Prophylactic Central Neck Dissection Increases the Cost of Thyroid Cancer Care

Abstract

Over the past several decades, health care spending has risen faster than any other segment of the United States economy and continues to rise. Media attention has been focused on health care costs since the introduction of the Patient Protection and Affordable Care Act of 2010, which aims to reduce costs of health care while improving outcomes. Physicians are in the best position to determine which treatments are effective and which patients benefit most, and they are more cognizant than ever of the mandate to spend our limited health care dollars wisely. Cost minimization should be the goal of every physician, as long as quality of care does not diminish. The incidence of papillary thyroid cancer (PTC) is increasing in the United States, but thankfully survival is excellent compared with many other cancers. Patients diagnosed when the disease is limited to the thyroid gland are nearly always cured with thyroidectomy. Unfortunately, regional lymph node metastases from PTC are very common, with the majority of patients having at least micrometastatic disease in the central neck at the time of diagnosis. Nodal involvement increases the risk of recurrence, which plays an important role in the long-term management of this disease. While there is no debate about removing clinically apparent lymph node disease at the initial surgery, there is significant debate regarding the utility of performing a prophylactic central lymph node dissection (pCND) as part of the initial thyroidectomy when there is no evidence of lymph node involvement. There has not been a definitive randomized controlled trial to date, and there are strong advocates on both sides of the argument. Proponents claim pCND saves future morbidity of repeat operations without adding much operative risk to the initial operation, while opponents feel it adds operative morbidity without altering long-term outcomes for the majority of patients. Most of the available literature has struggled to address either the risk or the benefit of pCND, and there has been no consensus. Lang et al., in this current issue, aim to answer the question from a costeffectiveness perspective, adding yet another dimension to this debate at a timely moment in national discourse. They report, unsurprisingly, that the initial procedural costs are higher for pCND at the time of initial surgery for node-negative PTC versus performing a simple thyroidectomy alone. The key question is whether that initial investment (and higher costs of more initial complications) saves health care spending in the long term by reducing the rates of reoperations and future complications. Using data from their recent well-done meta-analysis of 14 studies with 3,331 patients, the authors used odds ratios for complications of both initial surgeries, recurrence rates, and the likelihood of radioactive iodine (RAI) treatment to create a mathematical model. This model projected out costs for a hypothetical cohort of 100,000 women with a 1.5-cm papillary thyroid cancer. Using it, they found that pCND is not cost saving and calculated that, over 20 years, the accumulated direct costs of a thyroidectomy with pCND is $3000 more than initially performing a thyroidectomy alone and dealing with recurrences as they arise. In this hypothetical cohort of patients, the higher costs of pCND are mostly attributable to (1) longer operative time and greater complexity of the operation, (2) more initial complications, and (3) higher percentage of postoperative RAI in patients with pCND. Reoperations actually have similar costs in this model, and while fewer This is an editorial to the article available at doi: 10.1245/s10434013-3234-9.