Consumption of health resources in older people with differentiated thyroid carcinoma: a multicenter analysis

doi:10.21203/rs.3.rs-2455525/v1

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Research Article

Consumption of health resources in older people with differentiated thyroid carcinoma: a multicenter analysis

https://doi.org/10.21203/rs.3.rs-2455525/v1

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Journal Publication

published 27 Apr, 2023

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Objective

There is hardly any information on the consumption of healthcare resources by older people with differentiated thyroid cancer (DTC). We analyzed these consumptions in older patients with DTC and compared patients 75 years and older with subjects aged 60–74 years.

Methods

A multicenter, retrospective analysis was designed. We recorded three groups of health resources consumption (visits, diagnostic procedures, and therapeutic procedures) and identified a subgroup of patients with high consumption of resources. We compared elderly patients (group 1, 60–74 years) with very old patients (group 2, ≥ 75 years).

Results

We included 1654 patients (women, 74.4%), of whom 1388 (83.9%) belonged to group 1 and 266 (16.1%) to group 2. In group 2, we found a higher proportion of patients requiring emergency department visits (7.89% vs 4.32%, P < 0.05) and imaging studies (24.1% vs. 17.3%; P < 0.05) compared to group 1. However, we did not find any significant difference between both groups in the consumption of other visits, diagnostic procedures, or therapeutic procedures. Overall, 340 patients (20.6%) were identified as high consumers of health resources, 270 (19.5%) in group 1 and 70 (26.3%) in group 2 (P < 0.05). Multivariate logistic regression analysis showed that the risk of recurrence and mortality, radioiodine treatment, tumor size, and vascular invasion were significantly related to the high global consumption of resources. However, the age was not significantly related to it.

Conclusion

In patients with DTC over 60 years of age, advanced age is not an independent determining factor in the consumption of health resources.

Differentiated thyroid carcinoma

elderly

health resources

elderly

Recent data indicate that the incidence of differentiated thyroid carcinoma (DTC) has increased worldwide [1–5] and that between 2.5 and 12% of all DTCs occur in patients older than 65 years [6]. In most cases DTC is a slow-progressing tumor with a favorable prognosis [7]. Despite this, recurrences are common, and patients require lifelong follow-up, multiple medical visits and various diagnostic and therapeutic procedures [8, 9].

Some authors have shown that the incidence of thyroid cancer increases with age [10]. Furthermore, worse outcomes for DTC have been attributed to older people. Some studies have shown that DTC in the elderly tend to be larger, and to present more commonly with aggressive histological types, extrathyroid disease, and distant metastases [11–17] and, consequently, worse prognosis [18]. This translates into a higher recurrence rate [19–22] and, therefore, a greater consumption of health resources during follow-up.

The aging of populations is a trend in all countries [23] and this is a challenge for public health [24]. It is foreseeable that clinicians and surgeons increasingly face elderly patients with thyroid cancer who require treatment and lifelong follow-up. In these patients, the presence of frailty and comorbidities that increase surgical risk are common and may have an impact on the need for diagnostic and therapeutic procedures [25, 26].

In a previous multicenter study, we evaluated in a large group of patients over 60 years of age whether advanced age played a prognostic role in patients with DTC [27]. Our data showed that, in the Spanish population, age at diagnosis was a conditioning factor for overall survival but was not a predictor of disease recurrence throughout follow-up. Consequently, and given that some studies have associated thyroid cancer in the elderly with a significant economic burden for the healthcare system [28], in the present study we set out to analyze whether advanced age is related to the consumption of health resources. To do this, we evaluated whether patients aged 75 or over are more resource consumers than patients below that age.

Subjects

This was a multicenter, retrospective study that included patients diagnosed with DTC, who were ≥ 60 years old at the time of diagnosis. The inclusion criteria were: (1) surgical treatment by lobectomy or thyroidectomy (total or near-total), with or without lymph node dissection, followed or not by radioiodine (RAI) treatment, (2) availability of a histological report, and (3) follow-up time ≥ 12 months in the same hospital. An initial phase of this study analyzed disease-free and overall survival in a group of 1668 patients who met these inclusion criteria [27]. In the present study, we deal with assessing the influence of age on the consumption of health resources in these same patients.

