title: Cost-effectiveness of FDG-PET/CT for cytologically indeterminate thyroid nodules: a decision analytic approach.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  The model was representative for adult patients with cytologically indeterminate thyroid nodules.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Departments of Radiology and Nuclear Medicine (D.V., W.J.G.O., L.F.d.G.-O.), Health Evidence (E.M.M.A.), Internal Medicine Section of Endocrinology (R.T.N.-M.), Internal Medicine (J.W.A.S.), and Surgery (J.H.W.d.W.), Radboudumc, 6500 HB Nijmegen, The Netherlands.
authors.forename: D
authors.initials: D
authors.lastname: Vriens
authors.forename: E M M
authors.initials: EM
authors.lastname: Adang
authors.forename: R T
authors.initials: RT
authors.lastname: Netea-Maier
authors.forename: J W A
authors.initials: JW
authors.lastname: Smit
authors.forename: J H W
authors.initials: JH
authors.lastname: de Wilt
authors.forename: W J G
authors.initials: WJ
authors.lastname: Oyen
authors.forename: L F
authors.initials: LF
authors.lastname: de Geus-Oei
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D019788:Fluorodeoxyglucose F18; D017048:Health Care Costs; D006801:Humans; D008390:Markov Chains; D017059:Models, Econometric; D064847:Multimodal Imaging / Q000191:economics* / Q000379:methods; D049268:Positron-Emission Tomography / Q000191:economics* / Q000379:methods; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D013964:Thyroid Neoplasms / Q000000981:diagnostic imaging / Q000191:economics; D016606:Thyroid Nodule / Q000000981:diagnostic imaging / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics* / Q000379:methods
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18