Inequities in Time to Treat Thyroid Cancer

Discussion

Our analysis shows that many factors including race, SES, type of insurance, and location contribute to inequities in time to treat thyroid cancer. Hispanic patients had to wait the longest to receive treatment compared to non-Hispanic and other minority patients. Several studies have shown that Hispanic patients usually present with more advanced disease, making treatment more complex (14, 15). Additionally, Hispanic patients may have lower SES and education level, which may lead to increased financial burdens from receiving treatment. This has been shown to correspond with higher levels of anxiety about recurrence and mortality, which negatively impacts overall quality of life (5, 16). Cultural and language barriers may also contribute to inequities in care. Radhakrishnan et al. found that Hispanic patients are more likely to receive their cancer diagnosis from a Primary Care Provider (PCP) than from a surgeon or endocrinologist and were more likely to receive inadequate treatment that deviated from published standards of care (17). Other studies have shown that Hispanic patients are less likely to receive care at quality hospitals and from high volume surgeons (18). This ethnic disparity is likely multifactorial and requires further research to be better understood and combatted.

In contrast with many other studies, our analysis found that black patients had shorter wait times to first treatment and to surgery when compared to their white counterparts. One possible explanation for this is that black patients may present with more aggressive or advanced disease, and therefore require more immediate treatment (19). However, our study shows that black patients were significantly delayed in receiving chemotherapy and radiation. Jaap et al. performed a study involving 262,041 patients with differentiated thyroid cancer (DTC) culled from the National Cancer Data Base (1998-2012) that demonstrated black patients were less likely to undergo total thyroidectomy or to receive appropriate radiation treatment (20). Underutilization of these treatment options has been shown to result in recurrence and decreased OS. Black patients are less likely to have private insurance and are more likely to have lower SES. According to the National Cancer Institute, lack of insurance and decreased SES directly contribute to healthcare disparities (21). Genetics may also play a role in worse outcomes for African Americans as they are more likely to have anaplastic thyroid cancer, the rarest and most aggressive type (22). In our study, papillary thyroid cancer comprised about 90% of cases, whereas medullary and anaplastic cancer each represented approximately 1-2% of cancers. Better understanding of the biological factors in conjunction with socioeconomics must be considered to treat all thyroid patients more effectively.

In addition to race, demographic factors like insurance, SES, and location play a major role in the quality and level of care patients receive. Our study demonstrates that a lack of insurance and low SES contributed to longer wait times for all treatments. Ginzberg et al. showed that patients who were insured through Medicaid were more likely to be undertreated with radiation and surgery, in comparison to privately insured patients (23). Multiple studies have also demonstrated that underinsured patients not only have longer wait times to surgery, but also are treated at lower quality hospitals by lower volume surgeons (18). Individual surgeon experience has been shown to be directly related to length of hospital stay and post-operative complications (24). Our study also found patients treated in metropolitan areas and at academic facilities had longer time intervals to treatment. Increased wait times at academic facilities may be partially a result of the increase diagnosis of thyroid cancer, likely due to modern screening techniques (25). This may increase patient load on academic facilities, making it more challenging for patients to receive timely treatment. Also, referral time likely plays a role in increased wait times in academic facilities.

It is clear that inequities in thyroid cancer treatment is a pervasive issue, which requires further research and steps to improve patient care. A potential first step would be to establish updated clinical guidelines for treatment available to physicians on a national level. This would eliminate ambiguity in treatment protocol, making it more likely for patients, regardless of demographics, to receive appropriate care. Additionally, as pointed out by Radhakrishnan et al., there should be a standard pathway to treatment so that Primary Care Practitioners can get their patients to qualified, high volume specialists much faster (17).

To address cultural inequities, having sufficient translators available may help patients to better understand their prognosis and treatment, especially for Hispanics as they had the greatest delays in time to treatment. Physicians could benefit from more education about differences in culture and how to best speak with patients to assuage fear and distrust, which is often not a pillar of medical education.

To address the biological differences which contribute to disparities in care, more effort needs to be made in the recruitment and retention of minority patients in clinical trials. As new treatments and breakthrough therapies are developed, it is crucial that they are tested and confirmed effective for underrepresented patients. Chen et al. explains how many patients face barriers to enroll in clinical trials and consequently cannot benefit from the newest, most effective treatments (26). Clinical research is a major part of advancing medicine and improving patients’ lives. In order for black and Hispanic patients to have greater OS, it is imperative this improves.

It is imperative to continue research regarding these issues in health care disparities, particularly for thyroid cancer treatment. There is a lack of more current data about disparities in healthcare, and especially about wait times to treatment. It would also be helpful to investigate more patient related anxiety and the psychological effects of cancer diagnosis because this can impact quality of life. Patient interviews and engagement could be used to obtain a more comprehensive understanding of the burden and inequities associated with thyroid cancer care.

Study limitations. This study is limited in nature because it utilizes data from the NCDB and is retrospective. Using a large database for analysis presents several problems including missing or incomplete data, which makes it difficult to generalize our results. Additionally, the NCDB does not include data such as quality of life or rate of recurrence. There is also a lack of information about types of surgeries, patient preferences to undergo certain treatments, and information about patient education or understanding.

In summary, our study shows several factors which contribute to delays in thyroid cancer treatment. Chiefly race, SES, and insurance type were significant disparities for time to treatment. Further research and education about these inequities in care is crucial to helping patients live longer and with a better quality of life.