Abstract
Background
Thyroid cancer (TC) is the most prevalent malignancy among middle-aged and young adults. Many patients will face the challenge of return-to-work (RTW) after TC surgery. If patients cannot return to work successfully, it may affect their social recovery and quality of life. This study used the random forest algorithm to identify the predictors of RTW after TC surgery.
Methods
A cross-sectional study was conducted, encompassing a sample of 242 patients who underwent TC surgery in Zhujiang Hospital of Southern Medical University from April to December 2023. The participants completed questionnaires including the general information questionnaire, the Return-To-Work Self-Efficacy Questionnaire (RTW-SE), the Cancer Fatigue Scale (CFS), and the Vancouver Scar Scale (VSS). In this study, the predictors of RTW after TC surgery were analyzed by univariate analysis, multiple logistic regression, and random forest model (RFM).
Results
The final 229 TC patients were included in this study, of which 183 (79.9%) returned to work, of which 46 (20.1%) failed to return to work. The median time of RTW was 30.00(14.00, 33.75) days after TC surgery. The RFM indicated that RTW-SE was a key predictor related to RTW after TC surgery and other predictors were ranked in order of importance as follows: postoperative time, neck scar (NS), medical insurance, complications, and rehabilitation exercise.
Conclusions
20.1% (46/229) of patients still failed to return to work after TC surgery. Healthcare professionals ought to emphasize the importance of modifiable factors, improving TC patients’ RTW-SE, reducing the formation of NS, minimizing the occurrence of complications, and promoting rehabilitation exercise may help to facilitate RTW after TC surgery.
Keywords: Thyroid cancer surgery, Return to work, Self-efficacy, Random forest model
Background
Thyroid cancer (TC) is the most common malignancy in head and neck cancer (HNC). According to GLOBOCAN 2020 the International Agency for Research on Cancer, there are 586,000 new cases of TC worldwide, ranking ninth among all cancer types and first among HNC [1]. In China, there were 39,080 newly diagnosed TC cases in 2019 [2]. Simultaneously, the incidence of TC is rapidly increasing, especially among middle-aged and young adults aged 20 to 45, who are diagnosed at working age [3]. Due to the advancements in ultrasound examination technology, TC can now be diagnosed earlier. The 5-year and 10-year survival rates of TC patients can reach as high as 95.21% and 89.09% in China [4], which means TC patients demand to face the decision of return-to-work (RTW).
At present, the mainstays of treatment for TC include surgical resection of the primary lesion, reasonable neck lymph node dissection, radioactive iodine therapy as needed, and thyrotropin (TSH) suppressive therapy [5]. With the transition from the traditional medical model to the biopsychosocial model, RTW has become a crucial measure of postoperative rehabilitation and quality of life. RTW is defined as people who leave their work due to injury or illness and then re-engage in the original work, return to a similar work or start a new work, including paid part-time and full-time employment [6]. RTW-SE is patients’ belief that they can meet the requirements required to return to work [7], which has been shown to be an important predictor of RTW by several previous studies [8]. The 2022 HNC survivorship consensus statement emphasized RTW as a core component of survival care for HNC survivors [9]. For individuals, RTW can alleviate the burden of self-perception and social isolation, enhance personal value, and improve the quality of life after surgery [10, 11]. In addition, RTW can reduce the financial burden for families and contribute to economic benefits for society [12].
Despite a good prognosis for TC patients, studies in France have shown that up to 12.3% of TC patients did not return to work within 5 years post-diagnosis [13]. Previous studies have highlighted that HNC survivors face unique challenges and treatment-specific issues that may affect their ability to RTW [14]. More specifically, surgical trauma, neck cicatrix, postoperative reexamination, permanent TSH suppressive therapy, cancer-related fatigue, and other problems may bring challenges to RTW after TC surgery [13, 15]. Cancer-related fatigue is a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment [16]. Previous studies have shown that cancer-related fatigue often has a significant impact on RTW for patients [17]. Almost half of TC patients reported the highest levels of neck scar (NS) [18]. Up till the present moment, research on RTW mainly has focused on other types of cancer, particularly breast cancer and colorectal cancer. Prior research emphasizes factors associated with RTW including individual characteristics, work-related factors, clinical factors, general health, well-being, etc [14]. While less research pays attention to the situation and predictors of RTW after TC surgery.
