Document Type

Capstone Experience

Graduation Date


Degree Name

Master of Public Health



First Committee Member

Chair, Paraskevi A Farazi, PhD

Second Committee Member

Faculty, Elizabeth Lyden, MS

Third Committee Member

Whitney S Godner, MD

Fourth Committee Member

Anupam Kotwal, MD



Background and objective: Multiple studies have shown that the place of residence and the distance to travel from one's residence to nearby health care providers impact cancer diagnosis and treatment. The stage of cancer at the time of diagnosis is paramount for cancer treatment and affects survival. Disparities in cancer treatment exist which affect the outcome disproportionately to certain segments of the population. To date, much of the focus has been on the racial and socioeconomic disparities in the management of thyroid cancer. The effect of geography and location (urban-rural status) on thyroid cancer stage diagnosis has not been well studied. Therefore, the purpose of this study was to- 1) To investigate geographic disparities in thyroid cancer stage at the time of diagnosis. 2) To identify the factors affecting the stage of thyroid cancer at the time of diagnosis.


A cross-sectional study was conducted with the sample of 800 thyroid cancer patients using the integrated Cancer data Repository for Cancer Research (iCaRe2) database. Residents in urban or rural counties at the time of diagnosis were categorized by 2013 Rural-Urban Continuum Codes and mapping between FIFS and Zip codes. The distance between the patient's residence and the case reporting hospital, University of Nebraska Medical center (UNMC) was characterized as short(12.5 to <50 >miles) or long(>=50miles). The American Joint Committee on Cancer (AJCC) the tumor-node-metastasis (TNM) staging 7th edition, was used for staging of differentiated thyroid cancer. We dichotomized the stages as early (Stage I) and late (stage II) for thyroid cancer patients' less than 45 years old. For patients over 45 years old, we have dichotomized the stage as early (Stage I and II) and late (stage III, IV). Patients' demographics and clinicopathological features were compared between the Urban and Rural populations using the chi-square test. We performed a multivariable logistic regression model to look at the association factors between location of residence and outcome variable (stages of thyroid cancer at diagnosis (early vs. late stage)), after adjusting for age at diagnosis and gender.


The odds of late-stage thyroid cancer diagnosis compared to early-stage diagnosis were 1.6 (95% CI, 1.04 to 2.4) times higher among patients 45 years and older living in rural counties compared to urban counties, after adjusting for age at diagnosis and gender (p=0.032).

Similarly, among patients 45 years and older, the odds of late versus early stage at diagnosis were 2.0 (95% CI, 1.2-3.2) times greater for thyroid cancer patients living long distance (>= 50 miles) versus short distances (


Multiple studies have been conducted regarding racial disparities to improve its outcome among various populations. However, the disparities of patients living in rural areas who face travel burden and medical access to health that can affect thyroid cancer outcomes have been overlooked. In our study, we found that patients 45 years and older living in rural areas and longer distance from the diagnosing reporting hospital have higher odds of being diagnosed at advanced stages of thyroid cancer compared to those living in urban areas.

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