McMullin Jessica Liu, Sharma Jyotirmay, Gillespie Theresa, Patel Snehal G, Weber Collin J, Saunders Neil D
Department of Surgery, Emory University, Atlanta, GA, USA.
Ann Surg Oncol. 2023 Nov;30(12):7165-7171. doi: 10.1245/s10434-022-12734-3. Epub 2022 Nov 11.
The 2009 American Thyroid Association (ATA) guidelines for medullary thyroid cancer (MTC) were created to unify national practice patterns. Our aims were to (1) evaluate national adherence to ATA guidelines before and after 2009, (2) identify factors that are associated with concordance with guidelines, and (3) evaluate whether there is an association between survival and concordant treatment.
Patients with MTC were identified from the 2009 to 2015 National Cancer Database. Adherence to ATA recommendations regarding extent of surgery (R61-R66) was analyzed. Logistic regression was used to determine predictors of discordance and propensity score matching was used to compare concordant treatment rates between time periods. Kaplan-Meier survival analysis was used to determine association between survival and concordant treatment.
There were 3421 patients with MTC, and of these 3087 had M0 disease and 334 had M1 disease. We found that 72% of M0 cases adhered to R61-66, and 68% of M0 cases without advanced local disease were adherent to R61-63. Following propensity score matching, the adherence rate was 67% before 2009 and 74% after. Patient factors associated with discordant treatment were female gender, older age, treatment at a nonacademic facility, and living within 50 miles of the treatment facility. Adherence to guidelines was associated with improved overall survival (OS) (p < 0.01).
Treatment of MTC was discordant from guidelines in 26% of cases from 2009 to 2015 compared with 33% prior to 2009 in a propensity matched analysis, and was most often in cases with localized, noninvasive disease. Improved adherence to guidelines may improve overall survival.
2009年美国甲状腺协会（ATA）发布了甲状腺髓样癌（MTC）指南，旨在统一全国的诊疗模式。我们的目的是：（1）评估2009年前后全国对ATA指南的遵循情况；（2）确定与指南一致性相关的因素；（3）评估生存与符合指南的治疗之间是否存在关联。
从2009年至2015年的国家癌症数据库中识别出MTC患者。分析了对ATA关于手术范围（R61-R66）建议的遵循情况。采用逻辑回归确定不一致的预测因素，并使用倾向评分匹配来比较不同时间段内符合指南治疗的比例。采用Kaplan-Meier生存分析来确定生存与符合指南治疗之间的关联。
共有3421例MTC患者，其中3087例为M0期疾病，334例为M1期疾病。我们发现，72%的M0期病例遵循R61-66，68%无局部进展性疾病的M0期病例遵循R61-63。倾向评分匹配后，2009年前的遵循率为67%，2009年后为74%。与治疗不一致相关的患者因素包括女性、年龄较大、在非学术机构接受治疗以及居住在距治疗机构50英里范围内。遵循指南与总体生存率（OS）改善相关（p < 0.01）。
在倾向匹配分析中，2009年至2015年26%的MTC病例治疗与指南不一致，而2009年前为33%，且最常见于局限性、非侵袭性疾病的病例。提高对指南的遵循可能会改善总体生存率。
