Cost-Effectiveness of FDG-PET/CT for Cytologically Indeterminate Thyroid Nodules: A Decision Analytic Approach

• Published in: The journal of clinical endocrinology and metabolism Vol. 99; no. 9; pp. 3263 - 3274
• Main Authors: Vriens, D., Adang, E. M. M., Netea-Maier, R. T., Smit, J. W. A., de Wilt, J. H. W., Oyen, W. J. G., de Geus-Oei, L. F.
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01.09.2014
• Subjects: Adult; Cellular biology; Computed tomography; Cost analysis; Cost-Benefit Analysis; Cytology; Decision Support Techniques; Decision Trees; Fluorodeoxyglucose F18; Gene expression; Health Care Costs; Humans; Markov Chains; Models, Econometric; Multimodal Imaging - economics; Multimodal Imaging - methods; Nodules; Patients; Positron emission tomography; Positron-Emission Tomography - economics; Positron-Emission Tomography - methods; Quality of life; Radiopharmaceuticals; Sensitivity analysis; Sensitivity and Specificity; Surgery; Thyroid; Thyroid gland; Thyroid Neoplasms - diagnostic imaging; Thyroid Neoplasms - economics; Thyroid Nodule - diagnostic imaging; Thyroid Nodule - economics; Tomography; Tomography, X-Ray Computed - economics; Tomography, X-Ray Computed - methods
• ISSN: 0021-972X; 1945-7197; 1945-7197
• DOI: 10.1210/jc.2013-3483

Context:Patients with thyroid nodules of indeterminate cytology undergo diagnostic surgery according to current guidelines. In 75% of patients, the nodule is benign. In these patients, surgery was unnecessary and unbeneficial because complications may occur. Preoperative fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was found to have a very high negative predictive value (96%) and might therefore avoid futile surgery, complications, and costs. In the United States, two molecular tests of cytology material are routinely used for this purpose.Objective:Five-year cost-effectiveness for routine implementation of FDG-PET/CT was evaluated in adult patients with indeterminate fine-needle aspiration cytology and compared with surgery in all patients and both molecular tests.Design:A Markov decision model was developed to synthesize the evidence on cost-effectiveness about the four alternative strategies. The model was probabilistically analyzed. One-way sensitivity analyses of deterministic input variables likely to influence outcome were performed.Setting and Subjects:The model was representative for adult patients with cytologically indeterminate thyroid nodules.Main Outcome Measures:The discounted incremental net monetary benefit (iNMB), the efficiency decision rule containing outcomes as quality-adjusted life-years and (direct) medical cost, of implementation of FDG-PET/CT is displayed.Results:Full implementation of FDG-PET/CT resulted in 40% surgery for benign nodules, compared with 75% in the conventional approach, without a difference in recurrence free and overall survival. The FDG-PET/CT modality is the more efficient technology, with a mean iNMB of €3684 compared with surgery in all. Also, compared with a gene expression classifier test and a molecular marker panel, the mean iNMB of FDG-PET/CT was €1030 and €3851, respectively, and consequently the more efficient alternative.Conclusion:Full implementation of preoperative FDG-PET/CT in patients with indeterminate thyroid nodules could prevent up to 47% of current unnecessary surgery leading to lower costs and a modest increase of health-related quality of life. Compared with an approach with diagnostic surgery in all patients and both molecular tests, it is the least expensive alternative with similar effectiveness as the gene-expression classifier.