in Low-Risk Differentiated Thyroid Cancer: Reducing Overtreatment in an Era of Overdiagnosis

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.

Impact of Insurer on Papillary Thyroid Carcinoma Outcomes, Stage, and Treatment Modalities

BACKGROUND

While the impact of insurance has been described for thyroid cancer as a whole, we sought to further characterize this relationship for the papillary sub-group (PTC).

METHODS

Those patients with primary site thyroid tumors from 2007 to 2016 with histology-confirmed PTC were extracted from the SEER database. These parameters yielded 103 219 participants for demographic, extent of disease, and treatment parameter study and 103 025 for outcome studies.

RESULTS

Compared to their counterparts, those with Medicaid were more likely to have stage T3 or greater (<.0001) disease at presentation. Those with Medicare/private insurance were more likely to have No staging at diagnosis (P < .0001). Similarly, those with Medicaid exhibited poorer overall (98.0%, 90.9%, 81.6% vs 98.9%, 95.0%, 90.0%; P < .0001) and cause-specific (99.3%, 98.0%, 95.8% vs 99.7%, 99.1%, 98.4%; P < .0001) survival after 1, 5, and 9 years respectively.

CONCLUSION

Insurer has a significant impact on the stage at diagnosis of papillary thyroid carcinoma while having limited effect on the treatment modalities offered. Statistically significant overall and cause-specific mortality differences were appreciated but are likely clinical insignificant. Further work to elucidate the social factors likely affecting these patients is warranted.

Disparities in Thyroid Care

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.

Thyroid Cancer Screening Using Tumor-Associated DN T Cells as Immunogenomic Markers

Background

Thyroid nodules are an extremely common entity, and surgery is considered the ultimate diagnostic strategy in those with unclear malignant potential. Unfortunately, strategies aiming to predict the risk of malignancy have inadequate specificity. Our group recently found that the microenvironment of thyroid cancer is characterized by an enhanced immune invasion and activated immune response mediated by double-negative T lymphocytes (DN T) (CD3+CD4-CD8-), which are believed to enable or promote tumorigenesis. In the present work, we try to use the DN T cells’ proportion in thyroid fine-needle aspiration (FNA) material as a predictor of the risk of malignancy.

Methods

We recruited 127 patients and obtained ultrasound-guided FNA samples from subjects with cytology-positive or suspicious for malignancy and from those with benign nodular goiter associated with compressive symptoms (such as dysphagia, shortness of breath, or hoarseness), Hashimoto thyroiditis, and Graves’ disease. Out of 127, we investigated 46 FNA samples of patients who underwent total thyroidectomy and for which postoperative histological diagnosis by the academic pathologists was available. We specifically measured the number of cells expressing CD3+CD4-CD8- (DN T) as a function of total CD3+ cells in FNA samples using flow cytometry. We correlated their FNA DN T-cell proportions with the pathological findings.

Results

The DN T cells were significantly more abundant in lymphocytic infiltrates of thyroid cancer cases compared to benign nodule controls (p &lt; 0.0001). When the DN T-cell population exceeded a threshold of 9.14%, of total CD3+ cells, the negative likelihood ratio of being cancer-free was 0.034 (96.6% sensitivity, 95% CI, 0.915–1.000, p &lt; 0.0001). DN T cells at &lt;9.14% were not found in any subject with benign disease (specificity 100%). The high specificity of the test is promising, since it abolishes a false-positive diagnosis and in turn unnecessary surgical procedures.

Conclusion

The present study proposes DN T cells’ proportion as a preoperative diagnostic signature for thyroid cancer that with integration of RNA transcriptomics can provide a simplified technology based on the PCR assay for the ease of operation.

