A cost-utility analysis for prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma

Ann Surg Oncol. 2014 Mar;21(3):767-77. doi: 10.1245/s10434-013-3398-3. Epub 2013 Nov 26.

Abstract

Background: Although prophylactic central neck dissection (pCND) may reduce future locoregional recurrence after total thyroidectomy (TT) for low-risk papillary thyroid carcinoma (PTC), it is associated with a higher initial morbidity. We aimed to compare the long-term cost-effectiveness between TT with pCND (TT+pCND) and TT alone in the institution's perspective.

Methods: Our case definition was a hypothetical cohort of 100,000 nonpregnant female patients aged 50 years with a 1.5-cm cN0 PTC within one lobe. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between TT+pCND and TT alone after a 20-year period. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000 per quality-adjusted life year (QALY). Sensitivity and threshold analyses were used to examine model uncertainty.

Results: Each patient who underwent TT+pCND instead of TT alone cost an extra US$34.52 but gained an additional 0.323 QALY. In fact, in the sensitivity analysis, TT+pCND became cost-effective 9 years after the initial operation. In the threshold analysis, none of the scenarios that could change this conclusion appeared clinically possible or likely. However, TT+pCND became cost-saving (i.e., less costly and more cost-effective) at 20 years if associated permanent vocal cord palsy was kept ≤ 1.37 %, permanent hypoparathyroidism was ≤ 1.20 %, and/or postoperative radioiodine ablation use was ≤ 73.64 %.

Conclusions: In the institution's perspective, routine pCND for low-risk PTC began to become cost-effective 9 years after initial surgery and became cost-saving at 20 years if postoperative radioiodine use and/or permanent surgical complications were kept to a minimum.

MeSH terms

  • Carcinoma, Papillary / economics*
  • Carcinoma, Papillary / pathology
  • Carcinoma, Papillary / surgery
  • Cohort Studies
  • Cost-Benefit Analysis
  • Decision Trees
  • Female
  • Follow-Up Studies
  • Humans
  • Markov Chains
  • Middle Aged
  • Neck Dissection / economics*
  • Neoplasm Staging
  • Prognosis
  • Quality-Adjusted Life Years
  • Thyroid Neoplasms / economics*
  • Thyroid Neoplasms / pathology
  • Thyroid Neoplasms / surgery
  • Thyroidectomy / economics*