Introduction

Based on the lasted Global Cancer Observatory (GLOBOCAN) 2022 data from the WHO International Agency for Research on Cancer, thyroid cancer has the seventh highest cancer incidence worldwide, accounting for 4.1% of all cancer cases1. Surgical intervention, with or without radioactive iodine (RAI), is the primary curative treatment2.

Thyroidectomy via an anterior neck incision has been widely employed due to its effectiveness and relatively low complication rates. However, the resulting neck scars may negatively impact patients’ quality of life (QOL) and contribute to psychosocial stress3. In response, minimally invasive surgical techniques, especially the transoral endoscopic thyroidectomy vestibular approach (TOETVA) have gained attention as scar-free alternatives4. Some studies suggest that TOETVA offers better cosmetic outcomes and a comparable safety profile to open surgery, with similar oncological results5,6. Nevertheless, patients with thyroid cancer often experience a reduced post-surgery quality of life compared to the general population7,8,9.

In previous studies, specific impaired aspects of quality of life and their associated factors have varied. Some of the QOL issues specific to thyroid cancer and treatment have also not been adequately described. In additional, research comparing the impact of different surgical methods on postoperative physical, psychological and social well-being remained limited, particularly between TOETVA and open surgery. Further research using specific questionnaires is necessary.

Therefore, this study was designed to assess the postoperative quality of life, physical appearance and mental health in patients undergoing TOETVA and open surgery employing both generic and disease-specific questionnaires. Furthermore, we evaluated scarring and emotional well-being to inform the decision-making in surgical management of thyroid cancer.

Materials and methods

Study design and participants

This retrospective cross-sectional study was conducted through an online thyroid cancer surveillance platform and standardized questionnaires. The cohort included 673 individuals diagnosed with thyroid cancer and treated at Tongde Hospital, Zhejiang Province, from January 1, 2017, to September 1, 2024.

Inclusion criteria required: (1) diagnosis of thyroid cancer confirmed by pathological biopsy; (2) age of 18 years or older; (3) absence of distant metastasis; and (4) availability of comprehensive clinical data. Exclusion criteria included: (1) a history of neck surgery or radiotherapy (2) presence of comorbidities or other malignancies that could significantly influence treatment outcomes; (3) mental disorders or cognitive impairments; (4) underwent lateral neck dissection and (5) unwilling to participate or inability to complete follow-up.

Eligible patients were invited via an online link and provided informed consent. Standardized QOL questionnaires, along with scar and mental health assessments, were completed 1–3 months after surgery via online platforms, phone surveys, or in-person follow-ups. Incomplete or invalid survey data were re-collected within six months post-surgery. Data collection and verification were conducted by two research team members. The study protocol was approved by the Ethics Committee of Tongde Hospital, Zhejiang, and performed in accordance with relevant guidelines and regulations.

Measures

Patient demographic and clinical variables

A specific questionnaire was designed to collect demographic information, including age, gender, body mass index (BMI), marital status, educational background, employment, residence and monthly income. Clinical variables, such as type of surgery, tumor-related details were extracted from the surveillance system with patient consent and approval from the institutional ethics board. TNM staging for thyroid cancer was performed according to the 8th edition of the UICC/AJCC TNM classification system10. In additional, temporary hypoparathyroidism was defined as a parathormone level below 15.0 pg/ml on the first postoperative day11.

Questionnaires regarding quality of life

The general quality of life was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), designed for all patients with cancer. The global health status reflects overall QOL, with higher scores on the global health and functional subscales indicating better prognosis, while higher scores on the symptom subscales signal poorer quality of life12. Moreover, the Thyroid Cancer-specific Quality of Life Questionnaire (THYCA-QOL) was used to evaluate symptoms specific to thyroid cancer13. The summary THYCA-QOL score, calculated as the average of the subscale scores, provides an overall measure of thyroid cancer-related QOL, with higher summary and subscale scores indicating worse quality of life7. Both the Chinese versions of the EORTC QLQ-C30 and THYCA-QOL has demonstrated robust reliability and validity14,15.

Scar and mental health assessment

Scar satisfaction was evaluated by both researchers and respondents using the Patient and Observer Scar Assessment Scale (POSAS), with higher subscale scores indicating lower satisfaction with the scar from observer and patient16. In additional, mental health was assessed using the Hospital Anxiety and Depression Scale (HADS), and scores above 8 indicated the presence of depression or anxiety17. The reliability and validity of these scales have been confirmed in earlier research18,19.

Statistical analysis

All analyses were performed using R (version 4.3.1) and RStudio software. Continuous variables were represented as means ± standard deviation (SD) or medians with interquartile ranges (IQR), while categorical variables were expressed as frequencies and percentages. Differences in participant characteristics were analyzed using independent sample t-tests or one-way analysis of variance (ANOVA), alongside Chi-square test or the Fisher’s exact tests. Subsequently, univariate and multivariate liner or logistic regression analyses were performed to identify factors influencing QOL, scar satisfaction and emotional well-being. A p-value of less than 0.05 was considered statistically significant.