The logistic regression model only demonstrates the direction and degree of the independent variable’s influence on the dependent variable, while the importance of each predictor couldn’t be measured. In order to evaluate the importance of various predictors affecting RTW after TC surgery, this study established the random forest model (RFM) for TC patients’ RTW in China. RFM can more accurately rank the importance of various predictors to achieve visualization of predictors. Therefore, this study aimed to use the random forest algorithm to identify the predictors of RTW after TC surgery. The findings are expected to provide valuable and modifiable factors to help TC patients return to work after surgery successfully.
Materials and methods
Patients
We conducted a cross-sectional study following the STROBE standards in Guangzhou from April to December 2023. A convenient sampling method was used to recruit TC patients who had undergone postoperative reexamination at Zhujiang Hospital of Southern Medical University in Guangzhou. The inclusion criteria for TC patients were as follows: (1) having undergone thyroid surgery and postoperative pathohistological confirmation of TC; (2) the age of 18–60 for males and 18–55 for females (the legal working age in China); (3) knowing own condition and diagnosis; (4) being employed before TC surgery and having the ability to RTW after assessment of healthcare professionals; (5) having normal communication and understanding abilities. The exclusion criteria for TC patients were as follows: (1) retiring early due to special reasons; (2) merging with other organic malignant tumors or severe diseases.
Data collection
After TC patients completing the postoperative follow-up clinic, the researchers invited participants to fill out the questionnaire in a separate clinic office, following the principles of informed consent, voluntariness, and confidentiality during the process. The participants were fully informed of the research subjects of the purpose, process, and potential hazards and benefits of participating in the study. If participants had difficulty in filling out the questionnaire due to education level, physical function, and other reasons, the researchers would use unified guidance to assist them in completing the questionnaire. The researchers collected the questionnaire after inspection and supplemented any missing items promptly. Disease-related information was collected by the researchers through the medical record system. This study was approved by the institutional ethical committee of Zhujiang Hospital of Southern Medical University(2023-KY-248-01). Written informed consent was obtained from each participant.
Measures
The general information questionnaire comprised three sections: (1) Demographic data, including gender, age, education level, residence, marital status, income, and medical insurance; (2) Disease-related data, including postoperative time (the time from surgery to completing the questionnaires), pathological type, tumor stage, risk-stratification, and the most recent test values of thyroid stimulating hormone (TSH) and parathyroid hormone (PTH); (3) Work-related data including five questions: ① Type of work; ② Characteristic of work; ③ Hours required to work every day; ④ Whether to return to work at present?; ⑤ If you have already returned to work, how long did you return to work after the surgery?
Return-To-Work Self-Efficacy Questionnaire (RTW-SE) (Chinese version) was used to evaluate the self-efficacy of RTW of TC patients. The RTW-SE, developed by Lagerveld in 2010, was translated into Chinese by Gao in 2021 [19, 20]. This scale consists of 11 items, including 8 positive and 3 negative items. Using the Likert 6-level scoring method, the scores are calculated from 1 to 6 in sequence. The average score of each item reflects the total score of the scale. A higher average score indicates a better RTW-SE, while a score below 4.5 points indicates a low RTW-SE. Cronbach’s α of the scale is 0.90–0.96.
The Cancer Fatigue Scale (CFS), to evaluate the degree of cancer-related fatigue (CRF), was developed by Okuyama [21] in 2000 and translated into Chinese by Zhang [22] in 2011. The scale consists of 15 items, including 3 dimensions: 7 items for physical fatigue (PF), 4 items for emotional fatigue (EF), and 4 items for cognitive fatigue (CF). Using the Likert 5-level scoring method, the total score ranges from 0 to 60 points, with higher scores indicating a higher level of fatigue. 0 to 5 points indicate no fatigue, 6 to 15 points indicate mild fatigue, 16 to 30 points indicate moderate fatigue and 31 to 60 points indicate severe fatigue. Cronbach’s α of the scale is 0.88.
The Vancouver Scar Scale (VSS) (Chinese version) was used to assess the NS of TC patients by thyroid surgeons independently. It is an international scale, which was translated into Chinese by Liu in 2006 [23]. It evaluates the recovery of scars based on factors such as color, vascular distribution, thickness, and softness. The total score is 15 points, which is negatively correlated with the recovery.