Study design

A review of the medical records of all patients who met the inclusion criteria and with at least one follow-up visit between January 1, 2016 and December 31, 2021 was performed. We collected information on clinical and demographic data, initial surgery, RAI treatment, pathological details, initial patient classification, and follow-up data including the consumption of health resources. Data were collected up to the date of the last follow-up visit or patient’s death. All patient’s data were obtained under the standard medical care conditions. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The patient’s confidential information was protected according to national law, and the study was approved by the local ethics committee of the hospital Puerta de Hierro Majadahonda (Madrid, Spain) (PI 235 − 20). Since our study was conducted through patient chart reviews, the ethics committee waived the need for consent.

Patient classification

For the classification of patients at the time of diagnosis, then TNM staging system was used according to the criteria of the American Joint Committee on Cancer, 8th edition [29]. The initial risk of recurrence was classified according to the 2009 American Thyroid Association (ATA) criteria, with the modifications proposed in 2015 [30]. For comparative purposes, we considered two age groups: group 1 (elderly patients) consisted of patients aged 60 to 74 years at the time of diagnosis, while group 2 (very old patients) was made up of people diagnosed at age 75 or older.

Consumption of health resources

The health resources studied were classified into three groups: visits, diagnostic procedures, and therapeutic procedures. Visits included follow-up visit to the doctor’s office (including only those to specialists related to thyroid cancer), emergency department visits and hospital admissions related to thyroid cancer or its complications (including admissions for therapeutic procedures detailed below). The following diagnostic procedures were quatified: measurements of thyroglobulin (and/or anti-thyroglobulin antibodies), neck ultrasounds, fine-needle aspiration citologies (FNAC), imaging tests other than cervical ultrasound (computerized tomography [CT] scan, and magnetic resonance imaging [MRI]), and diagnostic radionuclide scans (RAI scan, positron emission tomography [PET]). The therapeutic procedures included in the study were: cervical and extracervical surgeries, RAI treatments, external radiotherapy treatments (cervical and extracervical), and lines of treatment with targeted therapies or with other antineoplastic drugs.

Definitions

A high consumer of visits was defined as a patient with one or more visits to the emergency department, one or more hospital admissions, or more than 10 follow-up visits per year. High consumption of diagnostic procedures was defined as more than one FNAC per year, more than one imaging procedure per year, more than one radionuclide scan per year, more than 4 measurements of thyroglobulin per year, or more than 4 neck ultrasounds per year. Patients considered to be high consumers of therapeutic procedures were those who had, apart from the initial surgery and RAI, at least one cervical or extracervical surgery, one treatment with RAI, one cycle of treatment with cervical or extracervical radiotherapy, or one line of targeted therapies or other antineoplastic drugs. Lastly, a high overall consumption of resources was considered in patients who were high consumer of visits, diagnostic resources or therapeutic resources.

Statistical analysis

The consumption of health resources for each patient was quantified exclusively during the last 5 years of follow-up prior to the date of the last review or death. In the event that the patient had less than 5 years of follow-up, consumption was quantified during the available years (minimum 1 year). In all cases, the number of years of assessment of consumption was recorded so that it was possible to calculate the number of resources per year for each patient. Only the consumptions produced in the clinical follow-up of DTC were quantified. The consumptions related to the initial treatment (surgery, RAI) were excluded from the data processing. For each group of patients, we quantified the number of resources consumed per 100 patient-years, as well as the number of patients with resource consumption per 100 patient-years. For quantitative variables, results are expressed as median (interquartile range, IQR). Categorical variables are described as absolute values, ratios or percentages. For comparisons of means between two groups of patients, the Mann-Whitney test was used. For ratio comparisons, the chi-square test or Fisher’s exact test was used. Several models of logistic regression analysis were used to assess the presence of high consumption of health resources (visits, diagnostic, and therapeutic procedures) as a function of quantitative and qualitative variables. All used tests were two-sided and differences were considered significant when P < 0.05.

Studied patients

Of the 1668 patients initially included in our study, 14 were excluded due to lack of information on the consumption of health resources. Of the 1654 patients included (1230 women, 74.4%) there were 1388 (83.9%) in group 1 and 266 (16.1%) in group 2. Most of the patients had papillary thyroid carcinoma (1499, 87.6%) and had been treated with total thyroidectomy without (1025, 62.0%) or with (521, 31.5%) lymph node dissection followed by radioiodine ablation (1213, 73.3%) (Table 1).

