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Comparative Study
. 2018 Jan;163(1):88-96.
doi: 10.1016/j.surg.2017.10.004. Epub 2017 Nov 8.

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance

Courtney J Balentine  1 , David J Vanness  2 , David F Schneider  3
Affiliations
Comparative Study

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance

Courtney J Balentine et al. Surgery. 2018 Jan.

Abstract

Background: We evaluated whether diagnostic thyroidectomy for indeterminate thyroid nodules would be more cost-effective than genetic testing after including the costs of long-term surveillance.

Methods: We used a Markov decision model to estimate the cost-effectiveness of thyroid lobectomy versus genetic testing (Afirma®) for evaluation of indeterminate (Bethesda 3-4) thyroid nodules. The base case was a 40-year-old woman with a 1-cm indeterminate nodule. Probabilities and estimates of utilities were obtained from the literature. Cost estimates were based on Medicare reimbursements with a 3% discount rate for costs and quality-adjusted life-years.

Results: During a 5-year period after the diagnosis of indeterminate thyroid nodules, lobectomy was less costly and more effective than Afirma® (lobectomy: $6,100; 4.50 quality-adjusted life- years vs Afirma®: $9,400; 4.47 quality-adjusted life-years). Only in 253 of 10,000 simulations (2.5%) did Afirma® show a net benefit at a cost-effectiveness threshold of $100,000 per quality- adjusted life-years. There was only a 0.3% probability of Afirma® being cost saving and a 14.9% probability of improving quality-adjusted life-years.

Conclusions: Our base case estimate suggests that diagnostic lobectomy dominates genetic testing as a strategy for ruling out malignancy of indeterminate thyroid nodules. These results, however, were highly sensitive to estimates of utilities after lobectomy and living under surveillance after Afirma®.

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Figures

Figure 1
Figure 1
Markov decision-analytic model comparing diagnostic lobectomy versus genetic testing with Afirma for evaluation of indeterminate thyroid nodule. Post-operative states consist of the presence or absence of complications. Surveillance represents ongoing observation of an initially benign nodule monitored for growth or malignant characteristics that trigger repeat evaluation. Both the Undetected Disease and the Surveillance nodes include the potential for future thyroidectomy, and the Undetected Disease node includes potential for disease progression and death.
Figure 2
Figure 2
Marginal probabilistic sensitivity analysis of net-benefit as each parameter is sampled 1,000 times from its probability distribution while other parameters are held constant. Boxes represent the interquartile range of net benefit; vertical bars within boxes represent the median; whiskers represent the 95% uncertainty interval and circles represent outliers. The top ten most influential parameters are presented: u_AL is the utility after lobectomy (including possibility of hormone replacement); u_Surv is the utility of surveillance; u_AT is the utility after thyroidectomy; c_TL is the cost of lobectomy; c_Vera is the cost of the Afirma test; c_Surv is the cost of surveillance; c_TT is the cost of thyroidectomy; p_specA is the specificity of the Afirma test; u_Vera is the utility of Afirma surveillance; p_STT is the probability of thyroidectomy after suspicious Afirma result.
Figure 3
Figure 3
Recursive partitioning analysis of 100,000 Monte Carlo replications of the Markov decision model. Boxes represent subsets of replications where parameter values meet all splitting criteria listed above the box. Within each box, the top number represents the proportion of replications in which Afirma is cost-effective at a threshold of $100,000 per QALY gained (which can be interpreted as the probability of cost-effectiveness; the bottom number represents the proportion of replications meeting the splitting criteria. u_dif is equal to the utility of Afirma minus the utility of post-lobectomy (without hormone replacement) health states; u_DL is the utility of detected local cancer health state; c_TL is the cost of lobectomy.
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Comment in

  • Discussion.
    [No authors listed] [No authors listed] Surgery. 2018 Jan;163(1):95-96. doi: 10.1016/j.surg.2017.10.007. Epub 2017 Nov 8. Surgery. 2018. PMID: 29128186 No abstract available.

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