Effect of malignancy rates on cost-effectiveness of routine gene expression classifier testing for indeterminate thyroid nodules

Wu, James X.; Lam, Raymond; Levin, Mary; Rao, Jianyu; Sullivan, Peggy; Yeh, Michael W.

doi:10.1016/j.surg.2015.05.035

Cited by 50 publications

(44 citation statements)

References 22 publications

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“…Previous studies have established that Afirma® lowers costs, with the primary benefit being a reduction in surgery for nodules that are ultimately benign. 6 However, cost modeling for Afirma® was limited to a short follow up period that failed to consider the long-term costs of surveillance for thyroid nodules. 7 The purpose of this study is to compare the cost-effectiveness of molecular testing (Affirma®) versus diagnostic lobectomy for indeterminate thyroid nodules.…”

Section: Introductionmentioning

confidence: 99%

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance

Balentine

Vanness

2018

Surgery

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Section: Introductionmentioning

confidence: 99%

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance

Balentine

Vanness

2018

Surgery

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“…The initial study reported a negative (benign) predictive value of 85–95% depending on the exact cytology (19). However, this gene expression classifier is expensive, and the cost-effectiveness depends on the institutional rates of malignancy for each cytologic category (21). Nonetheless, this rule-out strategy may prevent an oncologically excessive extent of initial surgery as we found in this study.…”

Section: Discussionmentioning

confidence: 99%

“…More recently, several molecular tests have been developed to classify ITN as either benign or malignant. These tests, while accurate in some settings, also carry a significant expense (19–21). …”

Section: Introductionmentioning

confidence: 99%

Gauging The Extent Of Thyroidectomy For Indeterminate Thyroid Nodules: An Oncologic Perspective

et al. 2017

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Introduction Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITN), present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN. Methods We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or over-treatment at initial operation. Results There were 639 patients with ITN. The median age was 52 (range 18 – 93), 78.4% were female, and final pathology revealed a cancer > 1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hurthle cell neoplasm (20.2%). CT or initial oncologic under-treatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with total thyroidectomy for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with total thyroidectomy in benign disease (OR 2.1, 95% C.I. 1.0 – 4.5, p = 0.05). Age >45 predicted correct initial use of DL (OR 2.6, 95% C.I. 1.2 – 5.7, p = 0.02). Suspicious for PTC (OR 5.7, 95% C.I. 2.1 – 15.3, p<0.01) and frozen section (OR 9.7, 95% C.I. 2.5 – 38.6, p<0.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). Total thyroidectomy for benign final pathology occurred most frequently in patients with a Hurthle cell neoplasm (24.8%). Conclusions In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to preoperatively identify both benign and malignant disease can assist in the complex decision-making to gauge the proper extent of initial surgery for ITN.

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“…Designed to lower patient morbidity and the cost of care by decreasing unnecessary surgery for benign thyroid nodules, the majority of studies have demonstrated the utility of the Afirma GEC, whereas others have questioned the actual cost‐benefit analysis of reflexively incorporating it into clinical care . Behind some of the various interpretations of the performance of the GEC are the inherent differences in agreement among thyroid cytopathologists .…”

Section: The Development Of Thyroid Molecular Testingmentioning

confidence: 99%

“…TERT mutation is an independent predictor of disease‐free survival . The combination of a TERT mutation and a BRAF or Ras mutation within the same tumor is associated with a high risk of structural disease recurrence and mortality . However, these are rare mutations and often clinically present with advanced and aggressive disease; thus, the current state of thyroid molecular testing does not add significantly to prognosis and treatment decisions beyond traditional pathologic and summary TNM staging .…”

Section: Comprehensive Tests To Improve Overall Accuracymentioning

confidence: 99%

Molecular testing for thyroid nodules: Review and current state

Roth

Witt

Steward

2017

Cancer

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Thyroid nodules affect nearly two-thirds of the world population. Fine-needle biopsy with cytologic evaluation remains the diagnostic test of choice to distinguish benign from malignant thyroid nodules yet fails to discriminate as benign or malignant in up to one-third of cases. This review discusses the limitation of current cytopathologic evaluation, the development of thyroid molecular testing, and the strengths and limitations of commercially available tests. Initial cytomolecular testing sought to identify specific gene mutations associated with thyroid cancer. Although the presence of a mutation was strongly associated with cancer, the likelihood of identifying a mutation was low; therefore, the test had low sensitivity. Subsequent tests developed have sought to improve the accuracy of cytomolecular testing for thyroid fine-needle aspirations, both to reassure patients and providers when malignancy may be absent and to confirm the malignancy when present. The development of cytomolecular testing for thyroid nodules has informed and improved current understanding of thyroid nodule formation and progression. When used appropriately and with clear understanding of the advantages and disadvantages, cytomolecular testing has the potential to improve patient care in the setting of indeterminate thyroid nodules by helping to guide both the need for and the extent of thyroid surgery. Cancer 2018;124:888-98. © 2017 American Cancer Society.

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Effect of malignancy rates on cost-effectiveness of routine gene expression classifier testing for indeterminate thyroid nodules

Cited by 50 publications

References 22 publications

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance

Gauging The Extent Of Thyroidectomy For Indeterminate Thyroid Nodules: An Oncologic Perspective

Molecular testing for thyroid nodules: Review and current state

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