Results

Study population and baseline characteristics

A total of 221 patients diagnosed with thyroid cancer were in included in this study (Fig. 1). The participants were divided into two groups: 136 patients (61.5%) underwent open surgery, and 85 patients (38.5%) were treated with the transoral endoscopic approach. Baseline characteristics of each group are presented in Table 1.

Table 1 Baseline characteristics of respondents.
Full size table
Fig. 1
figure 1

Flow chart of the study process.

Full size image

The majority of participants were middle-aged (mean age: 44.21 ± 12.25 years) and female (65.6%). Most patients were diagnosed with papillary thyroid carcinoma (PTC, 94.12%) and classified as T1 (95.93%), and 91.86% of tumors were further identified as Stage 1. The results showed no significant differences in these clinicopathological characteristics between patients underwent open surgery and those treated with TOETVA (all P > 0.05). Bilateral tumors were more common in the open surgery group (23.53% vs. 4.71%), whereas the TOETVA group had a higher proportion of tumors on the right side (54.12%) or the left side (38.82%). Partial thyroidectomy was more common in the TOETVA group than in the open surgery group (84.7% vs. 61.7%, P < 0.001). In additional, the risk of hypoparathyroidism was significantly lower in the TOETVA group (5.9% vs. 18.4%, P = 0.008). However, the median operative time for TEOTVA was significantly longer, at 185 min (IQR: 149–229), compared to 103 min (IQR: 81.5-120.3) for open surgery (P < 0.001). Similar patterns were observed for hospital length of stay and total costs, with TOETVA patients experiencing longer stays and higher expenses.

Other demographic variables, including marital status, education level, and residence, also demonstrated statistically significant differences between the groups (all P < 0.05). Patients undergoing TOETVA were more likely to have higher educational attainment (70.6% with a college degree or above) and reside in urban areas (89.4%), though a greater proportion were single or widowed compared to those in the open surgery group. In additional, the TOETVA group generally tended to have better-paying jobs and incomes. These findings suggest that socioeconomic factors may influence the choice of surgical approach.

Quality of life in patients with thyroid cancer

General cancer quality of life

The results of the general QOL assessment are presented in Table 2; Fig. 2. The global QOL score from EORTC QLQ-C30 showed no significant difference between the TOETVA and the open surgery group (81.3 vs. 83.4, P = 0.420). Among the functional subscales, social and role functioning had the highest mean scores (94.5 and 94.2 respectively). Patients in the TOETVA group reported higher scores for physical, emotional, and cognitive functioning subscales, with only cognitive functioning reaching statistical significance compared to the open surgery group. For symptom subscales, the pain score was lower in the open surgery group compared to the TOETVA group (5.5 vs. 10.2, P = 0.029). Other symptoms scores, such as fatigue, nausea/vomiting, dyspnea, insomnia, appetite loss, and constipation/diarrhea, were elevated in the open surgery group, though these differences were not statistically significant.

Table 2 Summary scores and subscales scores of EORTC QLQ-C30.
Full size table
Fig. 2
figure 2

Comparison of EORTC QLQ-C30 scores between the open surgery and TOETVA groups. (a) Displays the functional and symptom subscale scores for the open surgery and TOETVA groups, respectively. (b) Illustrates the global health status scores for both groups. There was no significant difference in global health status between the two groups (P = 0.420). TOETVA transoral endoscopic thyroidectomy vestibular approach. Statistical significance: *p < 0.05, **p < 0.01, ***p < 0.001.

Full size image

We further conducted linear regression analyses to identify the determinants of general cancer QOL scores (Table 3). In univariate analysis, education level, residence, employment status, monthly household income, and age were significantly correlated with the global QOL score (all P < 0.05). These significant factors were then included in multivariable regression models. Multivariable stepwise analysis indicated that higher monthly household income, particularly levels exceeding 5000 ¥, was significantly associated with improved general QOL (P < 0.05). Other income levels did not demonstrate significant associations. Although trends suggested rural residence, lower education attainment, retirement or unemployment status, and old age appeared were linked to reduced quality of life, these associations did not reach statistical significance. The choice of surgical approach was not significantly associated with general cancer QOL in either univariate or multivariate settings.

