Hattie H. Huston-Paterson

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.

Background: Patients residing in rural and frontier areas experience worse thyroid cancer outcomes than those in urban areas. This novel qualitative study sought the perspectives of rural surgeons to identify practical measures that could mitigate the disparities in thyroid cancer care between rural and urban contexts. Methods: We contacted general and head and neck surgeons at all of California’s Critical Access Hospitals (n = 35), which are remote, rural hospitals, and requested self-referral to our study through the American College of Surgeons. We performed semi-structured qualitative interviews with surgeons at rural hospitals to understand the assets and vulnerabilities of rural hospitals in providing the highest quality care to patients with thyroid cancer. Responses were coded and analyzed using mixed-methods qualitative analysis methodology. Results: Rural surgeons (n = 13) from a geographically diverse sample of states and regions (AK, AR, CA, NE, NC, NM, TX, UT, WY, and Newfoundland) participated. All initially trained in general surgery; 46% had fellowship training (15% in endocrine surgery) and performed a median of 8.5 thyroidectomies annually. Rural surgeons from all training backgrounds felt adequately trained to treat thyroid cancer and reported a strong desire to provide comprehensive thyroid cancer care. Most reported patients’ strong preference to be treated near home. Key challenges to local, comprehensive thyroid cancer care included limited or no access to medical endocrinology, lack of continuing education on thyroid cancer management, and professional isolation in decision-making. Interviewed rural surgeons identified connections with university health systems, expert colleagues, and telemedicine consultations as valuable assets in treating thyroid cancer in geographically isolated hospitals. Discussion: This study identified key challenges and clear avenues for interventions in treating rural thyroid cancer patients. Interviewed rural surgeons specifically suggest improving access to endocrinology specialists, developing educational initiatives on thyroid cancer management, and fostering connections and collaborations with urban colleagues to reduce professional isolation.

Objective: Rurality is associated with higher incidence and higher disease-specific mortality for most cancers. Outcomes for rural and ultrarural (“frontier”) patients with thyroid cancer are poorly understood. This study aimed to identify actionable deficits in thyroid cancer outcomes for rural patients. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for patients diagnosed with thyroid cancer (1999–2017). We analyzed time from disease stage at diagnosis, time from diagnosis to surgery, receipt of appropriate radioactive iodine ablation, surveillance status, and overall and disease-specific mortality for urban, rural, and frontier patients. Cox and logistic regression models controlled for clinical and demographic covariates a stepwise manner. All incidence figures are expressed as a proportion of newly diagnosed cases. Results: Our cohort comprised 92,794 subjects: (65,475 women [70.6%]; mean age 50.0 years). Compared to urban patients, rural and frontier patients were more likely to be American Indian, White, uninsured, and from lower quintiles of socioeconomic status ( p < 0.01). Distant disease at diagnosis was more common in rural (56.0 vs. 50.4 cases per 1000 new cases, p < 0.01) and frontier patients (80.9 vs. 50.4 per 1000, p < 0.01) compared to urban patients. The incidence of medullary thyroid cancer was greater in rural patients (17.9 vs. 13.6 cases per 1000, p < 0.01) and frontier patients (31.0 vs. 13.6 per 1000, p < 0.01) compared to urban patients. The incidence of anaplastic thyroid cancer was higher in frontier versus urban patients (15.5 vs. 7.1 per 1000, p < 0.01). When compared to urban patients, rural and frontier patients were more often lost to follow-up (odds ratio [OR] 1.69 [confidence interval, CI 1.54–1.85], and OR 3.03 [CI 1.89–5.26], respectively) and had higher disease-specific mortality (OR 1.18 [CI 1.07–1.30], and OR 1.92 [CI 1.22–2.77], respectively). Rural and frontier residence was independently associated with being lost to follow-up, suggesting that it is a key driver of disparities. Conclusion: Compared to their urban counterparts, rural and frontier patients with thyroid cancer present with later-stage disease and experience higher disease-specific mortality. They also are more often lost to follow-up, which presents an opportunity for targeted outreach to reduce the observed disparities in outcomes.

Background: Racially minoritized patients with thyroid cancer are less likely to receive high-quality and guideline-concordant care. Inaccessibility of high-volume centers may contribute to inequalities in thyroid cancer outcomes. This study sought to understand the extent to which access to higher volume thyroid cancer centers is associated with patient outcomes. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for thyroid cancer patients who received thyroid surgery between 1999 and 2017. Hospitals were stratified by their median annual volume of thyroid cancer operations: ultra-low volume (0–5 cases/year), low-volume (6–25 cases/year), mid-volume (26–50 cases/year), and high-volume (>50 cases/year). We analyzed the rates of complications, rates of reoperation for cancer recurrence, use of radioactive iodine ( ¹³¹ I), and mortality by median hospital volume of thyroid surgery. A multivariable regression controlled for high-risk tumor features. Differences in access by center volume were assessed based on patient demographics. Results: We studied 52,599 thyroid cancer patients who underwent thyroidectomy. Patients who underwent thyroidectomy at ultra-low volume centers were more likely to undergo reoperations for recurrent/persistent disease compared with patients at low- (odds ratio [OR] 1.17 [CI 1.02–1.35]), mid- (OR 1.25 [CI 1.06–1.46]), and high-volume centers (OR 1.26 [CI 1.03–1.56]). Patients who received thyroid operations at ultra-low volume centers were also less likely to receive guideline-concordant ¹³¹ I ablation compared with patients at higher volume centers (OR 0.77 [CI 0.72–0.82]). A pair-wise comparison between all volume categories for all outcomes revealed no statistically significant differences in outcomes between low-, mid-, or high-volume centers. Only ultra-low volume centers had significantly higher rates of adverse outcomes. Ultra-low volume centers were disproportionately accessed by women ( p < 0.05), Hispanic, Asian/Pacific Islander, and American Indian people ( p < 0.01), those from the lowest three quintiles of socio-economic status ( p < 0.01), and the uninsured and those on Medicaid or Medicare ( p < 0.01) when compared with higher volume centers. Conclusions: Patients receiving thyroid cancer surgery at centers performing ≤5 such operations per year were more likely to require reoperation for recurrent/persistent disease and less likely to receive appropriate ¹³¹ I ablation. Ultra-low volume centers served higher proportions of socially and economically marginalized communities.