Table 1

Clinical, pathological, and therapeutic characteristics of studied patients
Variable	Units or categories	No.	Value
Clinical
Age	Years	1654	67 (63–72)
Age group		1654
	60–74 yr		1388 (83.9)
	≥ 75 yr		266 (16.1)
Gender		1654
	Female		1230 (74.4)
	Male		424 (25.6)
Family history		1509	50 (3.3)
HNRT in childhood		1549	18 (1.2)
Pathological
Histology		1654
	Papillary		1499 (87.6)
	Follicular		106 (6.4)
	Hürthle		99 (6.0)
Tumor size	cm	1636	1.5 (0.7-3.0)
Multifocality		1646	672 (40.6)
Vascular invasion		1571	277 (16.7)
Extrathyroidal extension		1654
	No or micro		1565 (94.6)
	Gross		89 (5.4)
Incidental		1644	445 (27.1)
Therapeutic
Surgery		1654
	Lobectomy		108 (6.5)
	TT		1025 (62.0)
	TT + LND		521 (31.5)
Radioiodine		1654	1213 (73.3)
Risk classification
ATA risk		1652
	Low		1050 (63.6)
	Intermediate		405 (24.5)
	High		197 (11.9)
TNM stage		1654
	I		1147 (69.3)
	II		391 (23.6)
	III-IV		116 (7.0)
Data are the median (IQR) for quantitative variables, and the number (percentage) for categorical variables.
Abbreviations: No., total number of patients with available data; HNRT, head and neck radiation therapy; TT, total thyroidectomy; LND, lymph node dissection; ATA, American Thyroid Association.

When patients in group 1 (60–74 years) were compared with those in group 2 (75 years and older), we observed that the latter had significantly larger tumors (1.8 [0.8–3.2] vs. 1.5 [0.7–2.7] cm; P = 0.004) and a higher proportion of subjects with vascular invasion (23.9 vs. 16.4%; P = 0.005). The use of RAI was more common in group 1 compared to group 2 (74.6 vs 66.9%; P = 0.012). The ATA risk stratification showed that in group 2 there was a lower proportion of low-risk patients in relation to group 1 (57.4 vs. 67.7%; P = 0.007). However, no significant differences were observed between the groups regarding gender, family history of thyroid cancer, and personal history of head and neck radiation therapy in childhood. Neither were there significant differences in histological type, multifocality, extrathyroidal extension, proportion of subjects with incidental cancers, and proportion of use of the different surgical procedures. Furthermore, we did not find statistically significant differences in the mortality risk between the two groups according to the TNM staging system (Supplementary material, Table S1).

Consumption of health resources

The median follow-up time for the assessment of health resources was 5 (3–5) years, with a total of 6676.1 patient-years. 1291 patients (78.1%) had a resource evaluation time ≥ 3 years and 1109 of them (67.1%) had a resource evaluation time ≥ 4 years.

As expected, all patients underwent follow-up visits and thyroglobulin measurements (Table 2). In the case of follow-up visits, we registered 204.6 resources consumed per 100 patient-years and 24.8 patients with resource consumption per 100 patient-years. In the case of thyroglobulin determinations, we found 154.3 resources consumed per 100 patients-years, and 24.8 patients with resource consumption per 100 patient-years were registered. Only 81 patients (4.9%) and 201 patients (12.5%) required visits to the emergency department or hospital admissions, respectively.

Table 2

Consumption of healthcare resources in the whole cohort of patients studied
	Number of resources	Patients with resource consumption		Resources consumed per 100 patient-years	Patients with resource consumption per 100 patient-years
		Number	Percentage
Visits
Follow-up	13,658	1654	100	204.6	24.8
Emergency	188	81	4.9	2.8	1.2
Hospital admission	367	201	12.5	5.5	3.0
Diagnostic procedures
Thyroglobulin	10,302	1654	100	154.3	24.8
Neck US	3630	1443	87.2	54.4	21.6
FNAC	223	164	9.9	3.3	2.5
Imaging	1180	304	18.4	17.7	4.6
Radionuclide scan	784	447	27.0	11.7	6.7
Therapeutic procedures
Cervical surgery	100	84	5.1	1.5	1.3
Extracervical surgery	37	21	1.3	0.6	0.3
RAI therapy	231	165	10.0	3.5	2.5
Cervical EBRT	29	28	1.7	0.4	0.4
Extracervical EBRT	24	18	1.1	0.4	0.3
Targeted therapy	73	53	3.2	1.1	0.7
Other antineoplastic drugs	5	5	0.3	0.1	0.1
Data include 1654 patients with 6,676.1 patient-years of follow-up.
Abreviations: US, ultrasound; FNAC, fine-needle aspiration cytology; RAI, radioactive iodine; EBRT, external beam radiation therapy.