Trends in the Management of Localized Papillary Thyroid Carcinoma in the United States (2000-2018)

Background: In response to evidence of overdiagnosis and overtreatment of papillary thyroid carcinoma (PTC), the 2009 and 2015 American Thyroid Association (ATA) adult guidelines recommended less extensive surgery (lobectomy vs. total thyroidectomy) and more restricted use of postsurgical radioactive iodine (RAI) in management of PTC at low risk of recurrence. In 2015, active surveillance was suggested as a viable option for some <1-cm PTCs, or microcarcinomas. The 2015 ATA pediatric guidelines similarly shifted toward more restricted use of RAI for low-risk PTCs. The impact of these recommendations on low-risk adult and pediatric PTC management remains unclear, particularly after 2015. Methods: Using data from 18 Surveillance, Epidemiology, and End Results (SEER) U.S. registries (2000-2018), we described time trends in reported first-course treatment (total thyroidectomy alone, total thyroidectomy+RAI, lobectomy, no surgery, and other/unknown) for 105,483 patients diagnosed with first primary localized PTC (without nodal/distant metastases), overall and by demographic and tumor characteristics. Results: The declining use of RAI represented the most pronounced change in management of PTCs <4 cm (44-18% during the period 2006-2018), including microcarcinomas (26-6% during the period 2007-2018). In parallel, an increasing proportion of PTCs were managed with total thyroidectomy alone (35-54% during the period 2000-2018), while more subtle changes were observed for lobectomy (declining from 23% to 17% during the period 2000-2006, stabilizing, and then rising from 17% to 24% during the period 2015-2018). Use of nonsurgical management did not meaningfully change over time, impacting <1% of microcarcinomas annually during the period 2000-2018. Similar treatment trends were observed by sex, age, race/ethnicity, metropolitan vs. nonmetropolitan residence, and insurance status. For pediatric patients (<20 years), use of RAI peaked in 2009 (59%), then decreased markedly to 11% (2018), while use of total thyroidectomy alone and, to a lesser extent, lobectomy increased. No changing treatment trends were observed for ≥4-cm PTCs. Conclusions: The declining use of RAI in management of low-risk adult and pediatric PTC is consistent with changing recommendations from the ATA practice guidelines. Post-2015 trends in use of lobectomy and nonsurgical management of low-risk PTCs, particularly microcarcinomas, were more subtle than expected; however, these trends may change as evidence regarding their safety continues to emerge.

Year in Thyroidology-Recent Developments and Future Challenges: Clinical Science Review

Background: The 2021 Year in Thyroidology-Recent Developments and Future Challenges: Clinical Science Review featured key clinical research within five categories: Thyroid Nodules and Cancer, Thyroid Function and Thyroid Eye Disease, Thyroid and Pregnancy, Thyroid and Pediatrics, and Disparities in Thyroid. Methods: A literature search of PubMed from November 2019 to August 2021 was performed to identify relevant peer-reviewed articles published in English and with a focus on human subjects. Results: There were three nominees for each of the five categories and one featured article per category. The featured articles had the most potential to change clinical practice, focused on a novel topic, and/or included of strong methodology. Conclusions: There were many strong publications on thyroid between November 2019 and August 2021; the 15 nominees and 5 featured articles span a breadth of topics and methodological approaches. The featured articles all have potential to change practice patterns or to stimulate further research that will ultimately change practice patterns.

Opposite Incidence Trends for Differentiated and Medullary Thyroid Cancer in Young Dutch Patients over a 30-Year Time Span

Simple Summary

Thyroid cancer is a rare disease in childhood; however, its incidence is rising. Thyroid cancer consists of three main types: Papillary thyroid cancer (PTC), follicular thyroid cancer (FTC), and medullary thyroid cancer (MTC). The aim of our retrospective study was to investigate the incidence and survival trends of these three thyroid cancer types in Dutch children, adolescents, and young adults over a 30-year life span. In total, 839 patients aged 0–24 years had been diagnosed with thyroid cancer between 1990 and 2019. The incidence of PTC increased significantly over time, the incidence of FTC showed a stable trend, while the incidence of MTC decreased significantly. Overall, the 10-year survival rates over the last decades were high (>95%) for PTC, FTC, and MTC in young individuals.