Statistical analysis
Epidata 3.1 was used to input and organize the data. SPSS version 25.0(IBM Inc, Armonk, NY, USA) was used for data analysis. The measurement data, which followed a normal distribution, was described using Mean ± SD, and group differences were compared using an independent sample t-test. The measurement data, which did not follow a normal distribution, was described using M (P25, P75), and group differences were compared using the Mann-Whitney U test. Counting data was described in terms of frequency (percentage) and group differences were compared using either the chi-square test or Fisher’s exact test. The factors that showed statistical significance in the univariate analysis were included in a binary logistic regression to explore the predictors of RTW in TC patients. In addition, R 4.4.2 was used to establish the RFM to evaluate and rank the importance of predictors. P < 0.05 was considered statistically significant.
Results
Patient characteristics
A total of 242 questionnaires were distributed in this study, however, 13 participants quit the survey due to reasons such as unavailability at the time of the survey or physical discomfort. Ultimately, 229 valid questionnaires were completed, with an effective recovery rate of 94.6%. The average age of the 229 participants (70 men and 159 women) was 37.73 ± 8.03 years; 177 were married and 52 were single, divorced, or widowed; the average postoperative time was (385.07 ± 415.69) days. 46 (20.1%) TC patients did not return to work after surgery, while 183 (79.9%) TC patients returned to work successfully. The average time of RTW in TC patients was (53.74 ± 96.42) days after surgery. The mean score of RTW-SE was (4.37 ± 0.66) points. The mean score of CRF was (21.65 ± 7.95) points. The mean score of NS was (3.53 ± 2.55) points. More details about the socio-demographic and clinical characteristics of the participants can be found in Table 1.
Table 1.
The Socio-demographic and clinical characteristics of TC patients and univariate analysis (N = 229)
| Variables | No RTW (n = 46) | RTW (n = 183) | t/x²/Z | P-value |
|---|---|---|---|---|
| Age, M (P25, P75), years | 37.50(32.00, 44.00) | 37.00(32.00, 42.00) | -0.770 | 0.441 |
| Gender, n (%) | ||||
| Male | 8(17.4) | 62(33.9) | 4.709 | 0.030 |
| Female | 38(82.6) | 121(66.1) | ||
| Marital status, n (%) | ||||
| Married | 34(73.9) | 143(78.1) | ||
| Single/Divorced/Widowed | 12(26.1) | 40(21.9) | ||
| Education level, n (%) | ||||
| ≤Junior high school and below | 13(28.3) | 30(16.4) | 4.855 | 0.183 |
| Senior high school or technical secondary school | 7(15.2) | 26(14.2) | ||
| Junior college | 11(23.9) | 39(21.3) | ||
| ≥Bachelor degree | 15(32.6) | 88(48.1) | ||
| Type of work before surgery, n (%) | ||||
| Office clerk | 28(60.9) | 102(55.7) | 2.830 | 0.418 |
| Farmer/worker | 4(8.7) | 20(10.9) | ||
| Teacher/Civil Servant | 4(8.7) | 32(17.5) | ||
| Individual business | 10(21.7) | 29(15.8) | ||
| Characteristics of work before surgery, n (%) | ||||
| Mental work | 21(45.7) | 100(54.6) | 1.513 | 0.469 |
| Manual work | 8(17.4) | 22(12.0) | ||
| Mental and manual work | 17(37.0) | 61(33.3) | ||
| Family monthly income, n (%), yuan | ||||
| < 3000 | 7(15.2) | 10(5.5) | 7.866 | 0.044 |
| 3000∼ | 16(34.8) | 45(24.6) | ||