Apart from thyroglobulin, the most used diagnostic resource was neck ultrasound (54.4 resources consumed per 100 patient-years and 21.6 patients with resource consumption per 100 patient-years). In the group of therapeutic procedures, the most used resource was RAI therapy (3.5 resources consumed per 100 patient-year, 2.5 patients with resource consumption per 100 patient-years). All diagnostic resources except FNAC were used by more than 10% of patients. However, there was no therapeutic resource that was used by more than 10% of the patients (Table 2).

Consumption of resources by age groups

The comparison of the use of healthcare resources in the two age groups is summarized in Table 3. In group 2 there were 21 patients (7.9%) who required visits to the emergency department, while this percentage was significantly lower in group 1 patients (60 patients, 4.3%; P < 0.05). No differences were found between both groups in follow-up visits or hospital admissions.

Table 3

Consumption of healthcare resources (visits, diagnostic and therapeutic procedures) in patients classified by age groups
	Group 1 (60–74 years)				Group 2 (75 years and older)
	Number of resources	Patients with resource consumption	Resources consumed per 100 patient-years	Patients with resource consumption per 100 patient-year	Number of resources	Patients with resource consumption	Resources consumed per 100 patient-years	Patients with resource consumption per 100 patient-year
Visits
Follow-up	11,008	1388 (100)	195.1	24.6	2260	266 (100)	218.5	25.7
Emergency	150	60 (4.3)	2.7	1.1	38	21 (7.9)*	3.7	2.0
Hospital admissions	300	167 (12.0)	5.3	3.0	67	34 (12.8)	6.5	3.3
Diagnostic procedures
Thyroglobulin	8667	1388 (100)	153.6	24.6	1635	266 (100)	158.0	25.7
Neck US	3076	1213 (87.4)	54.5	21.5	554	230 (86.5)	53.6	22.2
FNAC	184	135 (9.7)	3.3	2.4	39	29 (10.9)	3.8	2.8
Imaging	957	240 (17.3)	17.0	4.3	223	64 (24.1)*	21.6	6.2
Radionuclide scan	650	372 (26.8)	11.5	6.6	134	75 (28.2)	13.0	7.3
Therapeutic procedures
Cervical surgery	85	71 (5.1)	1.5	1.3	15	13 (4.9)	1.5	1.3
Extracervical surgery	30	17 (1.2)	0.5	0.3	7	4 (1.5)	0.7	0.4
RAI therapy	190	132 (9.5)	3.4	2.3	41	33 (12.4)	4.0	3.2
Cervical EBRT	24	23 (1.7)	0.4	0.4	5	5 (1.9)	0.5	0.5
Extracervical EBRT	19	15 (1.1)	0.3	0.3	5	3 (1.1)	0.5	0.3
Targeted therapy	60	42 (3.1)	1.1	0.8	13	11 (4.1)	1.3	1.1
Other antineoplastic drugs	4	4 (0.3)	0.1	0.1	1	1 (0.4)	0.1	0.1
Data include 1388 patients with 5,641.8 patient-years of follow-up in group 1, and 266 patients with 1034.5 patient-years of follow-up in group 2.
Abbreviations: US, ultrasound; FNAC, fine needle aspiration cytology; RAI, radioiodine; EBRT, external beam radiation therapy.
*P < 0.05 for the difference in the proportion of cases with resource in the two age groups (chi-square test).

The proportion of patients who required imaging investigations was significantly higher in group 2 (64 patients, 24.1%) compared to group 1 (240 patients, 17.3%, P < 0.05). We did not find any other significant differences in the consumption of diagnostic procedures in patients classified by age groups. Nor did we find differences between both groups concerning the consumption of the therapeutic procedures.

