Are We Following Treatment Guidelines for Papillary Thyroid Carcinoma? Cost Implications: A SEER-Medicare Study

Abstract

Objectives:

The National Comprehensive Cancer Network (NCCN) guidelines are evidence-based management algorithms for papillary thyroid carcinoma (PTC). We sought to determine whether actual practice patterns coincide with these guidelines and whether management outside NCCN guidelines affected Medicare costs.

Methods:

Surveillance, Epidemiology, and End Results (SEER) Medicare linked data were examined to determine treatment patterns for 4,582 patients with PTC from 1988-2007 that met our inclusion criteria. Indications for lobectomy, total thyroidectomy, and postoperative radioactive iodine ablation (RAI) were based on NCCN guidelines, including tumor size, extrathyroidal extension, positive lymph nodes, and aggressive histology. The cost related to PTC treatments was Medicare payments linked directly to each treatment’s claim code.

Results:

Seventy-six percent underwent total thyroidectomy, and 34% underwent thyroid lobectomy. According to NCCN guidelines, 90% received appropriate surgical management. Of patients with aggressive features based on NCCN guidelines, 33.4% should have received RAI. Based on intermediate tumor size, positive lymph nodes, and aggressive histology, 37.7% would have benefited from RAI. Of patients with tumors less than 1 cm and no ETE, 42% should not have received postoperative RAI. Patients undergoing thyroid lobectomy cost Medicare $50,175, while total thyroidectomy cost $54,455 (P = 0.293). Postoperative RAI cost Medicare approximately $47,652 yearly.

Conclusions:

Ninety percent of patients received appropriate surgical management. However, 40% of patients did not receive appropriate postoperative RAI management. As the incidence of PTC rises, the use of evidence-based guidelines can reduce cost attributed to Medicare.