Abstract

Thyroid cancer is the most common endocrine malignancy in children. A rising incidence has been reported worldwide. Possible explanations include the increased use of enhanced imaging (leading to incidentalomas) and an increased prevalence of risk factors. We aimed to evaluate the incidence and survival trends of thyroid cancer in Dutch children, adolescents, and young adults (0–24 years) between 1990 and 2019. The age-standardized incidence rates of differentiated thyroid cancer (DTC, including papillary and follicular thyroid cancer (PTC and FTC, respectively)) and medullary thyroid cancer (MTC), the average annual percentage changes (AAPC) in incidence rates, and 10-year overall survival (OS) were calculated based on data obtained from the nationwide cancer registry (Netherlands Cancer Registry). A total of 839 patients aged 0–24 years had been diagnosed with thyroid carcinoma (PTC: 594 (71%), FTC: 128 (15%), MTC: 114 (14%)) between 1990 and 2019. The incidence of PTC increased significantly over time (AAPC +3.6%; 95%CI +2.3 to +4.8), the incidence rate of FTC showed a stable trend ((AAPC −1.1%; 95%CI −3.4 to +1.1), while the incidence of MTC decreased significantly (AAPC: −4.4% (95%CI −7.3 to −1.5). The 10-year OS was 99.5% (1990–1999) and 98.6% (2000–2009) in patients with DTC and 92.4% (1990–1999) and 96.0% (2000–2009) in patients with MTC. In this nationwide study, a rising incidence of PTC and decreasing incidence of MTC were observed. For both groups, in spite of the high proportion of patients with lymph node involvement at diagnosis for DTC and the limited treatment options for MTC, 10-year OS was high.

Insurance type is associated with appropriate use of surgical and adjuvant care for differentiated thyroid carcinoma

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.

Association of medicaid expansion of the Affordable Care Act with the stage at diagnosis and treatment of papillary thyroid cancer: A difference-in-differences analysis

BACKGROUND

The Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage and improved various cancer outcomes. Its impact in papillary thyroid cancer (PTC) remains unclear.

METHODS

Non-elderly patients (40-64 years-old) with PTC living in low-income areas either in a 2014 expansion, or a non-expansion state were identified from the National Cancer Database between 2010 and 2016. Insurance coverage, stage at diagnosis, and RAI administration were analyzed using a difference-in-differences analysis.

RESULTS

10,644 patients were included. Compared with non-expansion states, the percentage of uninsured patients (adjusted-DD -2.6% [95%-CI -4.3to-0.8%],p = 0.004) and patients with private insurance decreased, and those with Medicaid coverage increased (adjusted-DD 9.7% [95%-CI 6.9-12.5%],p < 0.001) in expansion states after ACA implementation. The percentage of patients with pT1 did not differ between expansion and non-expansion states; neither did the use of RAI.

CONCLUSIONS

Medicaid expansion has resulted in a smaller uninsured population in PTC patients, but without earlier disease presentation nor change in RAI treatment.

Analysis of adjuvant chemotherapy in patients undergoing curative-intent resection of localized adrenocortical carcinoma

BACKGROUND

Studies evaluating the role of adjuvant chemotherapy (ACT) in Adrenocortical Carcinoma (ACC) are limited due to its rarity. The objective of this study was to evaluate if ACT provides a survival benefit in patients who underwent curative-intent resection of localized ACC and to determine factors associated with receipt of ACT.

METHODS

The National Cancer Data Base was queried to identify patients (2010-2016) with curative-intent resection of localized ACC (T1-T3, N0, M0).

RESULTS

Of 577 patients with adrenalectomy, 389 (67%) had adrenalectomy alone, and 188 (33%) received ACT. Private insurance, lymphovascular invasion, stage II, and radiotherapy were predictors of ACT (P < 0.05). Advanced (T3) stage lymphovascular invasion, and being uninsured were associated with decreased OS (P < 0.05). There was no association between ACT and OS.

CONCLUSIONS

For patient who underwent curative-intent resection of localized ACC, there was no association between ACT and OS. Private insurance, lymphovascular invasion, stage II disease, and radiotherapy were associated with receipt of ACT.

Disparities Research in Thyroid Cancer: Challenges and Strategies for Improvement

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.