| 5000∼ | 12(26.1) | 66(36.1) | ||
| 10000∼ | 11(23.9) | 62(33.9) | ||
| Medical insurance, n (%) | ||||
| Residents’ medical insurance | 20(43.5) | 43(23.5) | 16.998 | 0.001 |
| Employee medical insurance | 12(26.1) | 100(54.6) | ||
| New rural cooperative medical insurance | 7(15.2) | 11(6.0) | ||
| Government insurance | 1(2.2) | 12(6.6) | ||
| Self-paying | 6(13.0) | 17(9.3) | ||
| Postoperative time, M (P25, P75), days | 30.00(30.00, 352.50) | 270.00(90.00, 630.00) | -4.158 | <0.001 |
| Surgical modality, n (%) | ||||
| Traditional open surgery | 33(71.7) | 139(76.0) | 0.350 | 0.554 |
| Minimally invasive surgery | 13(28.3) | 44(24.0) | ||
| Extent of thyroidectomy, n (%) | ||||
| Total thyroidectomy | 31(67.4) | 121(66.1) | 0.027 | 0.870 |
| Thyroid lobectomy | 15(32.6) | 62(33.9) | ||
| Extent of lymph node dissection, n (%) | ||||
| Central | 38(82.6) | 166(90.7) | 2.481 | 0.115 |
| Ipsilateral cervical | 8(17.4) | 17(9.3) | ||
| Risk of recurrence, n (%) | ||||
| Low-risk | 27(58.7) | 100(56.4) | 3.807 | 0.149 |
| Intermediate-risk | 12(26.1) | 69(37.7) | ||
| High-risk | 7(15.2) | 14(7.7) | ||
| TSH, M (P25, P75), µlU/mL | 0.24(0.04, 1.35) | 0.11(0.03, 0.60) | -1.629 | 0.103 |
| PTH, M (P25, P75), pmol/L | 2.63(1.50, 3.87) | 2.88(2.20, 4.04) | -1.451 | 0.147 |
| Complications, n (%) | ||||
| None | 25(54.3) | 138(75.4) | 13.293 | 0.003 |
| Hypocalcemia | 8(17.4) | 21(11.5) | ||
| Hoarseness | 8(17.4) | 22(12.0) | ||
| Hypocalcemia combined with hoarseness | 5(10.9) | 2(1.1) | ||
| Rehabilitation exercise, n (%) | ||||
| No | 37(80.4) | 112(61.2) | 5.982 | 0.014 |
| Yes | 9(19.6) | 71(38.8) | ||
| RTW-SE, M (P25, P75), points | 4.00(3.66,4.36) | 4.18(4.00,4.91) | -3.353 | <0.001 |
| CRF | ||||
| Total score, mean (SD), points | 23.65 ± 8.23 | 21.14 ± 7.82 | 1.925 | 0.055 |
| PF, M (P25, P75), points | 10.00(8.00, 13.00) | 9.00(6.00, 12.00) | -1.108 | 0.268 |
| EF, M (P25, P75), points | 7.00(4.00, 8.00) | 5.00(3.00, 7.00) | -1.754 | 0.079 |
| CF, M (P25, P75), points | 8.00(6.00, 9.00) | 7.00(5.00, 8.00) | -2.128 | 0.033 |
| NS, M (P25, P75), points | 6.00(0.00, 6.75) | 4.00(2.00, 5.00) | -3.073 | 0.002 |
TC, thyroid cancer; TSH, thyroid stimulating hormone; PTH, parathyroid hormone; RTW-SE, Return-To-Work Self-Efficacy; CRF, cancer-related fatigue; SD, standard deviation; PF, physical fatigue; EF, emotional fatigue; CF, cognitive fatigue; NS, neck scar
Predictors associated with RTW of TC patients
In the univariate analysis, several predictors were found to influence the RTW of TC patients. These predictors included gender, family monthly income, medical insurance, postoperative time, complications, rehabilitation exercise, RTW-SE, EF, and NS. To determine the variables that significantly affected RTW, a multivariate analysis was conducted. The dependent variable was RTW (No = 0, Yes = 1), and the variables entered into the equation were gender, family monthly income (< 3000 as the control), medical insurance (residents’ medical insurance as the control), postoperative time, complications (none as the control), rehabilitation exercise, RTW-SE, EF, and NS. The results, as shown in Table 2, revealed that medical insurance, postoperative time, complications, rehabilitation exercise, RTW-SE, and NS were significantly associated with RTW in TC patients.
Table 2.
