• Craig White, Milton C Weinstein, Abbey L Fingeret, Gregory W Randolph, Akira Miyauchi, Yasuhiro Ito, Tiannan Zhan, Ayman Ali, G Scott Gazelle, and Carrie C Lubitz.
• Graduate School of Arts and Sciences, Harvard University, Cambridge, MA.
• Ann. Surg. 2020 Apr 1; 271 (4): 765-773.

ObjectiveTo assess relative clinical and economic performance of the revised American Thyroid Association (ATA) thyroid cancer guidelines compared to current standard of care.BackgroundDiagnosis of thyroid cancer in the United States has tripled whereas mortality has only marginally increased. Most patients present with small papillary carcinomas and have historically received at least a total thyroidectomy as a treatment. In 2015, the ATA released the revised guidelines recommending an option for active surveillance (AS) of small papillary thyroid carcinoma and thyroid lobectomy for larger unifocal tumors.MethodsWe created a Markov microsimulation model to evaluate the performance of the ATA's 2015 guidelines compared to the ATA's 2009 guidelines. We modeled a cohort of simulated patients with demographic and thyroid nodule characteristics representative of those presenting clinically in the United States. Outcome measures include life expectancy, quality-adjusted life years, costs, and frequency of surgical adverse events.ResultsIn our base case analysis, the ATA 2015 strategy dominates the ATA 2009 strategy. The ATA 2015 strategy delivers greater discounted average quality-adjusted life years (13.09 vs 12.43) at a lower discounted average cost ($14,752 vs $20,126). Deaths due to thyroid cancer under the 2015 strategy are higher than the 2009 strategy but this is offset by a reduction in surgical deaths, leading to greater average life expectancy under the ATA 2015 strategy. The optimal strategy is sensitive to patients who experience a greater decrement in quality of life while undergoing AS.ConclusionsThe ATA 2015 Guidelines represent a cost-effective strategy regarding AS and extent of surgery.

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