Huston-Paterson Hattie H, Mao Yifan, Tseng Chi-Hong, Kim Jiyoon, Bobanga Iuliana, Wu James X, Yeh Michael W
Section of Endocrine Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California, USA.
Thyroid. 2024 May;34(5):635-645. doi: 10.1089/thy.2023.0357. Epub 2024 Jan 22.
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. 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. 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 ( < 0.01). Distant disease at diagnosis was more common in rural (56.0 vs. 50.4 cases per 1000 new cases, < 0.01) and frontier patients (80.9 vs. 50.4 per 1000, < 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, < 0.01) and frontier patients (31.0 vs. 13.6 per 1000, < 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, < 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. 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.
在大多数癌症中，农村地区与更高的发病率和特定疾病死亡率相关。对于农村和超农村（“边远地区”）甲状腺癌患者的治疗结果，人们了解甚少。本研究旨在确定农村患者甲状腺癌治疗结果中可采取行动加以改善的不足之处。我们查询了加利福尼亚癌症登记处和加利福尼亚州全州卫生规划与发展办公室的关联数据库，以获取1999年至2017年期间被诊断为甲状腺癌的患者信息。我们分析了城市、农村和边远地区患者从诊断疾病阶段开始的时间、从诊断到手术的时间、接受适当放射性碘消融治疗的情况、监测状况以及总体和特定疾病死亡率。Cox和逻辑回归模型逐步控制了临床和人口统计学协变量。所有发病率数据均表示为新诊断病例的比例。我们的队列包括92,794名受试者：（65,475名女性[70.6%]；平均年龄50.0岁）。与城市患者相比，农村和边远地区患者更有可能是美洲印第安人、白人、未参保者，且来自社会经济地位较低的五分位数群体（P<0.01）。与城市患者相比，农村（每1000例新病例中有56.0例，而城市为50.4例，P<0.01）和边远地区患者（每1000例中有80.9例，而城市为50.4例，P<0.01）在诊断时出现远处转移疾病的情况更为常见。与城市患者相比，农村患者（每1000例中有17.9例，而城市为13.6例，P<0.01）和边远地区患者（每1000例中有31.0例，而城市为13.6例，P<0.01）甲状腺髓样癌的发病率更高。与城市患者相比，边远地区甲状腺未分化癌的发病率高于城市患者（每1000例中有15.5例，而城市为7.1例，P<0.01）。与城市患者相比，农村和边远地区患者更常失访（比值比[OR]分别为1.69[置信区间，CI 1.54 - 1.85]和OR 3.03[CI 1.89 - 5.26]），且特定疾病死亡率更高（OR分别为1.18[CI 1.07 - 1.30]和OR 1.92[CI 1.22 - 2.77]）。农村和边远地区居住与失访独立相关，表明这是差异的关键驱动因素。与城市甲状腺癌患者相比，农村和边远地区患者就诊时疾病分期较晚，且特定疾病死亡率更高。他们也更常失访，这为有针对性的外展工作提供了机会，以减少观察到的治疗结果差异。
