Article Title

Can Thyroid Cancer Overdiagnosis, Overtreatment, and Costs Be Reduced by Following Guidelines?

Publication Date



cancer, clinical practice patterns/guidelines, health care costs/resource use


Background: There is worldwide consensus on an alarming increase in overdiagnosis and overtreatment of papillary thyroid cancer in recent decades, mostly attributable to increased screening with more advanced diagnostic technology (eg, ultrasound, computed tomography and magnetic resonance imaging) detecting small papillary nodules. In 2009, evidence-based guidelines by the American Thyroid Association recommended against routine fine needle aspiration for unsuspicious papillary nodules of < 1 cm. The purpose of this study is to compare the change in the ratio of patients with thyroid cancer to all patients with thyroid nodules before and after the issuance of the 2009 guidelines as well as to provide national health care cost estimates.

Methods: The hypothesis is adherence to evidence-based guidelines targeting inappropriate testing of small nodules, which are highly prevalent in the general population and are mostly benign (~80%), will be effective at reducing overdiagnosis of thyroid cancer without significant harm to patients with malignant nodules (~20%), which can be tested and treated when they are larger. We use the Medical Expenditure Panel Survey (MEPS), which provides annual nationally representative cross-sectional data on respondents’ health service utilization as well as the cost of these services. Binary variables will be used to denote the presence of thyroid nodules and thyroid cancer in adults based on three-digit ICD-9-CM diagnosis condition codes.

Results: MEPS data estimates will be used to compare the difference in the proportion of respondents with thyroid cancer to thyroid nodules before and after the issuance of the 2009 guidelines and measure the cost of thyroid nodules over the recent 10-year period, 2005–2014, by using generalized linear models with a log-link function on total, inpatient, outpatient and prescription medication health care expenditures.

Conclusion: The results of this analysis will contribute additional information to the growing body of evidence on overdiagnosis and overtreatment as well as the financial burden of thyroid cancer in the United States. It highlights the need for further study using detailed medical record data inclusive of nodule size and diagnostic procedures to determine the extent of guideline adherence and whether better adherence would effectively address a substantial portion of the overdiagnosis and overtreatment problem.