Table 3 Associations between patient characteristics and EORTC QLQ-C30 global scores.
Full size table

Thyroid cancer-specific quality of life

Table 4; Fig. 3 present the thyroid cancer-specific QOL scores, focusing on adverse reactions experienced by patients and higher scores reflect poorer health-related outcomes. The mean summary THYCA-QOL score significantly higher in the open surgery group compared to the TOETVA group (15.3 vs.12.4, P = 0.033). For symptom-specific subscales, the TOETVA group reported a higher score for decreased sexual interest (P = 0.002). Aside from this, the open surgery group had higher scores across all the other subscales, and statistically significantly differences were observed in neuromuscular symptoms, concentration difficulties, sensory disturbances, scar-related concerns and sensations of coldness (all P < 0.05).

Table 4 Summary scores and subscales scores of THYCA-QOL.
Full size table
Fig. 3
figure 3

Comparison of THYCA-QOL scores between the open surgery and TOETVA groups. (a) Displays the thyroid cancer specific symptom scores for the open surgery and TOETVA groups, respectively. (b) Illustrates the summary THYCA-QOL score for both groups, suggesting significant difference between the two groups (P = 0.033). LS less interest in sex; GW gained weight, SE sensory, PC psychological,TM throat/mouth problems, VO voice, FC felt chilly, ST sympathetic, CT concentration, NM neuromuscular, SC problems with scar, HE headache, TI tingling hands/feet, TOETVA transoral endoscopic thyroidectomy vestibular approach. Statistical significance: *p < 0.05, **p < 0.01, ***p < 0.001.

Full size image

In additional, associations between thyroid cancer-specific QOL and patient characteristics are detailed in Table 5. The results of univariate analysis showed that transoral endoscopic surgery was associated with a greater reduction in symptom scores (β = -2.91, 95%CI: -5.56 to -0.26, P = 0.033). However, this association did not remain significant in the multivariate model (β = -2.06, 95%CI: -5.18 ~ 1.07, P = 0.198). Similarly, other factors, such as male gender, unilateral tumor, partial resection, younger age, higher education level, and stable employment, were associated with lower scores in the univariate analysis, but these associations were not significant in the multivariate analysis.

Table 5 Associations between patient characteristics and THYCA-QOL summary score.
Full size table

Observer and patient scar assessment

Postoperative scars were evaluated using the POSAS scale, with results summarized in Table 6. The overall cosmesis score in both the Observer Scar Assessment Scale (OSAS) and Patient Scar Assessment Scale (PSAS) were higher in the open surgery cohort comparted to the TOETVA group (OSAS: 3.6 vs. 2.5, P < 0.001; PSAS: 3.6 vs. 2.1, P < 0.001; Fig. 4). Except for the pain subscale, significant differences could be observed across all scale subscales (P < 0.05 for all except pain). The results of observer evaluations suggested that the most obvious differences in scar appearance compared to normal skin were in color, thickness, and softness subscales, consistent with patients’ self-assessments. While mean scores for abnormal vascularity and scar size were lower than other subscales, they remained elevated in the open surgery group. In addition, patients who underwent open surgery reported higher levels of pain and itching associated with scarring.

Table 6 Summary scores and subscales scores of POSAS.
Full size table
Fig. 4
figure 4

Comparison of POSAS scores between the TOETVA and open surgery groups. (a) Comparison of overall OSAS scores between the open surgery and the TOETVA groups (P < 0.001); (b) Comparison of overall PSAS scores between the open surgery and TOETVA groups (P < 0.001). POSAS patient and observer scar assessment scale, PSAS patient scar assessment scale, OSAS observer scar assessment scale, TOETVA transoral endoscopic thyroidectomy vestibular approach.

Full size image

Then, univariate analysis indicated that the surgical approach was significantly associated with OSAS and PSAS mean scores, and transoral endoscopic surgery was more effective in reducing the difference between scars and normal skin (OSAS: β = -1.25, 95% CI: -1.59 ~ -0.91, P < 0.001; PSAS: β = -1.54, 95% CI: -2.16 ~ -0.93, P < 0.001; Table 7). By the same token, unilateral tumors, particularly isthmus tumors were linked to lower scar assessment scores, while RAI treatment might induce raised OSAS scores. These findings were further confirmed in multivariate analysis. Despite minor impact, extended surgical time and hospital stay were found to reduce negative scores. Moreover, N0 stage, partial thyroidectomy and higher education levels were also linked to lower OSAS scores in univariate analysis (all P < 0.05).

Table 7 Associations between patient characteristics and summary scores of OSAS and PSAS.
Full size table

Mental health assessment

We also evaluated the mental health status for all participants (Table 1). The results showed that the majority of thyroid cancer patients experienced anxiety (95.0%) and depression (88.2%). Those who underwent transoral endoscopic surgery exhibited a higher tendency toward anxious symptoms, with the difference approaching statistical significance (P = 0.083).