High consumption of health resources

According to the previous definitions, we found 230 patients (13.9%) classified as high consumers of visits, 124 (7.5%) high consumers of diagnostic procedures and 234 (14.2%) high consumers of therapeutic procedures. Overall, 340 patients (20.6%) met the criteria of high consumers of healthcare resources.

Data in Table 4 show that males, patients classified as high ATA risk and those classified as TNM stages III-IV had significantly higher proportions of patients with a high consumption of visits and admissions (P < 0.001), diagnostic procedures (P < 0.001) and therapeutic resources (P < 0.001).

Table 4

Relationship between the high consumption of healthcare resources and the demographic and risk characteristics of the studied patients
	High consumption of hospital visits and admissions		High consumption of diagnostic resources		High consumption of therapeutic resources		High overall consumption of resources
	No (n = 1424)	Yes (n = 230)	No (n = 1530)	Yes (n = 124)	No (n = 1420)	Yes (n = 234)	No (n = 1314)	Yes (n = 340)
Age (yr)	67 (63–72)	68 (64–73)	67 (63–72)	69 (65–74)**	67 (63–72)	68 (64–74)*	67 (63–72)	68 (64–74)*
Age group
60–74 yr	1199 (84.2)	189 (82.5)	1290 (84.3)	98 (79.0)	1200 (84.5)	188 (80.3)	1118 (85.1)	270 (79.4)*
≥75 yr	225 (15.8)	41 (17.8)	240 (15.7)	26 (21.0)	220 (15.5)	46 (19.7)	196 (14.9)	70 (20.6)
Gender
Female	1079 (75.8)	151 (65.7)***	1156 (75.6)	74 (59.7)***	1089 (76.7)	141 (60.3)***	1013 (77.1)	217 (63.8)***
Male	345 (24.2)	79 (34.3)	374 (24.4)	50 (40.3)	331 (23.3)	93 (39.7)	301 (22.9)	123 (36.2)
ATA Risk¶
Low	985 (69.2)	65 (28.4)***	1034 (67.6)	16 (12.9)***	1001 (70.5)	49 (20.9)***	952 (72.5)	98 (28.8)***
Intermediate	341 (24.0)	64 (27.9)	376 (24.6)	29 (23.4)	332 (23.4)	73 (31.2)	301 (22.9)	104 (30.6)
High	97 (6.8)	100 (43.7)	118 (7.7)	79 (63.7)	85 (6.0)	112 (47.9)	60 (4.6)	137 (40.3)
TNM stage
I	1076 (74.9)	80 (34.8)***	1122 (73.3)	25 (20.2)***	1090 (76.8)	57 (24.4)***	1034 (78.7)	113 (33.2)***
II	314 (22.1)	77 (33.5)	350 (22.9)	41 (33.1)	296 (20.8)	95 (40.6)	263 (20.0)	128 (37.6)
III-IV	43 (3.0)	73 (31.7)	58 (3.8)	58 (46.8)	34 (2.4)	82 (35.0)	17 (1.3)	99 (29.1)
¶Sample size for ATA risk = 1652
P < 0.05; P < 0.01; **P < 0.001.

There was no significant relationships between age groups and any resource consumption. However, age as a quantitative variable was significantly related with both the high consumption of diagnostic (P < 0.01) and therapeutic resources (P < 0.05). In short, high overall consumption of resources was related to age (P < 0.05), but more significantly to gender, ATA risk and TNM stage (P < 0.001)

Logistic regression analysis

Several models of logistic regression analysis were performed to study the dependence of the variables related to high consumption of resources as a function of several independent variables (Supplementary material, Tables S2, S3 and S4; Fig. 1).

In model 1 (demographic and risk classification features) ATA risk and TNM staging were significantly related to high consumption of visits, diagnostic and therapeutic resources. Male gender was only related to the high consumption of therapeutic resources in this model (Supplementary material, Table S4). When therapeutic and histopathological variables were introduced in the model (model 2), tumor size and vascular invasion were also related to high consumption of the three types of health resources. Surgery with lymph node dissection was significantly related to the consumption of visits and diagnostic resources (Supplementary material, Tables S2 and S3). However, the age of the patients was not significantly related to high consumption of resources in any case (Fig. 1).

The relationship between the high overall consumption of resources and the independent variables is shown in Table 5. ATA risk, TNM staging, radioiodine treatment, tumor size and vascular invasion were significantly related to high overall consumption. Again, age was not a significant variable.