Logistic regression analysis of RTW of TC patients (N = 229)
| Variables | β | SE | Wald χ² | P | OR | 95%CI |
|---|---|---|---|---|---|---|
| Medical insurance | ||||||
| Postoperative time | 0.001 | 0.001 | 4.240 | 0.039 | 1.001 | (1.000, 1.002) |
| Complication | ||||||
| Hypocalcemia combined with hoarseness | -3.775 | 1.155 | 10.689 | 0.001 | 0.023 | (0.002, 0.221) |
| Rehabilitation exercise | 1.055 | 0.490 | 4.638 | 0.031 | 2.873 | (1.100, 7.504) |
| RTW-SE | 1.348 | 0.467 | 8.333 | 0.004 | 3.848 | (1.541, 9.609) |
| NS | -0.178 | 0.080 | 4.930 | 0.026 | 0.837 | (0.715, 0.979) |
β, standardized path coefficient beta; SE, standard error; OR, odds ratio; CI, confidence interval; RTW-SE, Return-To-Work Self-Efficacy; NS, neck scar
The importance ranking of predictors associated with RTW of TC patients
To evaluate the importance of various factors affecting RTW of TC patients, furthermore, this study established the RFM for RTW of TC patients using RTW as the dependent variable and six influencing factors as independent variables. The data was divided into a training set (80%) and a test set (20%) to establish the RFM with parameters mtry 6 and ntree 500. The RFM measured the influence of each variable on the dependent variable by Gini index. the greater the average reduction of the Gini index, the more important this variable is Fig. 1 and Table 3 showed the ranking results of predictors according to the mean reduction of Gini, which indicated that RTW-SE was the key factor related to RTW of TC patients, and other predictors were ranked in order of importance as follows: postoperative time, NS, medical insurance, complications, rehabilitation exercise.
Fig. 1.
The ranking of the importance of RTW of TC patients. RTW-SE, Return-To-Work Self-Efficacy; NS, neck scar
Table 3.
The importance ranking of predictors for RTW of TC patients
| Rank | Variables | Mean Gini reduction |
|---|---|---|
| 1 | RTW-SE | 19.651 |
| 2 | Postoperative time | 15.744 |
| 3 | NS | 13.681 |
| 4 | Medical insurance | 7.660 |
| 5 | Complication | 5.830 |
| 6 | Rehabilitation exercise | 4.116 |
RTW-SE, Return-To-Work Self-Efficacy; NS, neck scar
Discussion
This study demonstrated that 183 (79.9%) TC patients returned to work, while 46 (20.1%) did not return to work. This rate of not returning to work was higher than 12.3% in the VICAN Survey of France [13]. The average time of RTW of TC patients was (53.74 ± 96.42) days after surgery, which significantly exceeded the reported median RTW time of 14 days in other regions’ studies [24]. There might have been a higher level of concern about RTW of cancer patients in developed countries than in developing countries. For example, the Netherlands had established a professional healthcare system, which guided cancer patients returning to work through multidisciplinary teams such as occupational physicians, insurance physicians, and labor experts [25].
Young TC patients often play a crucial role as the backbone of their families, the main source of the family economy, and the backbone of social development. Data showed that the labor participation rate in China has decreased from 82.58% in 2000 to 75.61% in 2019 [26]. Therefore, it is of utmost importance to assist work-aged TC patients in returning to work. The RFM indicated that RTW-SE was the key predictor related to RTW of TC patients and other predictors were ranked in order of importance as follows: postoperative time, NS, medical insurance, complications, and rehabilitation exercise. It is recommended that healthcare professionals discuss and develop a multidimensional RTW plan with TC patients after surgery, including health education, rehabilitation exercise, physical therapy, social psychology intervention, and career counseling to promote their RTW early. For TC patients who have already returned to work, healthcare professionals should take high notice of their physical function and mental health to ensure they can adapt to the rhythm of RTW and actively maintain it.
The research findings indicated that TC patients who had higher RTW-SE were more likely to return to work, which aligned with the findings of previous research by Rikke [8]. The social cognitive theory (SCT), proposed by American psychologist Bandura, reveals that there is a dynamic interaction between individual behavior, individual factors, and environmental factors, in which individual cognition (such as self-efficacy) plays a central role. RTW-SE refers to the patient’s confidence in their ability to RTW, which is a prominent predictive indicator [27]. People with higher self-efficacy may have higher self-management abilities and are more likely to adapt to changes in social roles after illness [28]. However, the survey revealed that the average RTW-SE score of TC patients was (4.37 ± 0.66) points, which was at a relatively low level. Healthcare professionals should evaluate and identify TC patients with low RTW-SE in time, and provide them with information support related to RTW, as well as social and psychological interventions.
