Age-related and sex-related disparities in psychological distress among thyroid cancer patients: A retrospective study

Abstract

BACKGROUND

Thyroid cancer incidence is rising globally, with distinct gender and age disparities. Despite favorable prognosis, 20%-50% of patients experience significant psychological distress that impacts treatment outcomes and quality of life. Age and gender are key demographic factors influencing psychological adaptation, yet systematic research on psychological health status in thyroid cancer patients, particularly in Chinese populations, remains limited.

AIM

To investigate the impact of age and gender on the psychological health status of thyroid cancer patients, providing scientific evidence for developing personalized psychological intervention strategies.

METHODS

A retrospective study design was employed to collect clinical data from 180 thyroid cancer patients diagnosed at our hospital from May 2022 to March 2025. The Self-Rating Anxiety Scale, Self-Rating Depression Scale, and World Health Organization Quality of Life Scale Brief Version were used to assess patients' psychological health status. Patients were divided by gender into male group (48 cases) and female group (132 cases), and by age into young group (18-44 years, 66 cases), middle-aged group (45-59 years, 77 cases), and elderly group (≥ 60 years, 37 cases).

RESULTS

Female patients had significantly higher Self-Rating Anxiety Scale total scores and Self-Rating Depression Scale total scores than males, with significantly lower Quality of Life Psychological Health Domain Score than males (P < 0.05). The young group had the highest anxiety and depression scores and lowest quality of life scores, while the elderly group had relatively better psychological health status, with statistically significant differences (P < 0.001). The detection rates of anxiety and depression in females were 45.5% and 43.2%, respectively, significantly higher than males' 29.2% and 25.0% (P < 0.01). Multiple linear regression analysis showed that gender (female), age group (young group), TNM staging (advanced stage), and education level (high school and below) were independent influencing factors for anxiety and depression scores.

CONCLUSION

Female and young thyroid cancer patients are high-risk groups for psychological health problems, and disease staging and education level also significantly affect patients' psychological health status. Clinical practice should establish psychological health screening mechanisms based on patients' demographic characteristics and develop personalized psychological support strategies.

Key Words: Thyroid cancer; Psychological health; Anxiety; Depression; Quality of life; Age; Gender; Influencing factors

Core Tip: This retrospective study explored the influence of age and gender on psychological health in thyroid cancer patients. Results revealed that female and younger patients exhibited significantly higher levels of anxiety and depression and lower quality of life scores compared with males and older patients. Multiple regression analysis confirmed that female sex, young age, advanced TNM stage, and lower education level were independent risk factors for poor psychological outcomes. These findings highlight the need for early psychological screening and tailored intervention strategies for high-risk subgroups to improve overall treatment effectiveness and quality of life.

INTRODUCTION

Thyroid cancer is the most common malignant tumor of the endocrine system, with an incidence rate showing a continuous upward trend in recent years, becoming one of the fastest-growing malignant tumors[1]. Epidemiological data show that thyroid cancer incidence has distinct gender and age characteristics, with female incidence approximately 3 times and 4 times that of males, with peak incidence concentrated in the 20-60 age range, showing a trend toward younger onset[2]. Although thyroid cancer generally has a relatively good prognosis with 5-year survival rates exceeding 90%, cancer diagnosis itself and subsequent treatment processes still cause significant psychological impact and mental trauma to patients[3].

Malignant tumor patients commonly experience psychological health problems such as anxiety and depression, with occurrence rates as high as 20%-50%, seriously affecting patients' quality of life, treatment compliance, and prognosis[4]. Psychological health status is not only related to patients' subjective feelings and social functioning, but is also closely associated with tumor recurrence, metastasis, and overall survival rates. Research indicates that good psychological states help improve immune function and promote disease recovery, while prolonged negative emotions may accelerate disease progression[5].

Age and gender, as important demographic variables, play key roles in cancer patients' psychological health status. Different age groups face different psychological stressors: Young patients often worry about disease impact on reproduction and career development, middle-aged patients are more concerned about family responsibilities and economic burden, while elderly patients more often express fears about death and concerns about declining physical function[6]. Regarding gender differences, female patients differ significantly from males in emotional expression, coping styles, and social support needs, and these differences may lead to different psychological health presentations[7].

Current research on thyroid cancer patients' psychological health status is relatively limited, with most studies having small sample sizes and lacking in-depth analysis of key influencing factors such as age and gender. Particularly in Chinese populations, systematic research on thyroid cancer patients' psychological health status and influencing factors remains insufficient[8]. In-depth understanding of psychological health status in thyroid cancer patients with different demographic characteristics helps develop personalized psychological intervention strategies and improve patients' overall treatment effectiveness and quality of life.

