Cost-effectiveness of FDG-PET/CT for cytologically indeterminate thyroid nodules: A decision analytic approach

Abstract

Results: Full implementation of FDG-PET/CT resulted in40%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, themeaniNMBof FDG-PET/CTwas-1030and-3851, respectively,andconsequently 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. 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. Copyright 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.Themodelwasprobabilistically analyzed.One-waysensitivity 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.