Table 5

Results of two models of logistic regression to study the influence of several covariates on the presence of high overall resource consumption
	Model 1			Model 2
	OR	95% CI	OR	95% CI	P
Age (yr)	1.01	0.99–1.04	0.220	1.01	0.99–1.04	0.379
Gender (male)	1.41	1.04–1.91	0.028	1.38	0.99–1.90	0.055
ATA risk (interm)	2.08	1.45-3.00	< 0.001	1.38	0.92–2.08	0.119
ATA risk (high)	4.56	2.67–7.79	< 0.001	2.49	1.32–4.70	0.005
TNM stage (II)	2.37	1.65–3.40	< 0.001	1.54	0.99–2.36	0.051
TNM stage (III-IV)	13.55	6.57–27.93	< 0.001	12.08	5.38–27.11	< 0.001
Surgery (TT + LND)				1.44	0.99–2.08	0.052
Radioiodine				2.00	1.15–3.48	0.014
Histology (non-pap)				1.01	0.63–1.61	0.969
Tumor size (cm)				1.18	1.07–1.31	0.001
Multifocality				1.04	0.76–1.41	0.821
Vascular invasion				1.82	1.21–2.73	0.004
ETE (gross)				1.04	0.53–2.03	0.914
Incidental (no)				1.08	0.66–1.74	0.793
Model 1: Demographic and risk classification features are included as independent variables.
Model 2: In addition to the above, therapeutic and histopathological variables are included.
Abbreviations: OR, odds ratio; CI, confidence interval; ATA, American Thyroid Association; TT, total thyroidectomy; LND, lymph node dissection; non-pap, non-papillary; ETE, extrathyroidal extension.
Bold values indicate statistically significant values.

Close and ongoing surveillance is necessary in patients with DTC to detect and treat potential recurrences. Given that the number of DTC cases is increasing, it is foreseeable that resource consumption and cost related to follow-up will inevitably increase [31]. This study reports a comparative analysis of the consumption of health resources in patients with DTC classified into two age groups. Main results show that very old patients (≥ 75 years) consume more frequently than elderly patients (60–74 years) visits to the emergency service and imaging tests other than neck ultrasound, but not other resources related to visits, diagnostic or therapeutic procedures. Furthermore, we did not find significant differences in the proportions of the two groups of patients among high consumers of visits, diagnostic resources, and therapeutic resources, although we found that age group was significantly related with high overall consumption of resources. However, our multivariate regression analysis in no way showed that age was a variable significantly related to the high consumption of health resources, while other independent variables, such as ATA risk, TNM stage, surgery, radioiodine, tumor size or vascular invasion, were significantly related to some of the high consumption assessed. Altogether, these results suggest that age does not condition per se and independently the consumption of health resources in people aged 75 or over with DTC compared to what was found in patients between 60 and 74 years of age.

In our multivariate analysis, the high consumption of resources was directly related to the risk groups for recurrence or mortality and also with tumor size and vascular invasion. Extensive surgery was directly related to the consumption of visits and diagnostic procedures, but not with the consumption of therapeutic resources. RAI treatment was related only to overall consumption. Taken together, these data suggest that patients with more advanced disease generate a greater consumption of resources and, therefore, a higher cost for the healthcare system. These data are consistent with those of some recent studies that showed higher costs for patients with renal cell carcinoma diagnosed in advanced stages compared to those diagnosed in earlier stages [32], as well as in patients undergoing more complex treatments [33].

Although several investigators have analyzed the recurrence rate of thyroid cancer in older patients [16, 17] we have not found specific studies focusing on the consumption of healthcare resources. In an analysis of all thyroid cancers diagnosed in a single center using artificial intelligence methods, we were able to demonstrate that very old people (≥ 75 years) were not higher consumers of healthcare resources than elderly patients (60–74 years) [34]. We observed that patients ≥ 75 years presented a significant increase in the consumption of diagnostic procedures such as CT and PET scans. These results are in part similar to those of the current study, although the methodology of these analyses has been very different.

Several studies [35–37] have shown that patients over 80 years of age undergoing thyroid surgery differs significantly from younger patients in terms of several parameters such as comorbidities, costs and length of hospitalization and complications. However, various authors have shown that thyroid surgery is safe in the elderly and does not entail major complications when performed by expert surgeons [16, 38, 39]. Thus, age per se should not be considered an exclusionary criterion for thyroidectomy [16].