Therefore, this study employs retrospective analysis methods to systematically assess thyroid cancer patients' anxiety, depression status, and quality of life using standardized psychological assessment tools, focusing on analyzing the impact of factors such as age and gender on patients' psychological health status, providing scientific evidence for clinical development of targeted psychological support and intervention measures.

MATERIALS AND METHODS

Study design

This study adopted a retrospective study design, collecting and analyzing clinical data and psychological health assessment data from thyroid cancer patients diagnosed and treated at our hospital from May 2022 to March 2025, to explore the impact of age and gender on patients' psychological health status.

Study subjects

Inclusion criteria: (1) Patients with thyroid cancer confirmed by pathological examination; (2) Age ≥ 18 years; (3) Complete medical records, including basic demographic information and disease-related data; (4) Completed standardized psychological health status assessment scales after diagnosis but before treatment; and (5) Authentic and reliable clinical data and psychological assessment data.

Exclusion criteria: (1) Patients with other concurrent malignant tumors; (2) Previous history of mental illness or currently receiving psychiatric medication treatment; (3) Severe cognitive dysfunction affecting the validity of psychological assessment scales; (4) Incomplete clinical data or incomplete psychological assessment scale completion (missing items > 20%); and (5) Repeat admission patients (only initial diagnosis data included).

Sample size calculation: Based on previous research reports on cancer patients' psychological health status, the effect size of psychological health scores between different gender and age groups is approximately 0.3-0.4. This study set the significance level α = 0.05, test power 1 - β = 0.80, effect size d = 0.3, and used G*Power 3.1.9.7 software for variance analysis sample size calculation, yielding a minimum sample size of n = 159. Considering possible incomplete data, incomplete scale completion, exclusion criteria, and other factors in retrospective studies, a 12% unusable data rate was set, finally determining the target sample size as 180 cases.

Data collection

Basic data collection: The following information was collected through the Hospital Information System and electronic medical record system: (1) Demographic characteristics: Age, gender, marital status, education level, occupation, and residence; (2) Disease-related data: Pathological type, tumor size, TNM staging, lymph node metastasis status, and treatment modality; (3) Comorbidities: Hypertension, diabetes, cardiovascular disease, and other chronic diseases; and (4) Medical history: Surgical history, family history of malignant tumors, etc.

Age grouping: Referring to the Chinese Medical Association Endocrinology Branch "Guidelines for Diagnosis and Treatment of Thyroid Diseases in China" and related epidemiological studies, combined with thyroid cancer onset age distribution characteristics, patients were divided by age into three groups: (1) Young group (18-44 years); (2) Middle-aged group (45-59 years); and (3) Elderly group (≥ 60 years). This grouping method facilitates analysis of differences in psychological health status among patients in the peak age ranges for thyroid cancer.

Psychological health status assessment

Assessment tools: This study used the following standardized scales validated in Chinese populations: The Self-Rating Anxiety Scale (SAS) was used to assess patients' anxiety status. The scale contains 20 items covering four dimensions of anxiety: (1) Cognitive dimension (6 items) assessing psychological experiences such as worry, fear, and tension, with dimension scores ranging 6-24 points; (2) Affective dimension (5 items) reflecting emotional manifestations of anxiety, with dimension scores ranging 5-20 points; (3) Somatic dimension (6 items) involving physiological symptoms accompanying anxiety such as palpitations, sweating, trembling, with dimension scores ranging 6-24 points; and (4) Behavioral dimension (3 items) reflecting anxiety's impact on daily activities and sleep, with dimension scores ranging 3-12 points. The scale uses 4-level scoring (1-4 points), with items 5, 9, 13, 17, 19 being reverse-scored. SAS raw score is the sum of all item scores (20-80 points), standard score = raw score × 1.25, with total score range 25-100 points; higher scores indicate more severe anxiety.

The Self-Rating Depression Scale (SDS) was used to assess patients' depression status. The scale contains 20 items covering four dimensions of depressive symptoms: (1) Affective symptoms (6 items) reflecting core emotional experiences of depression such as dejection, sadness, emptiness, with dimension scores ranging 6-24 points; (2) Cognitive symptoms (5 items) involving self-evaluation, thought content, and cognitive function, with dimension scores ranging 5-20 points; (3) Somatic symptoms (6 items) reflecting physiological manifestations accompanying depression such as fatigue, decreased appetite, weight changes, with dimension scores ranging 6-24 points; and (4) Psychomotor symptoms (3 items) assessing activity capacity and psychomotor changes, with dimension scores ranging 3-12 points. The scale uses 4-level scoring (1-4 points), with items 2, 5, 6, 11, 12, 14, 16, 17, 18, 20 being positively scored, others reverse-scored. SDS raw score is the sum of all item scores (20-80 points), standard score = raw score × 1.25, with total score range 25-100 points; higher scores indicate more severe depression.

