Cost impact of molecular testing for indeterminate thyroid nodule fine-needle aspiration biopsies

Abstract

Introduction: Molecular testing of fine-needle aspiration (FNA) results helps diagnose thyroid cancer, although the additional cost of this adjunct has not been studied. We hypothesized that FNA molecular testing of two indeterminate categories (follicular lesion of undetermined significance and follicular/Hürthle cell neoplasm) can be cost saving.

Methods: For a hypothetical group of euthyroid patients with a 1-cm or larger solitary thyroid nodule, a decision-tree model was constructed to compare the estimated costs of initial evaluation according to the current American Thyroid Association guidelines, either with molecular testing (MT) or without [standard of care (StC)]. Model endpoints were either benign FNA results or definitive histological diagnosis.

Results: Molecular testing added $104 per patient to the overall cost of nodule evaluation (StC $578 vs. MT $682). In this distributed cost model, MT was associated with a decrease in the number of diagnostic lobectomies (9.7% vs. StC 11.6%), whereas initial total thyroidectomy was more frequent (18.2% vs. StC 16.1%). Although MT use added a diagnostic cost of $5031 to each additional indicated total thyroidectomy ($11,383), the cumulative cost was still less than the comparable cost of performing lobectomy ($7684) followed by completion thyroidectomy ($11,954) in the StC pathway, when indicated by histological results. In sensitivity analysis, savings were demonstrated if molecular testing cost was less than $870.

Conclusions: Molecular testing of cytologically indeterminate FNA results is cost saving predominantly because of reduction in two-stage thyroidectomy. Appropriate use of emerging molecular testing techniques may thus help optimize patient care, improve resource use, and avoid unnecessary operation.

Fig. 1.

Decision-tree structure for the clinical course of patients referred with a thyroid nodule. HCN, Hürthle cell neoplasm; Lobe, lobectomy; ND, nondiagnostic; Susp, suspicious.

Fig. 2.

One-way sensitivity analysis showing that the cost of the marker panel must be greater than $870 before the total diagnostic costs associated with each avoided lobectomy increases above the willingness-to-pay threshold ($7684).

Fig. 3.

One-way sensitivity analysis showing that the cost of the marker panel must be greater than $1000 before the total diagnostic costs associated with each additional TT in the MT pathway increases beyond the willingness-to-pay threshold ($7800).