This article is more than 5 years old. Information may no longer be current.
Cost of surveillance may outweigh benefit for low-risk papillary thyroid cancer
Click Here to Manage Email Alerts
Surveillance strategies to detect recurrences in low-risk patients with papillary thyroid cancer are not cost-effective and should be restructured, according to the results of a retrospective analysis.
The cost of surveilling low-risk patients to detect one recurrence was 6.6-times greater than surveillance of intermediate-risk patients and 7.1-times greater than surveillance of high-risk patients, according to the researchers.
Ian Ganly
Thyroid cancer incidence has greatly increased over the last 30 years; however, mortality rates have remained largely stable. The increase has been primarily caused by an upsurge in the diagnosis of subclinical disease due to improved detection methods.
“The increase in diagnoses has corresponded with an increase of patient follow-up,” Ian Ganly, MD, PhD, surgeon in head and neck service at Memorial Sloan Kettering Cancer Center, told HemOnc Today. “Working as a thyroid surgeon, I became increasingly aware of the amount of time spent in my clinic following up with low-risk patients and the volume of investigations being done. Despite all this follow-up, the incidence of recurrence is extremely small, around 2%.”
Ganly and colleagues sought to measure the relative cost-effectiveness of disease surveillance of low-risk patients with papillary thyroid cancer, compared with patients deemed intermediate or high risk based on American Thyroid Association risk categories.
Using an institutional database, researchers identified 2,932 patients who underwent thyroidectomy at Memorial Sloan Kettering Cancer Center between 2000 and 2010. They excluded patients (n = 1,845) who had non-papillary thyroid cancer, a secondary cancer or fewer than 36 months of follow-up.
The final analysis included data from 1,087 patients (median age, 44 years; range, 7-83). Low-risk patients comprised 33.3% of the study cohort (n = 362), intermediate-risk patients comprised 51.6% (n = 561) and high-risk patients comprised 15.1% (n = 164).
The researchers recorded the numbers of postoperative blood tests, imaging scans and biopsies, clinician office visits and recurrence events within the first 36 months of follow-up. They determined costs of surveillance using the CMS Physician Fee Schedule and Clinical Lab Fee Schedule.
In the first 36 months following surgery, recurrences occurred among three patients in the low-risk group (0.8%), 44 patients in the intermediate-risk group (7.8%) and 22 patients in the high-risk group (13.4%).
The cost of surveillance for each detected recurrence in the low-risk group was $147,819, whereas the cost for each detected recurrence was $22,434 in the intermediate-risk group and $20,680 in the high-risk group.
The researchers acknowledged limitations of their study, including the potential for selection bias associated with the retrospective design, as well as the large number of patients excluded from the final analysis. Further, they noted that their surveillance cost estimates may be underestimated, as some included patients underwent additional surveillance procedures at outside institutions.
“Our study is reflective of national and international trends, and therefore suggests we are spending far too much money and resources on a patient group which does not require it,” Ganly said. “Our objective was to increase awareness of this issue and hopefully propel and change in practice, which would entail redirecting resources to patients who really need it. We could spare a lot of physician time, avoid patient anxiety and reduce expenditure by stopping the current surveillance follow-up strategy that is being done globally for low-risk thyroid cancer.” – by Cameron Kelsall
For more information:
Ian Ganly, MD, PhD, can be reached at Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065; email: ganlyi@mskcc.org.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to Top
Colleen Veloski, MD, FACE
This retrospective single-institution study by Wang and colleagues compared the cost of surveillance among patients treated for papillary thyroid cancer at low, intermediate, and high risk of recurrence using American Thyroid Association (ATA) risk categories. Using very conservative estimates of costs associated with follow-up visits, imaging and blood tests performed during the first 36 months after thyroidectomy, the authors determined that the cost to detect one recurrence in low-risk patients ($147,819) was 6 to 7 times greater than the cost for intermediate- ($22,434) and high-risk patients ($20,680). The magnitude of differences persisted in a sensitivity analysis applying higher rates of recurrences and ultrasound usage.
The cost to detect a single recurrence seems out of proportion to the very low risk for recurrence (0.8% in this study), and even lower risk for disease-specific mortality. Moreover, the researchers observe that the true cost of surveillance is likely much higher because since their analysis included only those tests and visits undertaken at their center. The results of this study add to the growing body of evidence supporting diagnosis, treatment and surveillance strategies tailored to behavior of the disease — one size does not fit all.
Similar analyses should be performed at other institutions to confirm the findings, but Wang and colleagues have shown that “watchful waiting” for recurrence is tremendously expensive in low-risk patients. Spending more than $100,000 to detect a single recurrence is difficult to justify given most recurrences of low-risk papillary thyroid cancers do not prove fatal. Increasingly sensitive thyroglobulin assays and ultrasound technology now allow detection of subclinical recurrences that seldom warrant treatment, but often prompt additional interventions, including potentially morbid operations. Watchful waiting has high costs and limited benefit. The time to adopt “watchless waiting” has come; however, both doctors and patients must embrace the changes needed to match surveillance practices to outcomes.
Click Here to Manage Email Alerts