National Cancer Database Reveals Disparities in Access to Thyroid Cancer Surgery

In a study released earlier this year from the National Cancer Database (NCDB), the removal of the entire thyroid -- total thyroidectomy

CHICAGO, In a study released earlier this year from the National Cancer Database (NCDB), the removal of the entire thyroid -- total thyroidectomy -- was shown to reduce papillary thyroid cancer recurrence rates and improve survival in patients whose tumors are larger than 1.0 cm. With that knowledge, researchers from the American College of Surgeons (ACS) wanted to determine if this surgical procedure is best for all thyroid cancer patients, and if all patients have equal access to this treatment.

This latest study, released today, found that Medicare recipients, the uninsured, and African-Americans, among others, were less likely to receive optimal treatment. The NCDB is a nationwide oncology outcomes database maintained by the Commission on Cancer of the ACS for more than 1,400 Commission-approved cancer programs in the United States and Puerto Rico.

"Cancer specialists agree that large tumors merit removal of the entire thyroid gland. But, historically, the surgical management of papillary tumors-those that are smaller than 4.0 cm, and specifically, less than 2.0 cm, has been one of the great debates in surgery," according to Karl Bilimoria, MD, NCDB Research Fellow, American College of Surgeons and a general surgery resident at Northwestern University's Feinberg School of Medicine, Chicago, IL.

In the second phase of the largest study of papillary thyroid cancer ever conducted, lead researcher Dr. Bilimoria and ACS colleagues found that not all papillary thyroid cancer patients (PTC) have equal access to optimal treatment. "We discovered significant patient factors associated with the likelihood of undergoing a total thyroidectomy," Dr. Bilimoria reported. "We've seen these factors in other cancer sites, but this is the first time they have been identified for thyroid cancer."

Patients were less likely to undergo a total thyroidectomy if they were African-American, older than 45 years, were Medicare recipients, had lower household incomes, or had less education. Moreover, patients treated at NCCN/National Cancer Institute (NCI)-designated cancer centers were 23 percent more likely than patients undergoing an operation at non-NCCN/NCI hospitals to be treated with a total thyroidectomy. Patients, treated at hospitals routinely doing a high volume of thyroid operations, were also more likely to receive a total thyroidectomy than patients treated at low-volume or community hospitals.

ACS researchers examined the use of total thyroidectomy in the United States in over 90,000 papillary thyroid cancer patients from 1985 to 2003 to determine which factors affected treatment options. Guidelines from the American Thyroid Association and the National Comprehensive Cancer Network (NCCN) recommend total thyroidectomy for PTC greater than or equal to 1.0-1.5 cm.

"We wanted to identify which patients were not getting total thyroidectomy," explained Dr. Bilimoria who examined the data from the NCDB. The NCDB captures approximately 88 percent of all new thyroid cancers diagnosed annually.

"We were surprised to see that in addition to those factors that are expected to influence surgical treatment -- like tumor size and lymph node status -- that patients from certain ethnic/racial groups, insurance status, and those living in areas with higher mean income and education level were treated differently," co-researcher Cord Sturgeon, MD, FACS, Northwestern University, Department of Surgery, Chicago, said. "Disparities in medical care are a pressing issue overall, and the results of our study suggest that there are disparities that need to be addressed in thyroid cancer surgery as well."

"Looking at how to get high-quality care to all patients is probably the most important outcome consideration," Dr. Bilimoria concluded. "The fundamental issue here concerns quality of care in general and, in particular, appropriate utilization of procedures," David Winchester, MD, FACS, Medical Director, ACS Cancer Programs, observed. "A procedure can be overused and underused in the same hospital setting. However, our studies show that it is possible to develop criteria for appropriate use that can help health care providers deliver the best care to patients."

The thyroid gland is a butterfly-shaped organ located in the neck just below the Adam's apple. There are two lobes, the left and right, connected in the center. The thyroid produces thyroid hormone, which is important in regulating many bodily functions, including metabolism. Thyroid cancer is considered very treatable -- and if caught before it becomes too far advanced -- is rarely fatal. Treatments include partial or total surgical removal of the thyroid gland (thyroidectomy) as well as radioactive iodine treatment, and thyroid hormone replacement.

It is common to combine two or more of these methods, and most patients are cured of thyroid cancer through treatment. The American Cancer Society estimates that there will be about 33,000 new cases of thyroid cancer diagnosed in 2007. The incidence of thyroid cancer has more than doubled in the past 30 years in the United States, with most cases occurring in young women.

Source: PR Newswire
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