Some studies have analyzed the costs inherent in the initial surgical treatment of patients with DTC [40]. Some of them have evaluated the costs during follow-up [28], but none of them have analyzed in depth the effect of the age of the patients. Miccoli et al. [41] showed, in 116 patients who underwent thyroidectomy, that costs related to perioperative risk assessment and the duration of hospital stay were higher in patients aged over 80 years than in younger patients. Instead, surgery-related complications were not statistically different. However, this study does not analyze healthcare consumption and its long-term costs.

Another study, conducted using information from the SEER-Medicare linked data, analyzed the cumulative costs attributable to disease stage and treatment options of DTC in elderly patients over 5 years after diagnosis. They found numerous factors that have a significant influence on the costs attributable to the care of patients with DTC. These included advanced age, but also other characteristics such as male gender, disease extent, and the presence of frailty measured by the recorded number of comorbid diagnoses. However, all patients included in this Medicare based study were in the high-risk category on the basis of any number of the thyroid cancer risk scores [28].

Our results may have implications for clinical practice. The increase in life expectancy in the population of different countries has led to a large increase in the elderly population as well as an increase in prejudices concerning the elderly, who are seen as hindering productivity and social dynamism [42]. In addition, very old people tend to have a higher burden of cardiovascular and metabolic comorbidities than the elderly [28, 43]. Consequently, stereotypes about aging may influence decision-making in the clinical management of older persons with cancer. In our patients, a higher tumor burden and a worse prognosis were evident in subjects over 75 years of age. Despite this, the data show that the consumption of health resources was not higher in the older age group and that age was not an independent factor of the high consumption of diagnostic or therapeutic resources. These data support that elderly people should be managed with the same therapeutic effort as other younger patients. We believe that these results are compatible with the current trend in international organizations for the prevention of ageism, as advocated by the WHO [44], that is, avoiding existing stereotypes and prejudices in relation to age and, therefore, avoiding discrimination based on age.

The main strengths of our study are the high sample size and its multicenter nature. The data obtained represent standard clinical practice in Spanish centers with proven experience in DTC. Another strength is that only patients with follow-up from 2016 were included, to avoid follow-up with criteria prior to the 2015 ATA guidelines [30]. Health resources were quantified only in the last 5 years of follow-up to avoid past consumptions that could use different clinical criteria than the current ones. To ensure a minimum time for consumption assessment, patients with less than one year of follow-up were not included. Importantly, most patients included in our study had more than 4 years of consumption assessment. Since the greatest consumption of resources in patients with CDT is related to the initial treatment [28], our study excluded these and was limited to the consumption produced during clinical follow-up. In addition, given that comorbidity is common in older people with DTC [36, 37, 43], our study only considered healthcare consumption related to DTC follow-up, excluding those related to other diseases.

The limitations of our study are those inherent to retrospective analyses. Our survey is limited to the consumption of resources, but does not evaluate the costs of these consumptions. The used definition of high consumption of health resources is arbitrary, although we believe that it is coherently adapted to the clinical practice and that it allows us to clearly separate patients with high consumption of resources from the majority of patients who simply present a normal or slightly elevated consumption, without a great disruption on health spending.

In summary, we believe that adequate knowledge of the clinical course and health consumption generated by older people with DTC is essential to promote positive attitudes towards them in clinicians and avoid making decisions based solely on prejudices or stereotypes related to aging. The main finding of the present study is that very old patients with DTC do not consume, in a clinically relevant way, more healthcare resources than elderly patients, despite being carriers of more aggressive tumors and, consequently, it is plausible that they do not generate a higher economic burden. These findings should be confirmed in prospective studies, as they could be useful to avoid ageism in the management of elderly patients with DTC.

Funding

The present investigation has not received any financial support from public sector agencies, commercial sector, or non-profit entities.

Conflicts of interest

The authors have no conflicts of interest to declare.

Availability of data

Data are available through a reasonable request to the corresponding author.

Author contributions

Conception and design: JJD. Administrative support: all authors. Provision of study materials or patients: all authors. Collection and assembly of data: all authors. Data analysis and interpretation: all authors. Manuscript writing: all authors. Final approval of manuscript: all authors.

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Consumption of health resources in older people with differentiated thyroid carcinoma: a multicenter analysis

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