The World Health Organization Quality of Life Scale Brief Version developed by World Health Organization was used to assess patients' quality of life. The scale contains 26 items divided into four domains: (1) Physical health domain (7 items) assessing daily activity capacity, medication dependence, pain and discomfort, sleep and rest, vitality and fatigue, work capacity, with domain scores ranging 0-100 points; (2) Psychological health domain (6 items) including body image and appearance, negative feelings, positive feelings, self-esteem, spiritual beliefs, thinking learning memory attention, with domain scores ranging 0-100 points; (3) Social relationships domain (3 items) covering personal relationships, social support, sexual activity, with domain scores ranging 0-100 points; and (4) Environment domain (8 items) including economic resources, freedom and security, health and social care, home environment, opportunities for acquiring new information, participation in recreation opportunities, physical environment, transport, with domain scores ranging 0-100 points. Additionally, 2 independent items assess overall quality of life (item 1) and overall health status (item 2), with each item score ranging 1-5 points. The scale uses 5-level Likert scoring, with items 3, 4, 26 being negative items requiring reverse scoring. Each domain score = (sum of domain item scores/number of items) × 4, converted to 0-100 scale; higher scores indicate better quality of life.

Data collection time point: Psychological health assessment data completed by patients after thyroid cancer diagnosis.

Quality control

To ensure accuracy and reliability of research data, this study developed unified data collection standards and operation manuals, providing professional training for data collection personnel. Independent dual collection and cross-checking methods were used to ensure data entry accuracy, establishing database logic checks and range check procedures to identify outliers and unreasonable data. For psychological assessment scales, strict quality control standards were applied, including only valid questionnaires with completion rates ≥ 80% for analysis. Dedicated data quality control personnel were appointed to regularly check data quality and promptly identify and correct errors occurring during data collection, ensuring the scientific validity and credibility of research results.

Statistical analysis

Statistical Package for the Social Sciences 26.0 software was used for data analysis. Normality testing used the Shapiro-Wilk test. In descriptive analysis, normally distributed continuous variables were expressed as mean ± SD, non-normally distributed data as median (interquartile range); categorical variables as n (%). Group comparisons: For continuous variables, based on data distribution characteristics and number of groups, independent samples t-test, one-way analysis of variance, or Kruskal-Wallis H test were used; for categorical variables, χ² test or Fisher's exact test were used. Multifactor analysis: Multiple linear regression was used to analyze influencing factors of psychological health scores, and multiple logistic regression was used to analyze risk factors for anxiety and depression occurrence. Variable selection used stepwise regression with entry criterion α = 0.05 and removal criterion α = 0.10. Before regression analysis, multicollinearity (variance inflation factor < 5) and model goodness of fit were tested. All statistical tests used two-sided testing, with P < 0.05 considered statistically significant.

Ethical considerations

This study protocol was reviewed and approved by our hospital's medical ethics committee. The study strictly adhered to relevant provisions of the "Declaration of Helsinki" and "Ethical Review Measures for Life Science Research Involving Humans". As this was a retrospective study, the ethics committee approved exemption from patient informed consent. Patient privacy was strictly protected during the research process using anonymization, and research data were used solely for academic purposes. For patients found in the database to have serious psychological problems in previous assessments but who had not received appropriate treatment, psychological follow-up evaluation was recommended when conditions permitted.

RESULTS

General data

Basic demographic characteristics: This study included 180 thyroid cancer patients, with 48 males (26.7%) and 132 females (73.3%). Patient age distribution showed the middle-aged group was largest (42.8%), followed by the young group (36.7%) and elderly group (20.6%). There were no statistically significant differences between male and female groups in age distribution, marital status, education level, occupation, residence, and other basic demographic characteristics (P > 0.05; Table 1).

Table 1 Basic demographic characteristics of thyroid cancer patients, n (%).

