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

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 (R)) 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 (R) (lobectomy: $6,100; 4.50 quality-adjusted life-years vs Afirma (R) : $9,400; 4.47 quality-adjusted life-years). Only in 253 of 10,000 simulations (2.5%) did Afirma (R) 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 (R) 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 (R). Published by Elsevier Inc.