Calcitonin measurement in the evaluation of thyroid nodules in the United States: A cost-effectiveness and decision analysis

Context: European studies have shown that the use of routine calcitonin screening for detection of medullary thyroid cancer (MTC) in patients with thyroid nodules increases the detection of occult MTC and may improve patient outcomes. Calcitonin screening for MTC has not been recommended in recent U. S. practice guidelines. Objective: Our objective was to determine the cost-effectiveness (C/E) of routine calcitonin screening in adult patients with thyroid nodules in the United States. Settings/Subjects: A decision model was developed for a hypothetical group of adult patients presenting for evaluation of thyroid nodules in the United States. Patients were screened using current American Thyroid Association guidelines only, or American Thyroid Association guidelines with routine serum calcitonin screening. Input data were obtained from the literature, the Surveillance Epidemiology and End Results and Healthcare Cost and Utilization Project's Nationwide Inpatient Sample databases, and the Medicare Reimbursement Schedule. Sensitivity analyses were performed for a number of input variables. Main Outcome Measures: C/E, measured in dollars per life years saved (LYS), was calculated. Results: Addition of calcitonin screening to current American Thyroid Association guidelines for the evaluation of thyroid nodules would cost $ 11,793 per LYS ($ 10,941-$ 12,646). When extrapolated to the national level, calcitonin screening for MTC in the United States would yield an additional 113,000 life years at a cost increase of 5.3%. Calcitonin screening C/E is sensitive to patient age and gender, and to changes in disease prevalence, specificity of fine needle aspiration and calcitonin testing, calcitonin screening level, costs of testing, and length of follow-up. Conclusion: Routine serum calcitonin screening in patients undergoing evaluation for thyroid nodules appears to be cost effective in the United States, with C/E comparable to the measurement of thyroid stimulating hormone, colonoscopy, and mammography screening.