Division of General Surgery, Department of Surgery, Section of Endocrine Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Department of Surgery, Section of Endocrine Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Ann Surg Oncol. 2018 Apr;25(4):949-956. doi: 10.1245/s10434-018-6356-2. Epub 2018 Feb 7.
Some surgeons perform flexible fiberoptic laryngoscopy (FFL) in all patients prior to thyroid cancer operations. Given the low likelihood of recurrent laryngeal nerve (RLN) or aerodigestive invasion in clinically low-risk thyroid cancers, the value of routine FFL in this group is controversial. We hypothesized that routine preoperative FFL would not be cost effective in low-risk differentiated thyroid cancer (DTC).
A decision model was constructed comparing preoperative FFL versus surgery without FFL in a clinical stage T2 N0 DTC patient without voice symptoms. Total thyroidectomy and definitive hemithyroidectomy were both modeled as possible initial surgical approaches. Outcome probabilities and their corresponding utilities were estimated via literature review, and costs were estimated using Medicare reimbursement data. Sensitivity analysis was conducted to examine the uncertainty of cost, probability, and utility estimates in the model.
When the initial surgical strategy was total thyroidectomy, routine preoperative FFL produced an incremental cost of $183 and an incremental effectiveness of 0.000126 quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio (ICER) for routine FFL prior to total thyroidectomy was $1.45 million/QALY, exceeding the $100,000/QALY threshold for cost effectiveness. Routine FFL became cost effective if the preoperative probability of asymptomatic vocal cord paralysis increased from 1.0% to 4.9%, or if the cost of preoperative FFL decreased from $128 to $27. Changing the extent of initial surgery to hemithyroidectomy produced a higher ICER for routine FFL of $1.7 million/QALY.
Routine preoperative FFL is not cost effective in asymptomatic patients with sonographically low-risk DTC, regardless of the initial planned extent of surgery.
一些外科医生在进行甲状腺癌手术前对所有患者进行软性纤维喉镜（FFL）检查。鉴于临床低风险甲状腺癌中喉返神经（RLN）或气消化道侵犯的可能性较低，该组常规 FFL 的价值存在争议。我们假设在低风险分化型甲状腺癌（DTC）中，常规术前 FFL 没有成本效益。
构建了一个决策模型，比较了无术前 FFL 的临床 T2 N0 DTC 患者（无症状）和术前 FFL 的情况。总甲状腺切除术和明确的半甲状腺切除术均被建模为可能的初始手术方法。通过文献回顾估计总生存期概率及其相应效用，使用医疗保险报销数据估计成本。进行敏感性分析以检查模型中成本、概率和效用估计的不确定性。
当初始手术策略为全甲状腺切除术时，常规术前 FFL 产生 183 美元的增量成本和 0.000126 质量调整生命年（QALY）的增量效果。全甲状腺切除术前行常规 FFL 的增量成本效果比（ICER）为 145 万美元/QALY，超过 10 万美元/QALY 的成本效益阈值。如果术前无症状声带麻痹的概率从 1.0%增加到 4.9%，或者如果术前 FFL 的成本从 128 美元降低到 27 美元，常规 FFL 就具有成本效益。将初始手术范围改为半甲状腺切除术会导致常规 FFL 的更高 ICER，为 170 万美元/QALY。
对于超声低风险 DTC 且无症状的患者，常规术前 FFL 没有成本效益，无论初始计划手术范围如何。
