Routine prophylactic central neck dissection for low-risk papillary thyroid cancer is not cost-effective.

BACKGROUND: The role of routine prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the cost utility of the addition of routine CND in patients with low-risk PTC compared with total thyroidectomy (TT) alone. METHODS: A Markov model for low-risk PTC was constructed with a treatment algorithm based on the American Thyroid Association guidelines for well-differentiated thyroid carcinoma. Utilities and outcome probabilities were derived from published medical literature. US 2010 costs were examined from a society perspective using Medicare reimbursement rates and opportunity loss based on published US government data. Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost and utility estimates. RESULTS: Initial TT alone is more cost-effective than TT with CND, resulting in a cost savings of US $5763 per patient with slightly higher effectiveness per patient (0·03 QALY) for a cost savings of $285 per QALY. Sensitivity analysis shows that TT alone offers no advantage when radioactive iodine (RAI) becomes more detrimental to a patient's state of health, when the incidence of non-neck recurrence increases above 5% in patients undergoing TT alone or decreases below 3·9% in patients undergoing TT with CND or when the rate of permanent hypocalcaemia rises above 4%. CONCLUSIONS: TT with CND is not a cost-effective strategy in low-risk PTC. Initial TT alone is favourable because of the low complication rates and low recurrence rates associated with the initial surgery. Alternative strategies such as unilateral prophylactic neck dissection require additional study to assess their cost-effectiveness.

[Necessity for blood transfusion in head and neck surgery]. / Notwendigkeit der Bluttransfusion bei ausgewählten Operationen im Kopf-Hals-Bereich.

INTRODUCTION: Sometimes, use of blood products is necessary in head and neck surgery, but blood transfusion also entails risks for the patients and causes high costs for the department. Therefore, we examined the surgical procedures in our department and analysed how often transfusion of blood was necessary and which expenses were incurred. METHODS: Of 3989 operations performed in 1989, 187 patients were found to be at an increased risk for blood loss. The costs for blood group analysis (euro 23.16), cross-testing (euro 13.91) and the transfusion itself (euro 70.35) were estimated in each patient. RESULTS: In 1998 more than 60% of the 187 patients had undergone extensive head and neck surgery for advanced squamous cell carcinoma. Only 17 patients (<15%) received nearly 45% of all units of stored blood transfused that year. In patients who had undergone skull base surgery, the probability of receiving blood was 30%. The transfusion-related costs were estimated to be euro 20,000 during the observation period. Potential savings could have been achieved in cross-testing. CONCLUSION: Preparations should be done on an individual basis. Such preparations are sometimes unnecessary even in patients undergoing surgical procedures with a high risk for blood loss.