E. F. Garner1, I. I. Maizlin1, K. W. Gow2, M. Goldfarb3, M. Langer4, M. V. Raval5, J. G. Nuchtern6, S. A. Vasudevan6, J. J. Doski7, A. B. Goldin2, E. A. Beierle1 3John Wayne Cancer Institute/Providence St. John’s Medical Center,Department Of Sugery,Santa Monica, CA, USA 4Maine Medical Center,Division Of Pediatric Surgery,Portland, ME, USA 5Emory University School Of Medicine,Division Of Pediatric Surgery/Department Of Surgery,Atlanta, GA, USA 6Baylor College Of Medicine,Division Of Pediatric Surgery/Department Of Surgery,Houston, TX, USA 7University Of Texas Health Science Center At San Antonio, San Rosa Children’s Hospital,Division Of Pediatric Surgery/Department Of Surgery,San Antonio, TX, USA 1University Of Alabama,Division Of Pediatric Surgery/Department Of Surgery,Birmingham, Alabama, USA 2University Of Washington,Division Of Pediatric Surgery/Department Of Surgery,Seattle, WA, USA
Introduction: Well-differentiated thyroid cancer (WDTC) is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in adults undergoing thyroidectomy. However, few studies have looked at the effects of socioeconomic status on the management of pediatric thyroid cancer. We sought to determine if children with lower socioeconomic status experience delays in diagnosis and management of their thyroid cancer.
Methods: Patients <21 years of age with well-differentiated thyroid cancer (WDTD) were reviewed from the National Cancer Data Base (NCDB) from 1998-2013. Three socioeconomic surrogate variables were identified: insurance type, median income in the patient’s ZIP code, and percent of people with no high school degree in the patient’s ZIP code. Chi-square and pool-variance t-tests were then used to compare tumor characteristics, intervals from diagnosis to staging and diagnosis to treatment, as well as clinical outcome variables within each of the socioeconomic surrogate variables, while controlling for the effect of age, race and gender.
Results: A total of 9585 children with WDTC were reviewed; 8696 (90.72%) with papillary thyroid cancer and 889 (9.28%) with follicular thyroid cancer. 7914 (82.6%) were female. In multivariate analysis, lower income (p = 0.041, Hazard Ratio [HR] = 1.98, 1.88 and 1.68 in each successive quartile compared to highest one), lower educational quartile (p<0.001, HR=1.86, 1.50 and 1.12, compared to highest quartile) and insurance status (p < 0.001, HR = 2.26 for uninsured and HR = 1.46 for government insurance, as compared to private insurance) were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (p <0.002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared to those with government (19 days) or private (18 days) insurance (p < 0.001). However, despite diagnosis at a higher stage and requiring longer time between diagnosis and treatment, there was no significant difference in either overall survival or rate of complications (demonstrated by unplanned readmission rates) based on any of the socioeconomic surrogate variables.
Conclusion: Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their WDTC. These patients also presented with higher stage disease. These data suggest that a disparity exists in access to care for children from low-income families. Although these findings did not translate into worse outcomes for WDTC, future efforts should focus on reducing these differences.