br Studies have shown differences in the clinical
Studies have shown differences in the clinical management of thyroid cancer when comparing patients by race.48 One group re-ported that, although appropriate utilization of surgery for differ-entiated thyroid cancer has improved over time for all races, the
proportion of improvement has been lower for blacks compared with whites.49 The data from our study suggests no significant differences in surgical management for PTC among African Amer-icans. As practice patterns continue to evolve, ongoing attention to disparities among vulnerable groups is important. A greater like-lihood of thyroid lobectomy, relative to total thyroidectomy, was observed among male and older thyroid cancer patients in addition to individuals from Appalachian regions. The basis for sex differ-ences is uncertain but is perhaps grounded in preferences for more “aggressive” medical decisions among male patients.50 Overall, thyroid cancer is 2.9 times more common among women than men but tends have a worse prognosis among men.51 Consistent with the literature, less aggressive treatment approaches tend to be pursued among elderly cancer patients.52 Age differences could represent either age bias or a greater comorbidity burden among older populations, a difference worth further exploration. Among Appalachian populations, the lower likelihood of thyroid lobectomy fits a pattern of rural populations being less likely to receive rec-ommended services or high-quality treatment.53 This Puromycin may have more limited treatment options attributable to access barriers, including greater travel distances, lower socioeconomic status, and higher uninsurance rates. Greater travel distances may lead to more aggressive surgical choices because of the difficulty of returning for follow-up.
Study limitations include the lack of detail about clinical in-dications for surgery in the cancer registry, including the diagnostic evaluation beforehand. Furthermore, information about the clinical decision-making process, such as provider recommendations and patient preferences, are not routinely available. Therefore, although we cannot more fully understand the surgical choice among any single patient, the lack of change in practice patterns across this nationally representative PTC population suggests very low adop-tion of approaches associated with lower surgical risk and morbidity. In addition, because of the nature of SEER data, which ascertains initial surgical management, it is not possible to deter-mine incidence or proportion of patients who went on to receive a completion thyroidectomy. This type of surgery is performed when a thyroid lobectomy returns with a histologic diagnosis of cancer and the surgical team decides to return to the operating room and remove the contralateral thyroid lobe. Therefore, thigmotropism is possible that some patients who underwent a thyroid lobectomy in our cohort progressed to completion thyroidectomy. If true, one could argue that the proportion of total thyroidectomy here is an underesti-mation of the true proportion over time. Finally, the ATA currently recommends total thyroidectomy for patients with cancers <1 cm who had been treated with head and neck radiation, presented with nodal metastasis, or had familial thyroid carcinoma.36 Although unlikely to explain the observed differences between the receipt of thyroid lobectomy and total thyroidectomy, future work may help disentangle these outstanding issues.
The findings of this study highlight the need to better under-stand the reasons for the lack of adoption of guideline changes. In addition to the known lag of practice change after new guidelines are produced, it is possible that physicians and patients may not be comfortable with having a surgery less aggressive than a total thyroidectomy performed for any size PTC. However, the data are lacking on the long-term quality-of-life outcomes when patients are treated with a thyroid lobectomy versus total thyroidectomy. In addition, there may be reduced financial burden on patients asso-ciated with choosing one approach rather than another. These questions should be addressed in future studies and may provide additional data to inform the choice of surgery for smaller PTCs.
Future research should also continue to monitor rates of thy-roidectomy among tumor types and populations, including those seen by both high-volume and low-volume surgeons of varied
training backgrounds (ie, endocrine, head and neck, and general surgeons), to determine what factors influence practice in relation to clinical guidelines. Future study of the slow adoption of national guidelines for thyroid surgery can benefit from similarities and differences in what has been learned among populations with other low-risk cancers.45 Although it is perhaps not unexpected that practice change lags clinical guidelines, it is nonetheless important to note that the professional responsibility to deliver care consis-tent with the most recent evidencedand guidelinesdavailable is an urgent and more-than-reasonable patient expectation of phy-sicians caring for patients diagnosed with thyroid cancer.