title: A cost-effectiveness comparison between early surgery and non-surgical approach for incidental papillary thyroid microcarcinoma.
abstract: BACKGROUND
  The issue of whether all incidental papillary thyroid microcarcinoma (PTMC) should be managed by early surgery (ES) has been questioned and there is a growing acceptance that a non-surgical approach (NSA) might be more appropriate. We conducted a cost-effectiveness analysis comparing the two strategies in managing incidental PTMC.
  
  
  METHODS
  Our base case was a hypothetical 40-year-old female diagnosed with a unifocal intra-thyroidal 9 mm PTMC. The PTMC was considered suitable for either strategy. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between ES and NSA after 20 years. Outcome probabilities, utilities and costs were derived from the literature. The threshold for cost-effectiveness was set at USD 50,000/quality-adjusted life year (QALY). A further analysis was done for patients < 40 and ≥ 40 years. Sensitivity and threshold analyses were used to examine model uncertainty.
  
  
  RESULTS
  Each patient who adopted NSA over ES cost an extra USD 682.54 but gained an additional 0.260 QALY. NSA was cost saving (i.e. less costly and more effective) up to 16 years from diagnosis and remained cost-effective from 17 years onward. In the sensitivity analysis, NSA remained cost-effective regardless of patient age (< 40 and ≥ 40 years), complications, rates of progression, year cycle and discount rate. In the threshold analysis, none of the scenarios that could have changed the conclusion appeared clinically likely.
  
  
  CONCLUSIONS
  For a selected group of incidental PTMC, adopting NSA was not only cost saving in the initial 16 years but also remained cost effective thereafter. This was irrespective of patient age, complication rate or rate of PTMC progression.
authors.affiliation: Division of Endocrine SurgeryDepartment of Surgery, Queen Mary Hospital, University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, ChinaDepartment of Family Medicine and Primary Care3/F Ap Lei Chau Clinic, University of Hong Kong, 161 Main Street, Ap Lei Chau, Hong Kong, China blang@hku.hk.
authors.forename: Brian Hung-Hin
authors.initials: BH
authors.lastname: Lang
authors.affiliation: Division of Endocrine SurgeryDepartment of Surgery, Queen Mary Hospital, University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, ChinaDepartment of Family Medicine and Primary Care3/F Ap Lei Chau Clinic, University of Hong Kong, 161 Main Street, Ap Lei Chau, Hong Kong, China.
authors.forename: Carlos K H
authors.initials: CK
authors.lastname: Wong
mesh_terms: D000328:Adult; D002291:Carcinoma, Papillary / Q000191:economics* / Q000628:therapy; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D033162:Incidental Findings; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D013964:Thyroid Neoplasms / Q000191:economics* / Q000628:therapy; D013965:Thyroidectomy / Q000191:economics* / Q000379:methods; D057832:Watchful Waiting / Q000191:economics* / Q000379:methods