According to the result of logistic regression, the results of this study showed that the postoperative time was a predictor of RTW of TC patients, ranking second in the RFM. TC is a major source of physical and psychological stress for patients [29]. As time went by, the patients gradually recovered normal physical and mental functions. At the same time, they acquired certain disease-related health knowledge and coping abilities, which enable them to balance health, life, and work better. In addition, during the rehabilitation periods, TC patients had more time to take career development into consideration. RTW is a symbol of occupational rehabilitation and social reintegration for patients, considered one of the key indicators of complete recovery [30, 31]. Hence, healthcare professionals need to think highly of early continuation of care for patients with a short postoperative time and help them return to work smoothly to achieve true complete recovery.
The results indicated that the more severe NS of TC patients, the higher the risk of not returning to work, ranking third in the RFM. Traditional open thyroidectomy inevitably generates “suicidal” NS, leading to negative emotions such as physiological discomfort and psychological shame, which affects RTW of TC patients and reconstruction of social roles [32]. At present, multiple approaches of endoscopic thyroidectomy and minimally invasive thyroidectomy have been developed in clinical practice to reduce the generation of NS [33, 34]. It is crucial for healthcare professionals to prioritize effective communication with patients and assess their cosmetic needs before TC surgery. Simultaneously, Cognitive therapy, motivational interviews, and other psychological interventions should be taken to reduce the negative emotions of TC patients to encourage them to face diseases and participate in normal social work.
There were a few limitations to this study. First, participants were recruited by convenient sampling method from only one Grade A tertiary hospital in Guangzhou China. In the future, multi-center studies will be conducted to increase the generalizability of the findings. Second, this study was cross-sectional in nature, making it difficult to establish a causal relationship between variables such as RTW status and RTW-SE, which is a key predictor related to RTW of TC patients. Third, the data of TC patients’ RTW were self-reported data instead of registered data which is more accurate. Moreover, this study conducted a one-time measurement of RTW status of TC patients without conducting sub analysis of different time points. Therefore, it is necessary to conduct a longitudinal study in collaboration with government employment agencies to confirm the degree and relationship of change between RTW status and RTW-SE accurately at different postoperative time points, in order to provide a basis for developing personalized vocational rehabilitation intervention plans suitable for TC patients.
Conclusions
In this study, we explored the prevalence of RTW of TC patients and used the RFM to analyze the importance of various predictors associated with RTW of patients after TC surgery. This study demonstrated that 79.9% TC patients returned to work. The average time of RTW of TC patients was (53.74 ± 96.42) days after surgery. The RFM indicated that RTW-SE was the key predictor related to RTW of TC patients and other predictors were ranked in order of importance as follows: postoperative time, NS, medical insurance, complications, and rehabilitation exercise. Healthcare professionals ought to emphasize the importance of modifiable factors, improving TC patients’ RTW-SE, reducing the formation of NS, minimizing the occurrence of complications, and promoting rehabilitation exercise may help to facilitate RTW after TC surgery.
Acknowledgements
The authors thank all the thyroid cancer patients in the study for their participation.
Author contributions
Xiaoxia Tang: Conceptualization, Methodology, Formal analysis, Data acquisition, Data curation, Writing - Revised draft preparation. Xiaolin Yi: Conceptualization, Methodology, Reviewing and Editing. Huina Mao: Conceptualization, Methodology, Reviewing, Editing, and Supervision. Mei Wang: Conceptualization, Methodology. Rui Chen: Data acquisition, Data curation. Aoxue Zhu: Conceptualization, Methodology.
Funding
This study was supported by Guangdong Provincial Medical Science and Technology Research Fund Project (A2024390), Nursing Research Special Project of Southern Medical University (Y2024009).
Data availability
The data that support the findings of this study are available on request from corresponding authors.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethical Committee of Zhujiang Hospital of Southern Medical University (2023-KY-248-01). All patients provided written informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Xiaolin Yi and Huina Mao contributed equally to the article.
Contributor Information
Xiaolin Yi, Email: xiao8908@yeah.net.
Huina Mao, Email: maohuina2@126.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from corresponding authors.