title: Routine prophylactic central neck dissection for low-risk papillary thyroid cancer is not cost-effective.
abstract: BACKGROUND
  The role of routine prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the cost utility of the addition of routine CND in patients with low-risk PTC compared with total thyroidectomy (TT) alone.
  
  
  METHODS
  A Markov model for low-risk PTC was constructed with a treatment algorithm based on the American Thyroid Association guidelines for well-differentiated thyroid carcinoma. Utilities and outcome probabilities were derived from published medical literature. US 2010 costs were examined from a society perspective using Medicare reimbursement rates and opportunity loss based on published US government data. Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost and utility estimates.
  
  
  RESULTS
  Initial TT alone is more cost-effective than TT with CND, resulting in a cost savings of US $5763 per patient with slightly higher effectiveness per patient (0·03 QALY) for a cost savings of $285 per QALY. Sensitivity analysis shows that TT alone offers no advantage when radioactive iodine (RAI) becomes more detrimental to a patient's state of health, when the incidence of non-neck recurrence increases above 5% in patients undergoing TT alone or decreases below 3·9% in patients undergoing TT with CND or when the rate of permanent hypocalcaemia rises above 4%.
  
  
  CONCLUSIONS
  TT with CND is not a cost-effective strategy in low-risk PTC. Initial TT alone is favourable because of the low complication rates and low recurrence rates associated with the initial surgery. Alternative strategies such as unilateral prophylactic neck dissection require additional study to assess their cost-effectiveness.
authors.affiliation: Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, USA.
authors.forename: Arturo
authors.initials: A
authors.lastname: Garcia
authors.forename: Barnard J A
authors.initials: BJ
authors.lastname: Palmer
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Parks
authors.forename: Terrence H
authors.initials: TH
authors.lastname: Liu
mesh_terms: D000328:Adult; D000465:Algorithms; D002277:Carcinoma / Q000191:economics* / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D002291:Carcinoma, Papillary; D003131:Combined Modality Therapy / Q000191:economics / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D007457:Iodine Radioisotopes / Q000191:economics / Q000627:therapeutic use; D008390:Markov Chains; D037981:Neck Dissection / Q000191:economics* / Q000706:statistics & numerical data; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000517:prevention & control*; D065286:Prophylactic Surgical Procedures / Q000191:economics* / Q000706:statistics & numerical data; D018714:Radiotherapy, Adjuvant / Q000191:economics / Q000706:statistics & numerical data; D012307:Risk Factors; D016019:Survival Analysis; D000077273:Thyroid Cancer, Papillary; D013964:Thyroid Neoplasms / Q000191:economics* / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D013965:Thyroidectomy / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data
chemical_list: D007457:Iodine Radioisotopes