Insurance Status Is Associated with Extent of Treatment for Patients with Papillary Thyroid Carcinoma

Health insurance has been shown to be a key determinant in cancer care, but it is unknown as to what extent insurance status affects treatments provided to papillary thyroid cancer (PTC) patients. We hypothesized that insured patients with PTC would have lower-risk tumors at diagnosis and be more likely to receive adjuvant therapies at follow-up. The American College of Surgeons' National Cancer Database was queried to identify all patients diagnosed with PTCs >2 mm in size from 2004 to 2015. Patients were grouped according to insurance status, and frequency of high-risk features and microcarcinoma at diagnosis were assessed. Multivariable analyses were used to identify independent predictors of more extensive treatment: total thyroidectomy (vs. lobectomy), lymphadenectomy, and radioactive iodine (RAI). There were 190,298 patients who met inclusion criteria; the majority of patients had private insurance (139,675 [73.4%]) and were female (144,824 [76.1%]). Uninsured patients, as compared with privately insured patients, had higher rates of extrathyroidal extension of their cancers (25.2% vs. 18.9%, p < 0.001), lymphovascular invasion (16.2% vs. 12.0%, p < 0.001), and positive margins on final pathology (16.0% vs. 12.2%, p < 0.001). Conversely, patients with private insurance were 51% more likely to have microcarcinomas at diagnosis (odds ratio [OR] = 1.51 [confidence interval {CI} 1.35-1.68], p < 0.001) than uninsured patients, controlling for demographic, socioeconomic, and hospital factors. Private insurance was an independent predictor for treatment with total thyroidectomy (OR = 1.18 [CI 1.01-1.37], p < 0.05), formal lymphadenectomy (OR = 1.22 [CI 1.09-1.36], p < 0.001), and adjuvant RAI therapy (OR = 1.35 [CI 1.18-1.54], p < 0.001) as compared with no insurance, adjusted for socioeconomic, demographic, hospital, and oncologic differences. Patients with Medicare or Medicaid were no more likely to receive these treatments than uninsured patients. Privately insured patients have less aggressive PTCs at diagnosis, and they are more likely to be treated with total thyroidectomy, lymphadenectomy, and RAI compared with uninsured patients. Clinicians should take caution to ensure proper referral and follow-up for under- and uninsured patients to reduce disparities in treatment.