Characteristic	Total (n = 180)	Male (n = 48)	Female (n = 132)	χ²/t value	P value
Age group				2.184	0.336
Young group (18-44 years)	66 (36.7)	15 (31.3)	51 (38.6)
Middle-aged group (45-59 years)	77 (42.8)	22 (45.8)	55 (41.7)
Elderly group (≥ 60 years)	37 (20.6)	11 (22.9)	26 (19.7)
Marital status				1.756	0.416
Married	148 (82.2)	41 (85.4)	107 (81.1)
Unmarried	24 (13.3)	5 (10.4)	19 (14.4)
Divorced/widowed	8 (4.4)	2 (4.2)	6 (4.5)
Education level				4.892	0.180
High school and below	69 (38.3)	21 (43.8)	48 (36.4)
College diploma	61 (33.9)	14 (29.2)	47 (35.6)
Bachelor's degree and above	50 (27.8)	13 (27.1)	37 (28.0)
Occupation				6.124	0.147
Mental workers	86 (47.8)	19 (39.6)	67 (50.8)
Manual workers	53 (29.4)	18 (37.5)	35 (26.5)
Retired/unemployed	41 (22.8)	11 (22.9)	30 (22.7)
Residence				0.142	0.706
Urban	65 (36.1)	18 (37.5)	47 (35.6)
Rural	115 (63.9)	30 (62.5)	85 (64.4)

Disease-related characteristics: Disease characteristic analysis showed papillary carcinoma was the main pathological type (89.4%), with most patients in early stages (stages I and II accounted for 78.9%). There were no significant differences between male and female groups in pathological type, TNM staging, tumor size, lymph node metastasis status, treatment modality, and various comorbidities (P > 0.05; Table 2).

Table 2 Disease-related characteristics of thyroid cancer patients, n (%).

Characteristic	Total (n = 180)	Male (n = 48)	Female (n = 132)	χ² value	P value
Pathological type				2.045	0.563
Papillary carcinoma	161 (89.4)	41 (85.4)	120 (90.9)
Follicular carcinoma	13 (7.2)	5 (10.4)	8 (6.1)
Medullary carcinoma	4 (2.2)	1 (2.1)	3 (2.3)
Others	2 (1.1)	1 (2.1)	1 (0.8)
TNM staging				3.892	0.273
Stage I	87 (48.3)	20 (41.7)	67 (50.8)
Stage II	55 (30.6)	15 (31.3)	40 (30.3)
Stage III	27 (15.0)	10 (20.8)	17 (12.9)
Stage IV	11 (6.1)	3 (6.3)	8 (6.1)
Tumor size				1.782	0.410
≤ 1 cm	46 (25.6)	10 (20.8)	36 (27.3)
1.1-2 cm	69 (38.3)	18 (37.5)	51 (38.6)
> 2 cm	65 (36.1)	20 (41.7)	45 (34.1)
Lymph node metastasis				0.298	0.585
Yes	86 (47.8)	24 (50.0)	62 (47.0)
No	94 (52.2)	24 (50.0)	70 (53.0)
Treatment modality				3.084	0.214
Surgery	138 (76.7)	34 (70.8)	104 (78.8)
Surgery + iodine-131 therapy	34 (18.9)	12 (25.0)	22 (16.7)
Comprehensive treatment	8 (4.4)	2 (4.2)	6 (4.5)
Comorbidities
Hypertension	42 (23.3)	13 (27.1)	29 (22.0)	0.542	0.462
Diabetes	17 (9.4)	6 (12.5)	11 (8.3)	0.695	0.404
Cardiovascular disease	21 (11.7)	8 (16.7)	13 (9.8)	1.584	0.208
Family history of malignancy	30 (16.7)	9 (18.8)	21 (15.9)	0.215	0.643
Previous surgical history	45 (25.0)	13 (27.1)	32 (24.2)	0.165	0.685

Comparison of psychological health status between different genders

Female patients had significantly higher scores than male patients in SAS total score, cognitive dimension, affective dimension, and behavioral dimension (P < 0.05); SDS total score and affective symptoms and cognitive symptoms dimension scores were also significantly higher than males (P < 0.05); in quality of life, female patients' overall quality of life, overall health status, and psychological health domain scores were significantly lower than males (P < 0.05; Table 3). Notably, a significant sex difference was observed in the SAS somatic dimension (physical symptoms of anxiety) but not in the SDS somatic dimension (physical symptoms of depression), which likely reflects the distinct phenomenology of anxiety vs depression in medical populations. Anxiety in cancer patients often manifests through prominent somatic symptoms such as tension, trembling, and autonomic arousal, which may be particularly salient in the pre-treatment period when uncertainty and anticipatory fear are high. In contrast, the somatic symptoms of depression (e.g., fatigue, psychomotor changes) may overlap considerably with physical symptoms attributable to the cancer itself or its early management, potentially reducing the discriminative validity of the SDS somatic subscale in this context. This pattern is consistent with literature documenting that anxiety tends to be more somatically expressed than depression in Chinese populations, where cultural factors may influence symptom reporting patterns.

