title: Lobectomy is a more Cost-Effective Option than Total Thyroidectomy for 1 to 4 cm Papillary Thyroid Carcinoma that do not Possess Clinically Recognizable High-Risk Features.
abstract: Although lobectomy is a viable alternative to total thyroidectomy (TT) in low-risk 1 to 4 cm papillary thyroid carcinoma (PTC), lobectomy is associated with higher locoregional recurrence risk and need for completion TT upon discovery of a previously unrecognized histologic high-risk feature (HRF). The present study evaluated long-term cost-effectiveness between lobectomy and TT.
  
  
  
  Our base case was a hypothetical female cohort aged 40 years with a low-risk 2.5 cm PTC. A Markov decision tree model was constructed to compare cost-effectiveness between lobectomy and TT after 25 years. Patients with an unrecognized HRF (including aggressive histology, microscopic extrathyroidal extension, lymphovascular invasion, positive resection margin, nodal metastasis >5 mm, and multifocality) underwent completion TT after lobectomy. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000/quality-adjusted life-year (QALY). Sensitivity and threshold analyses were used to examine model uncertainty.
  
  
  
  After 25 years, each patient who underwent lobectomy instead of TT cost an extra US$772.08 but gained an additional 0.300 QALY. The incremental cost-effectiveness ratio was US$2577.65/QALY. In the sensitivity analysis, the lobectomy arm began to become cost-effective only after 3 years. Despite varying the reported prevalence of clinically unrecognized HRFs, complication from surgical procedures, annualized recurrence rates, unit cost of surgical procedure or complication, and utility score, lobectomy remained more cost-effective than TT.
  
  
  
  Despite the higher locoregional recurrence risk and having almost half of the patients undergoing completion TT after lobectomy upon discovery of a previously unrecognized HRF, initial lobectomy was a more cost-effective long-term option than initial TT for 1 to 4 cm PTCs without clinically recognized HRFs.
authors.affiliation: Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China. blang@hku.hk.
authors.forename: Brian Hung-Hin
authors.identifier: 0000-0002-9362-0086
authors.initials: BH
authors.lastname: Lang
authors.affiliation: Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong.
authors.forename: Carlos K H
authors.identifier: 0000-0002-6895-6071
authors.initials: CKH
authors.lastname: Wong
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002291:Carcinoma, Papillary / Q000191:economics / Q000556:secondary / Q000601:surgery*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008390:Markov Chains; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000191:economics / Q000601:surgery*; D018365:Neoplasm, Residual; D019057:Quality-Adjusted Life Years; D012086:Reoperation; D012307:Risk Factors; D013964:Thyroid Neoplasms / Q000191:economics / Q000473:pathology / Q000601:surgery*; D013965:Thyroidectomy / Q000191:economics* / Q000379:methods*; D013997:Time Factors; D047368:Tumor Burden