Why Does a Health Care Gap Exist in Pediatric Thyroid Surgery?

Total thyroidectomy is the standard of care for pediatric thyroid cancer, yet certain patients are still more likely to receive less extensive operations.

Thyroid cancer is the third most common malignancy in children, and the incidence is rising approximately one percent per year. Now a new analysis, published in Annals of Surgical Oncology, indicates that although the proportion of young patients undergoing total thyroidectomy (TT) increased by 34 percent between 1985 and 2007, a variety of hospital and patient factors—including disparities in access to surgeons and state-of-the-art care—affect whether a child actually receives this procedure or another less extensive operation.

The analysis was done by surgeons who examined data on approximately 8,000 patients—age 21 or younger—with differentiated thyroid cancer whose case records were collected by the National Cancer Data Base (NCDB) of the American College of Surgeons (ACS).

Pediatric thyroid cancer—the most common endocrine cancer in children—is often diagnosed in an advanced stage, but the disease is highly treatable. Because the overall rate of complications is higher for a repeat thyroid procedure than for most other surgical procedures, experts believe that having only one thyroid operation is of crucial importance.

Thus, many surgeons and endocrinologists say that TT—the complete removal of the thyroid gland—is the best care available for treating this condition and preventing a recurrence. Even so, less extensive operations—such as near total thyroidectomy, a procedure that removes most of the problem gland but leaves a small portion in place, or lobectomy, a resection of the lobe harboring the nodule—are thought to be lower risk, but a second operation may be required to treat residual disease left behind.

“In recent years we have been observing a trend in which surgeons are electing to use total thyroidectomy as the first-line modality to treat pediatric thyroid cancers,” lead study author Mehul V. Raval, MD, said. Dr. Raval was an American College of Surgeons Research Fellow at the time the analysis was performed and is a surgical resident at the Feinberg School of Medicine, Northwestern University, Chicago. With that trend in mind, the researchers sought to identify factors associated with the likelihood of undergoing TT as compared with near total thyroidectomy or lobectomy, Dr. Raval explained.

Not surprisingly, study authors found that patients who had larger tumors were 38 percent more likely to undergo TT than those with smaller tumors. However, they also discovered an important health care gap: Young patients treated in the highest-volume hospitals were 36 percent more likely to receive TT than patients cared for at low-volume hospitals, and Cancer Oncology Group centers were 26 percent more likely to perform TT than nonspecialty centers.

Other factors that increased a patient’s likelihood of receiving TT included higher household income, private insurance versus government insurance, and living in the southern and the western regions of the United States.

“Our study confirms the pattern we suspected based on individual institutional reports now using a large national cohort of patients,” Dr. Raval said. “These findings should encourage centers that are performing less than a total thyroidectomy to consider changing their practice,” he added.

According to study coauthor Marleta Reynolds, MD, FACS, head, department of surgery, Children’s Memorial Hospital, Chicago, the study is valuable because it characterizes some of the disparities in access to surgeons and state-of-the-art care for children across the country. “I’d like to think that all children could have access to physicians who are practicing surgery based upon the latest medical data,” she said.

Source: American College of Surgeons