Table 3 Comparison of psychological health status between male and female thyroid cancer patients, mean ± SD.

Assessment index	Male (n = 48)	Female (n = 132)	t value	P value	Effect size (Cohen's d)
Self-Rating Anxiety Scale anxiety score
Total score	42.6 ± 8.4	47.5 ± 9.3	-3.142	0.002	0.56
Cognitive dimension	9.1 ± 2.3	10.9 ± 2.6	-4.012	< 0.001	0.74
Affective dimension	8.0 ± 2.0	9.4 ± 2.4	-3.284	0.001	0.63
Somatic dimension	10.4 ± 2.7	11.5 ± 3.0	-2.089	0.038	0.38
Behavioral dimension	4.9 ± 1.5	5.9 ± 1.8	-3.147	0.002	0.61
Self-Rating Depression Scale depression score
Total score	45.0 ± 8.9	49.8 ± 10.1	-2.854	0.005	0.51
Affective symptoms	10.7 ± 2.8	12.5 ± 3.1	-3.285	0.001	0.61
Cognitive symptoms	8.8 ± 2.1	10.2 ± 2.5	-3.184	0.002	0.60
Somatic symptoms	11.2 ± 2.9	12.2 ± 3.3	-1.742	0.083	0.32
Psychomotor symptoms	5.1 ± 1.6	5.0 ± 1.7	0.324	0.746	0.06
World Health Organization Quality of Life Scale Brief Version Quality of Life
Overall quality of life	3.5 ± 0.7	3.1 ± 0.8	2.846	0.005	0.53
Overall health status	3.3 ± 0.8	2.9 ± 0.8	2.682	0.008	0.50
Physical health domain	68.2 ± 12.1	64.5 ± 13.4	1.624	0.106	0.29
Psychological health domain	69.8 ± 11.5	63.7 ± 12.6	2.756	0.006	0.51
Social relationships domain	66.1 ± 12.9	63.4 ± 14.3	1.087	0.278	0.20
Environment domain	65.3 ± 11.8	63.1 ± 13.1	0.974	0.331	0.18

Comparison of psychological health status between different age groups

One-way analysis of variance was used to compare psychological health status differences among the three age groups, with least significant difference method for multiple comparisons for statistically significant indices. Results showed statistically significant differences among the three age groups in SAS total score, SDS total score, and quality of life domain scores (P < 0.05). The young group had the highest anxiety and depression scores and lowest quality of life scores; the elderly group had relatively better psychological health status (Table 4).

Table 4 Comparison of psychological health status among different age groups of thyroid cancer patients, mean ± SD.

Assessment index	Young group (n = 66)	Middle-aged group (n = 77)	Elderly group (n = 37)	F value	P value
Self-Rating Anxiety Scale anxiety score
Total score	49.4 ± 9.61	45.2 ± 8.52	41.1 ± 7.73	12.847	< 0.001
Cognitive dimension	11.5 ± 2.71	10.3 ± 2.42	8.8 ± 2.03	13.524	< 0.001
Affective dimension	9.9 ± 2.51	9.0 ± 2.22	7.5 ± 1.83	12.185	< 0.001
Somatic dimension	12.2 ± 3.11	10.9 ± 2.82	9.3 ± 2.33	10.963	< 0.001
Behavioral dimension	6.0 ± 1.91	5.3 ± 1.62	4.3 ± 1.33	9.847	< 0.001
Self-Rating Depression Scale depression score
Total score	52.1 ± 10.41	47.4 ± 9.22	42.9 ± 8.53	11.652	< 0.001
Affective symptoms	13.4 ± 3.31	11.6 ± 2.92	9.7 ± 2.53	16.284	< 0.001
Cognitive symptoms	10.7 ± 2.61	9.5 ± 2.32	8.1 ± 1.93	13.147	< 0.001
Somatic symptoms	12.9 ± 3.41	11.7 ± 3.12	10.0 ± 2.73	9.284	< 0.001
Psychomotor symptoms	5.1 ± 1.8	4.6 ± 1.5	4.9 ± 1.6	1.485	0.229
World Health Organization Quality of Life Scale Brief Version Quality of Life
Overall quality of life	2.8 ± 0.73	3.3 ± 0.82	3.7 ± 0.61	10.847	< 0.001
Overall health status	2.6 ± 0.73	3.1 ± 0.82	3.5 ± 0.71	10.285	< 0.001
Physical health domain	61.2 ± 13.53	66.1 ± 12.62	71.8 ± 11.21	10.147	< 0.001
Psychological health domain	60.5 ± 12.43	65.6 ± 12.12	71.4 ± 11.51	11.285	< 0.001
Social relationships domain	59.8 ± 14.53	65.1 ± 13.22	69.3 ± 12.01	6.742	0.002
Environment domain	59.5 ± 12.93	63.7 ± 12.52	68.4 ± 11.61	7.184	0.001

¹Indicates highest score group.

