In 2015, the American Thyroid Association (ATA) issued updated guidelines for the treatment of thyroid cancer. Previous ATA guidelines favored removal of the all the thyroid (total thyroidectomy) for most papillary thyroid cancers greater than 1 cm in diameter. Now, the 2015 guidelines are much more flexible as they recommend removal of only the lobe containing the nodule (lobectomy) in addition to total thyroidectomy as options for surgery if the cancer is between 1-4 cm and limited to one lobe with no evidence of spread of the cancer to the lymph nodes in the neck. This has led to a significant increase in lobectomies being performed, especially in hospitals associated with medical centers associated with medical schools. Most medical centers associated with medical schools are located in or near cities (urban settings) while most hospitals in rural/country settings are located far away from medical schools.
This study looked to see whether there was a difference in extent of surgery between rural/country and urban settings in the United States and whether the 2015 guidelines changed any differences seen.
THE FULL ARTICLE TITLE
Collins R et al 2023 Urban and rural surgical practice patterns for papillary thyroid carcinoma. Thyroid.. Epub 2023 Apr 4. PMID: 37014086.
SUMMARY OF THE STUDY
The authors used a cancer data base called the U.S. Surveillance, Epidemiology, and End Results (SEER) and analyzed data from 2004 to 2019. Place of residence (urban vs. rural/country) was based on the 2013 Rural-Urban Continuum Codes. Data was broken down into two time periods (2004-2015 and 2016-2019) to evaluate the effect of the 2015 guidelines.
The study group was composed of 89,294 patients; 90% were from urban setting and only 10% from rural settings. Overall, prior to the 2015 guidelines, the percent of patients getting a total thyroidectomy were 79.9% and 83.1% for rural and urban settings, respectively. Overall, patients in rural settings were approximately 20% less likely to have total thyroidectomy compared to patients in urban settings. Following the publication of the 2015 guidelines, the percent of patients getting a total thyroidectomy in rural and urban settings were similar (75.5% and 74.3%, respectively) as there was an increase in lobectomies being done in both settings.
WHAT ARE THE IMPLICATIONS OF THIS STUDY?
Differences in care for rural versus urban patients are wellestablished and may be driven by many factors including lower income, lack of health insurance, higher unemployment rates and less high volume thyroid surgeons. It is surprising that the rate of lobectomies was higher in rural settings initially, given that patients from rural areas are more likely to present with advanced disease that would usually results in a total thyroidectomy. However, it is after publication of the 2015 guidelines that recommended lobectomy as an option that the proportion of patients undergoing total thyroidectomy is decreasing and is now similar in both rural vs urban settings.
— Marjorie Safran, MD