Thyroid carcinoma: correlation of the extent of disease at presentation and risk of death and recurrence with race/ethnicity and income differences
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Abstract
BACKGROUND: Many research publications indicate that racial minorities and people in lower socioeconomic status are negatively affected by a higher morbidity and mortality rate in many diseases, including many cancers such as thyroid cancer. Although these disparities may be attributed to multiple factors, it is unclear whether a biological pre-disposition and/or the differences in levels of health care education, intervention and resources result in people of low-income levels and minorities presenting with higher risk and advanced stage of cancer. This commonly results in poorer prognoses, response to therapy, and outcomes. Even though thyroid cancer has had a progressive annual increase in incidence rates in the last thirty years across all demographic categories, the overall survival rate remains excellent. However, previous publications suggest that minorities and those in lower socioeconomic classes may present with higher-risk thyroid cancer cases. The goal of this research is to determine if socioeconomic status (SES) and race/ethnicity (R/E) influence the stage of the cancer and predict the risk of recurrence from thyroid cancer. To investigate, we performed an examination of our comprehensive THYROid CAncer REgistry (ThyroCARE) at Boston Medical Center, an urban tertiary care hospital with a diverse population, many of whom are from minority and international backgrounds, for the effect of SES and R/E on the initial staging and response to treatment.
METHODS: A thyroid cancer registry was designed with the intent to capture both retrospective and prospective individual patient data at BMC. ThyroCARE resides in a browser-based Research Electronic Data Capture (REDCAP) program and contains 1,208 discrete data points related to initial and ongoing patient management. Patients were consented either in person or after receiving research documents through mail. Data is captured via individual record review and recorded in REDCAP. Analyses were performed with SPSS software. A total of 1305 BMC patients who have had treatment for thyroid cancer were consented and enrolled into the IRB approved BMC Thyroid Cancer Registry starting in 2010 with enrollment currently ongoing. Demographic, social history, and medical information were retrieved from the patients via IRB-approved surveys and a review of EPIC medical charts. An estimate of each patient’s median household income was determined by using their zip code and public data from the 2019 United States Census and American Community Survey that correlates income and zip codes. The information collected was then used to measure the initial and current risk of thyroid cancer, and the staging of the cancer across race/ethnicity and income level in the State of Massachusetts.
RESULTS: Overall, there was no overall significant difference of thyroid cancer subtype with R/E but subset analysis show Black/African Americans have a lower prevalence of classic PTC and higher prevalence of follicular variant of PTC while Hispanics and Asians show the reverse with a higher proportion of classic PTC and lower proportion of FVPTC. When income level and R/E were compared, Black/African American and Hispanic/Latino patients had the greatest representation in the low-income bracket while Asian American and White/Caucasian patients had the greatest representation in the high-income bracket. However, there was no statistical difference seen when initial ATA risk of tumor recurrence and AJCC staging classification for risk of mortality were distributed across R/E or income level. A difference was seen in current ATA risk that reflects response to therapy as Asian American and Hispanic/Latino patients had a greater representation in the intermediate risk of recurrence category. Furthermore, low-income level patients had the least representation in the current ATA low risk recurrence group.
CONCLUSION: In this safety net population of patients traditionally composed of patients who are non-Caucasians, have a low income and immigrant status, there was no statistical difference seen in the initial ATA risk and AJCC staging classification when distributed across levels of income or R/E. The initial presentation and extent of disease was not associated with R/E or income level. There is a difference in current ATA risk which reflects response to therapy. There was no significant difference in R/E in the ATA low or high current risk groups but, in contrast, the ATA intermediate risk demonstrated a higher prevalence of Asian and Latino/Hispanic patients. We hypothesize that this difference can be attributed to the higher percentage of Asian and Latino/Hispanic patients with classical papillary thyroid cancer, a tumor subtype with a higher potential for local invasion and lymph node metastases for these R/E groups. Future studies will examine if the difference in response to therapy is due to R/E or difference of tumor subtypes.