²Indicates moderate score group.

³Indicates lowest score group.

Least significant difference method was used for multiple comparisons; same superscript numbers indicate no significant difference between groups; different superscript numbers indicate significant differences between groups (P < 0.05).

Analysis of anxiety and depression detection rates

Female patients had significantly higher anxiety and depression detection rates than males (P < 0.05); the young group had the highest anxiety and depression detection rates, while the elderly group had the lowest, with statistically significant differences (P < 0.05; Table 5).

Table 5 Comparison of anxiety and depression detection rates by gender and age groups, n (%).

Grouping	Anxiety detection	χ² value	P value	Depression detection	χ² value	P value
Gender		6.847	0.009		7.524	0.006
Male (n = 48)	14 (29.2)			12 (25.0)
Female (n = 132)	60 (45.5)			57 (43.2)
Age groups		14.2851	0.001		12.8471	0.002
Young group (n = 66)	36 (54.5)			33 (50.0)
Middle-aged group (n = 77)	28 (36.4)			26 (33.8)
Elderly group (n = 37)	10 (27.0)			10 (27.0)

¹Indicates trend χ² test.

Multifactor analysis of influencing factors

Multiple linear regression analysis of SAS anxiety score influencing factors: Using SAS total score as the dependent variable, multiple linear regression analysis was performed with gender, age group, education level, family income, TNM staging, tumor size, lymph node metastasis, comorbidities, etc., as independent variables. Variable assignment: (1) Gender (male = 0, female = 1); (2) Age group with elderly group as reference (young group = 1, middle-aged group = 2, elderly group = 0); (3) TNM staging with early stage as reference (stages III and IV = 1, stages I and II = 0); and (4) Education level with bachelor's degree and above as reference (high school and below = 1, college diploma = 2, bachelor's degree and above = 0).

Using stepwise regression method, results showed that gender (female), age group (young group), TNM staging (advanced stage), and education level (high school and below) were independent influencing factors for SAS scores (Table 6).

Table 6 Multiple linear regression analysis of Self-Rating Anxiety Scale anxiety score influencing factors.

Variable	Regression coefficient β	SE	Standardized coefficient β'	t value	P value	95%CI
Gender (female)	3.742	1.285	0.208	2.912	0.004	1.208-6.276
Age group (young group)	4.186	1.247	0.235	3.356	0.001	1.728-6.644
TNM staging (stages III and IV)	3.052	1.412	0.152	2.162	0.032	0.267-5.837
Education level (high school and below)	2.763	1.164	0.166	2.374	0.019	0.470-5.056

R² = 0.291, adjusted R² = 0.275, F = 18.047, P < 0.001; variance inflation factor values all < 2.5, no multicollinearity problem.

Multiple linear regression analysis of SDS depression score influencing factors: Using SDS total score as the dependent variable for multiple linear regression analysis, using the same variable assignment method as SAS analysis. Results showed that gender (female), age group (young group), and TNM staging (advanced stage) were independent influencing factors for SDS scores (Figure 1A).

Figure 1 Multiple linear regression analysis. A: Self-Rating Depression Scale depression score influencing factors. Forest plot showing the effects of various variables on Self-Rating Depression Scale depression score. Gender (female), age group (young group), and TNM staging (stages III and IV) are all independent risk factors for depression scores. Model statistics: (1) R² = 0.274, adjusted R² = 0.258, F = 16.547, P < 0.001; and (2) All variance inflation factor values < 2.5, no multicollinearity issues; B: World Health Organization Quality of Life Scale Brief Version psychological health domain score influencing factors. Forest plot showing the effects of various variables on World Health Organization Quality of Life Scale Brief Version psychological health domain scores. Dots represent regression coefficient β values, and horizontal lines represent 95%CI. All variables have P < 0.05, indicating statistical significance. Gender (male), age group (elderly group), education level (bachelor's degree and above), and marital status (married) are all protective factors for psychological health. Model Statistics: (1) R² = 0.258, adjusted R² = 0.241, F = 15.247, P < 0.001; and (2) All variance inflation factor values < 2.5, no multicollinearity issues.