Practice Paradigms Before and After Introduction of the Diagnosis-Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP): an Institutional Experience

The recently adopted terminology of "Noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) reflects the indolent behavior of these tumors. In contrast to conventional papillary thyroid carcinomas, NIFTP can be managed conservatively. The purpose of this study was to investigate changes in surgical and pathologic practice patterns at our institution since the introduction of the NIFTP diagnosis in 2016. A retrospective analysis of all thyroid specimens received in our laboratory between January 2015 and April 2017 was performed. The final cohort consisted of 1508 thyroidectomy specimens from 1508 patients (1153 (76.5%) women and 355 (23.5%) men), of which 1011 (67%) were total thyroidectomies and 497 (33%) were partial thyroidectomies. There were 558 (69.2%) total thyroidectomies and 248 (30.8%) partial thyroidectomies performed prior to introduction of the NIFTP diagnosis and 453 (64.5%) and 249 (35.5%) total and partial thyroidectomies, respectively, after the change in nomenclature. Within a year following the initial use of this diagnosis, 67 NIFTP cases were identified (9.5% of all thyroidectomies), whereas compared with the year preceding it, malignant diagnoses decreased from 54.5 (439) to 44.6% (313), and the benign category remained unchanged from 44.5 (367) to 45.9% (322). For the entirely submitted 67 NIFTP cases, the mean number of blocks submitted was 14.7 (0.98 blocks/g); for malignant lesions 17.7 (0.92 blocks/g); and for benign lesions 16.6 (0.75 blocks/g). The results of our study suggest that NIFTP are encountered in almost 10% of thyroidectomies at our institution with expected shifts in cytology and surgical pathology diagnoses as a result of the change in nomenclature. During this time period, significant shifts towards less aggressive surgical management were not observed. All 67 NIFTP nodules were submitted entirely with no significant difference in the number of cassettes submitted for NIFTP nodules as compared with follicular variant papillary thyroid carcinoma (PTC), classic variant PTC, or follicular adenoma.

Impact of induction chemotherapy and socioeconomics on sinonasal undifferentiated carcinoma survival

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is an uncommon malignancy of the nasal cavity and accessory sinuses with limited available studies evaluating role of induction chemotherapy (IC), demographics, and socioeconomic factors on overall survival (OS).

METHODS

The 2004-2015 National Cancer Database was queried for patients with histologically confirmed SNUC. IC was defined as chemotherapy administered 6 months to 2 weeks before surgery or ≥45 days before radiotherapy.

RESULTS

Of 440 identified patients, 70 (16%) underwent treatments involving IC. This consisted of 52 (12%), 15 (3%), and 3 (1%) patients receiving IC before definitive radiation therapy, surgery and adjuvant radiotherapy, or surgery only, respectively. On univariate analysis, IC (p = 0.34) did not affect OS, whereas having government insurance (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.37-2.34; p < 0.001) and living in regions with ≥13% of the population without a high school diploma (HR, 1.38; 95% CI, 1.06-1.79; p = 0.02) were associated with worse OS. On log-rank test, patients with advanced stage had similar OS regardless of whether or not they received IC (p = 0.96). Patients who received IC lived closer to their treatment site (p = 0.02) and had worse overall health, with more comorbidities (p = 0.02). The timing of IC before definitive surgery or radiation did not affect OS (p = 0.69).

CONCLUSION

In this SNUC population-based analysis, IC did not appear to provide additional OS benefit regardless of disease stage or timing before definitive treatment. Distance to treatment and level of comorbidities may be associated with receiving IC, whereas type of insurance and residence education level may impact SNUC OS, regardless of treatment.

Early Diagnosis of Low-Risk Papillary Thyroid Cancer Results Rather in Overtreatment Than a Better Survival

We are witnessing a rapid worldwide increase in the incidence of papillary thyroid carcinoma (PTC) in the last thirty years. Extensive implementation of cancer screening and wide availability of neck ultrasound or other imaging studies is the main reason responsible for this phenomenon. It resulted in a detection of a growing number of clinically asymptomatic PTCs, mainly low-risk tumors, without any beneficial impact on survival. An indolent nature of low-risk PTC, particularly papillary thyroid microcarcinoma (PTMC), and the excellent outcomes raise an ongoing discussion regarding the adequacy of treatment applied. The question of whether PTMC is overtreated or not is currently completed by another, whether PTMC requires any treatment. Current ATA guidelines propose less extensive preoperative diagnostics and, if differentiated thyroid cancer is diagnosed, less aggressive surgical approach and limit indications for postoperative radioiodine therapy. However, in intrathyroidal PTMCs in the absence of lymph node or distant metastases, active surveillance may constitute alternative management with a low progression rate of 1%-5% and without any increase in the risk of poorer outcomes related to delayed surgery in patients, in whom it was necessary. This review summarizes the current knowledge and future perspectives of active surveillance in low-risk PTC.