Regression analyses were performed to explore factors associated with anxiety and depression, with detailed results presented in Supplement Tables 1 and 2. Univariate analysis showed that age, residence and surgical duration were significantly associated with depressive symptoms. In additional, patients with unilateral tumors and those undergoing TOETVA were more likely to experience anxiety. However, after adjusting for other variables, these associations did not remain significant in the multivariate analysis.

Discussion

This study is the first to comprehensively evaluated postoperative QOL, scar satisfaction and mental health outcomes in thyroid cancer patients undergoing traditional open surgery and transoral endoscopic surgery. Our findings indicate significant advantages of TOETVA across multiple dimensions.

Consistent with previous research, our results have shown that thyroid cancer patients often experience impaired QOL following treatment for thyroid cancer20. Despite no significant differences in general cancer QOL scores between two groups, patients in the TOETVA group demonstrated better thyroid cancer-specific QOL and reduced discomfort compared to the open surgery group. This difference was particularly pronounced among women, patients without hypoparathyroidism, those who were married or partnered, employed individuals, and those with higher educational attainment and income. In additional, regression analysis further confirmed that TOETVA was significantly associated with lower symptom scores. This aligns with the results from studies conducted by Nhuyen and Wongwattana et al.21,22. Furthermore, transoral endoscopic surgery has been confirmed to be safe, with similar survival outcomes as open thyroidectomy23,24. It also avoids neck incisions, reducing the negative impact on patients’ image and improving their psychological well-being and long-term quality of life23.

However, TOEVA is associated with longer operative duration and higher costs, which is supported by earlier study25. Patients who chose this approach often had higher incomes and better employment and living conditions, suggesting that socioeconomic factors play a role in treatment choices and QOL outcomes. Mongelli et al. also reported that financial distress was common in thyroid cancer survivors and was associated poorer health-related QOL26.

Our study found slightly higher postoperative pain scores in the TOETVA group. However, Anuwong et al. reported lower postoperative pain using visual analog scale (VAS) measures for TOETVA patients, suggesting that postoperative pain may warrant further investigation using standardized measures25. Previous studies have highlighted the negative impact of thyroidectomy complications, and we focus on hypoparathyroidism in this study27,28. Despite not completely avoiding, the rate of hypoparathyroidism in the TOETVA were significantly lower than that in the open surgery group. This suggests that TOETVA may have obvious advantage for protecting parathyroid function. However, some authors have reported similar total complication prevalence in both groups29,30. Differences in sample size, patient characteristics, and variations in surgical techniques are factors that need to be considered in interpreting these findings. Furthermore, our results have shown the value of THYCA-QOL scale in offering a comprehensive assessment of patient well-being that extends beyond general cancer scales, aligning with prior studies7,13.

We evaluated scars from observer and patient perspectives with 13 domains of POSAS scale. The results demonstrated that transoral endoscopic surgery significantly improved scar appearance and reducing scar-related discomforts. Scores for almost all symptom subscales were higher in the open surgery group, with the most notable differences in color, pliability and irregularity. In additional, better scar outcomes were observed in female patients and those who did not undergo partial thyroidectomy, had higher education and income, lived in urban areas, and had stable employment. Similar findings have been reported by Kim and Agne et al., further highlighting the role of TOETVA in enhancing scar outcomes31,32. Overall, evaluations from both observer and patient perspectives suggest that transoral endoscopic surgery leads to superior scar appearance, wound healing, and patient satisfaction.

In additional, subscales scores of PSAS were higher than OSAS, suggesting that patients may perceive scars more acutely than observers. Assessing scarring from both perspectives may provide a more comprehensive evaluation.

The emotional well-being of thyroid cancer survivors was often impaired in our cohort. A substantial proportion of our respondents reported high rates of depression (88.24%) and anxiety (95.02%), exceeding those documented in previous studies33. Patients in TOETVA group often may suffer more anxious emotion. In additional, the factors contributing to poor mental health differed from earlier research33. Although our findings require further validation, they suggest that thyroid cancer survivors after surgery might be in more need of psychosocial support than could be expected.

This study has some limitations. First, the sample size, particularly in the TOETVA group, is relatively small, which may affect the statistical power of the findings. Second, the follow-up period was limited to 6 months post-surgery, restricting insights into the long-term impact of surgical methods on QOL. In additional, the POSAS scale may have some limitations in evaluating mucosal wounds after transoral surgery: whether it can be achieved via more standardized wound assessment merits further study. Finally, the retrospective nature of our study may introduce certain biases.

Conclusion

In summary, our study suggests that transoral endoscopic surgery for thyroid cancer is associated with improved quality of life and greater scar satisfaction compared to traditional open surgery, though the choice of surgical method does not appear to significantly affect general cancer QOL outcomes. These findings may assist in decision-making for surgical approaches for thyroid cancer treatment, particularly when considering patient preferences and postoperative expectations. In addition, depression and anxiety of patients are also need attention.