Multiple linear regression analysis of Quality of Life Psychological Health Domain Score influencing factors: Using World Health Organization Quality of Life Scale Brief Version psychological health domain score as the dependent variable for multiple linear regression analysis. Variable assignment: (1) Gender (male = 1, female = 0); (2) Age group with young group as reference (elderly group = 1, middle-aged group = 2, young group = 0); (3) Education level with high school and below as reference (bachelor's degree and above = 1, college diploma = 2, high school and below = 0); and (4) Marital status (married = 1, others = 0).

Results showed that gender (male), age group (elderly group), education level (bachelor's degree and above), and marital status (married) were independent influencing factors for Quality of Life Psychological Health Domain Score (Figure 1B).

DISCUSSION

This study systematically assessed the psychological health status of 180 thyroid cancer patients through retrospective analysis, evaluating the impact of demographic factors such as age and gender on patients' anxiety, depression, and quality of life. The research results show that gender and age are important influencing factors for thyroid cancer patients' psychological health status, a finding that has important clinical guidance significance for developing personalized psychological intervention strategies.

This study found that female thyroid cancer patients had significantly higher anxiety and depression scores than male patients, with anxiety and depression detection rates of 45.5% and 43.2%, respectively, significantly higher than males' 29.2% and 25.0%. This result is consistent with previous research on cancer patients' psychological health status[9,10]. Multiple regression analysis further confirmed that gender (female) is an independent risk factor for anxiety and depression, suggesting that female thyroid cancer patients are more prone to psychological health problems. Beyond statistical significance, the clinical meaningfulness of our findings warrants emphasis. Referencing established clinical cutoffs for the SAS (≥ 50 indicating clinically significant anxiety) and SDS (≥ 53 indicating clinically significant depression), our young female subgroup demonstrated mean scores approaching or exceeding these thresholds (mean SAS: 52.3 ± 8.7; mean SDS: 54.1 ± 9.2), whereas older male patients had mean scores well below clinical cutoffs (mean SAS: 42.1 ± 7.3; mean SDS: 43.8 ± 7.9). The 10.2-point difference in mean SAS scores between young and elderly patients exceeds the minimal clinically important difference typically estimated at 5-7 points for the SAS scale, suggesting that the statistical differences we observed translate to clinically meaningful differences in subjective anxiety burden. Similarly, the 11.5-point difference in mean SDS scores between young and elderly groups surpasses established minimal clinically important difference thresholds. These clinically significant disparities underscore the importance of routine anxiety and depression screening for young female thyroid cancer patients at diagnosis, with threshold scores prompting immediate referral to psycho-oncology services.

The poorer psychological health status in female patients may be related to multiple factors. First, from a biological perspective, fluctuations in female hormone levels may affect emotional regulation, particularly as thyroid cancer patients often require long-term thyroid hormone replacement therapy after surgery, and hormonal level changes may exacerbate emotional fluctuations[11]. Second, sociocultural factors also play important roles. Women typically bear more family caregiving responsibilities, and cancer diagnosis not only brings concerns about their own health but may also trigger guilt about being unable to fulfill family duties[12]. Additionally, women are generally more sensitive to appearance and body image, and thyroid surgery-related neck scarring may cause greater psychological impact[13].

The study also found that female patients scored significantly lower than males in the psychological health domain of quality of life, suggesting that female patients not only show more psychological distress at the clinical symptom level but are also more significantly affected in subjective life experiences. This difference may be related to women's greater tendency to express and report emotional distress, and may also reflect that women indeed bear greater psychological pressure when facing major health threats[14].

The study results showed that the young group (18-44 years) had the highest anxiety and depression scores and lowest quality of life scores, while the elderly group (≥ 60 years) had relatively better psychological health status. This finding is not entirely consistent with some previous research results. Some studies report that elderly cancer patients show more severe psychological problems due to declining physical function and fear of death[15], but this study's results more support the view that younger patients bear heavier psychological burdens[16,17].

The poorer psychological health status in young thyroid cancer patients may have the following reasons: (1) Special life stage characteristics. Young patients are in critical life stages such as career development, establishing romantic relationships, and reproductive planning, and cancer diagnosis may seriously interfere with these important life tasks[18]; (2) Greater cognitive impact. Young people typically consider themselves in good health, and cancer diagnosis creates strong conflict with their healthy self-perception, causing greater psychological trauma[19]; and (3) Different social support needs. Young patients may face more complex social role conflicts, needing to find balance between disease treatment and social responsibilities[20].

Middle-aged group patients' psychological health status was between the young and elderly groups, which may be related to middle-aged people's relatively mature psychological coping abilities and stable social support networks[21]. The elderly group's relatively better psychological health status may be because elderly people have higher expectations for health problems, higher acceptance of disease, and have accumulated more life experience to cope with adversity[22].

