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.

Molecular Testing of Thyroid Nodules: A Review of Current Available Tests for Fine-Needle Aspiration Specimens

“…OTHER ISSUES RELATED TO THYROID MOLECULAR TESTS Yip et al 47 reported cost savings if molecular studies were performed and the costs were less than $870. They concluded that molecular testing of cytologically indeterminate FNA can allow cost savings and improve patient care by providing an indication for optimal initial surgical management with total thyroidectomy when molecular testing is positive.…”

Molecular markers in the diagnosis of thyroid nodules

“…High PPV tests with inadequate NPV performance can "rule in" cancer and perhaps alter the extent of surgery, but they cannot "rule out" cancer, so surgery cannot be avoided. Currently, the strongest argument for their use is where the decision has been made for surgery, but the extent of surgery may be determined by the test result (38,40). Based on the potential ability to prevent completion thyroidectomies by performing an initial total thyroidectomy in patients with indeterminate cytology when a DNA mutation is present, Yip and cols.…”

“…Based on the potential ability to prevent completion thyroidectomies by performing an initial total thyroidectomy in patients with indeterminate cytology when a DNA mutation is present, Yip and cols. reported the possibility of cost savings by mutation panel testing in a decision-tree model (40). Still, no prospective study using patients has assessed the clinical utility of DNA mutation panels on thyroid surgery.…”

Five Top Stories in Thyroid Pathology

“…41,134 Recently, the utility of molecular testing has been extensively reviewed by different groups to aid in the appropriate management of patients in this category. 41,152,153 The goal is to prevent unnecessary resection of benign thyroid lesions by exploiting an ancillary test with a high NPV and to obviate the need for a second surgery (completion thyroidectomy) by implementing a test with high positive predictive value (PPV) 154,155 ( Figure 9). 156 Molecular testing using panels targeting different alterations is now available and includes BRAF and RAS gene point mutations and RET/PTC and PAX8/PPARG gene rearrangements.…”

“…161 This makes the test a valuable tool in ruling out malignancy and therefore preventing unnecessary surgeries in cases where a more conservative approach can be used. 155,159 Cost-efficacy analyses showed that molecular testing followed by total thyroidectomy ($16 414, including the added cost of molecular testing) costs less than diagnostic lobectomy followed by completion total thyroidectomy ($19 638). 153 Quest Diagnostics (Chantilly, Virginia) also provides a thyroid cancer mutation panel assay on needle wash specimens fixed in CytoLyt (Hologic Inc, Bedford, Massachusetts) or formalin, as well as formalin-fixed paraffinembedded samples.…”