Department of Surgery, University of Texas Southwestern, Dallas, TX.
Department of Medicine, University of Utah, Salt Lake City, UT.
Surgery. 2023 Sep;174(3):542-548. doi: 10.1016/j.surg.2023.05.033. Epub 2023 Jun 30.
Comparisons of lobectomy versus total thyroidectomy for papillary thyroid cancer have not addressed significant threats to valid inference from observational data. The purpose of this study was to compare survival after lobectomy versus total thyroidectomy for papillary thyroid cancer while addressing bias from unmeasured confounding.
This retrospective cohort study included 84,300 patients treated with lobectomy or total thyroidectomy for papillary thyroid cancer in the National Cancer Database from 2004 to 2017. The primary outcome was overall survival evaluated by flexible parametric survival models and inverse probability weighting on the propensity score. Bias from unobserved confounding was assessed using two-way deterministic sensitivity analysis and 2-stage least squares regression.
The median age of treated patients was 48 years (interquartile range, 37-59), 78% were women, and 76% were white. We found no statistically significant differences in overall survival or 5- and 10-year survival between patients treated with lobectomy or total thyroidectomy. Additionally, we found no statistically significant difference in survival by subgroups, including tumor size (<4 cm or ≥4 cm), age (<65 or ≥65), or estimated risk of mortality. Sensitivity analyses suggested that an unmeasured confounder would need to have an extremely large effect to change the primary finding.
This is the first study to compare lobectomy and total thyroidectomy outcomes while adjusting for and quantifying the potential effects of unmeasured confounding variables on observational data. The findings suggest that total thyroidectomy is unlikely to offer a survival advantage over lobectomy regardless of tumor size, patient age, or overall risk of death.
针对甲状腺乳头癌的叶切除术与全甲状腺切除术的比较并未解决观察性数据中对有效推论的重大威胁。本研究的目的是在解决未测量混杂偏倚的同时，比较甲状腺乳头癌行叶切除术与全甲状腺切除术的生存情况。
本回顾性队列研究纳入了 2004 年至 2017 年期间国家癌症数据库中接受叶切除术或全甲状腺切除术治疗的 84300 例甲状腺乳头癌患者。主要结局是通过灵活参数生存模型和倾向评分的逆概率加权来评估总生存。使用双向确定性敏感性分析和两阶段最小二乘法回归评估未观察到的混杂偏倚。
治疗患者的中位年龄为 48 岁（四分位距，37-59 岁），78%为女性，76%为白人。我们发现接受叶切除术或全甲状腺切除术治疗的患者之间的总生存或 5 年和 10 年生存率无统计学差异。此外，我们在包括肿瘤大小（<4cm 或≥4cm）、年龄（<65 岁或≥65 岁）或估计死亡风险等亚组中均未发现生存差异。敏感性分析表明，未测量的混杂因素需要具有极大的影响才能改变主要发现。
这是第一项比较叶切除术和全甲状腺切除术结果的研究，同时调整和量化了未测量混杂变量对观察性数据的潜在影响。研究结果表明，无论肿瘤大小、患者年龄或总体死亡风险如何，全甲状腺切除术不太可能比叶切除术提供生存优势。