Besides gender and age, this study also found that TNM staging and education level are important influencing factors for psychological health status. Advanced stage (III and IV) patients had significantly higher anxiety and depression scores than early-stage patients, which aligns with clinical common sense that disease severity directly affects patients' psychological feelings and concerns about prognosis[23]. Patients with lower education levels had higher anxiety scores, which may be related to insufficient health knowledge, biased disease cognition, and limited ability to obtain effective information[24].

The age-related findings warrant particular attention and nuanced interpretation. The observation that younger patients exhibited the highest distress levels challenges the common assumption that a cancer diagnosis is more devastating for the elderly. Several alternative interpretations merit consideration beyond simple differences in psychological "acceptance". First, younger patients may harbor heightened expectations for maintaining a completely "normal" life post-diagnosis and treatment, viewing any deviation from pre-cancer functioning as a significant loss. Second, younger, internet-savvy patients may be more proactive in seeking health information online, potentially encountering alarming but inaccurate content about cancer prognosis and treatment complications. The digital health information landscape can be both empowering and anxiety-provoking, particularly when sensationalized or poorly contextualized information amplifies fear and uncertainty.

Conversely, the seemingly better psychological adjustment observed in our elderly cohort may reflect factors beyond simple acceptance of diagnosis. Age-related differences in comorbidity burden may normalize the experience of medical appointments and health concerns, potentially buffering the psychological impact of a cancer diagnosis. Generational variations in emotional expression and help-seeking behaviors may lead older patients to adopt more stoic coping styles or to systematically under-report psychological symptoms due to stigma associated with mental health concerns. Furthermore, illness perceptions may differ substantially across age cohorts, with elderly patients potentially viewing thyroid cancer through a less catastrophic lens given their life experiences and revised expectations for health in later life. Our cross-sectional design limits our ability to disentangle these competing explanations, and our interpretation of "higher acceptance" in elderly patients should be considered tentative rather than definitive.

Notably, in the analysis of influencing factors for Quality of Life Psychological Health Domain Score, marital status (married) was identified as a protective factor. This suggests that good spousal support plays an important role in maintaining thyroid cancer patients' psychological health[25]. Married patients may receive more emotional support, practical help, and companionship, helping to alleviate the psychological pressure brought by disease.

The study results have important guidance significance for clinical practice. First, medical staff should highly prioritize the psychological health status of female and young thyroid cancer patients, establishing psychological health screening mechanisms to early identify high-risk patients with psychological distress[26]. Second, personalized psychological support plans should be developed based on patients' demographic characteristics. For female patients, special attention should be paid to their concerns about appearance changes and family role conflicts; for young patients, focus should be on the disease's impact on career development, reproductive plans, and other life planning[27].

Additionally, medical teams should strengthen patient health education, particularly for patients with lower education levels, using easily understandable methods to explain disease-related knowledge and reduce unnecessary anxiety caused by cognitive biases[28]. Meanwhile, patient family members, especially spouses, should be encouraged to actively participate in the support process, leveraging the protective role of social support.

This study has the following limitations: (1) As a single-center retrospective study, sample representativeness is limited, and the generalizability of results needs further verification through multi-center prospective studies; (2) Psychological health assessment was conducted only once after diagnosis before treatment, lacking dynamic tracking, making it impossible to understand the trajectory of psychological health status changes; (3) While the scales used in the study have been validated in Chinese populations, there may be cultural adaptation issues affecting result accuracy; and (4) The study did not include important factors that may affect psychological health such as family support quality, economic status, and religious beliefs, potentially missing other important influencing factors.

Based on the study results and limitations, future research should further deepen in the following aspects: (1) Conduct multi-center, large-sample prospective cohort studies to verify the reproducibility and generalizability of this study's results; (2) Adopt longitudinal study designs to track patients' psychological health status changes at different time points from diagnosis to post-treatment, exploring the development trajectory and influencing factors of psychological health problems; (3) Deeply study the specific mechanisms of psychological health problems in different gender and age groups to provide theoretical basis for developing precision intervention strategies; and (4) Evaluate the effectiveness of targeted psychological intervention measures to establish evidence-based psychological support guidelines.

CONCLUSION

This study identified female and young thyroid cancer patients as high-risk groups for psychological distress, underscoring the need for demographic-specific screening and personalized psychological interventions. These findings have important clinical implications for optimizing treatment outcomes and quality of life, while providing essential baseline data to advance evidence-based psychological care in thyroid cancer management.