A. Zambeli-Ljepovic1, F. Wang1, M. Dinan1, T. Hyslop1, M. T. Stang1, S. Roman2, J. A. Sosa2, R. Scheri1 1Duke University Medical Center,Durham, NC, USA 2University Of California – San Francisco,San Francisco, CA, USA
Introduction:
Papillary thyroid cancer (PTC) is the fastest increasing cancer in the U.S. Despite an excellent prognosis for PTC overall, treatment has not been standardized for the elderly population, who are also more likely to suffer complications from thyroid surgery. This study aims to describe how extent of surgery (total thyroidectomy vs. lobectomy) and administration of radioactive iodine (RAI) affect complications, readmissions, and emergency department (ED) visits among elderly patients with low risk PTC.
Methods:
The linked SEER-Medicare database was used to identify patients ≥66 years treated for clinical T1N0M0 PTC between 1996 and 2011. Multivariable logistic regression was used to evaluate the effect of extent of surgery, RAI administration, and other factors on endocrine and RAI-specific complications, 90-day readmissions, and ED visits that did not result in admission. Complications occurring ≤30 days after surgery were defined as short-term; those present ≥6 months after surgery were considered long-term.
Results:
3341 patients met inclusion criteria; 77.3% were women, mean age was 72.9 years, mean tumor size was 0.8 cm, and 56.1% of tumors were found incidentally. Overall, 67.6% underwent total thyroidectomy, 32.4% underwent lobectomy, and 31.8% received postoperative RAI. Among patients who were known preoperatively to harbor PTC, 78.5% were treated with total thyroidectomy. Lobectomies outnumbered total thyroidectomies in the outpatient setting (37.7% vs. 27.6% respectively, P < 0.01). On multivariable analysis, patients treated with total thyroidectomy were more likely to have short-term complications [odds ratio (OR) 1.99, P < 0.01] and to be readmitted after surgery (OR 1.59, P < 0.01). Short-term complications were also independently associated with female sex (OR 1.34), black race (vs. white, OR 1.65), and comorbidity index (≥2 vs. 0, OR 1.43); all P < 0.01. Long-term endocrine complications were more common in female patients (OR 1.37, P = 0.025). Black patients and those with ≥2 comorbid conditions were more likely to present to the ED (OR 1.50 and 1.92, respectively) and to be readmitted after surgery (OR 2.19 and 2.29); all P < 0.01. RAI ablation was independently associated with complications of the eyes and salivary glands (OR 2.19, P < 0.01); RAI was not associated with an increased risk of ED visits or readmissions.
Conclusion:
Most elderly patients with low risk PTC undergo total thyroidectomy and a third receive postoperative RAI, treatments that place patients at risk for potentially avoidable complications and readmissions, since evidence does not support a survival benefit. Black and female patients appear to have greater inequities in access to quality care. There remain opportunities to improve postoperative health and quality of life while preserving the excellent prognosis of PTC.