Development of a new head and neck cancer-specific comorbidity index

BACKGROUND: Most patients with head and neck squamous cell carcinoma are older and may have coexistent or comorbid diseases. OBJECTIVES: To determine the prognostic impact of individual comorbid conditions in patients with head and neck cancer, to combine the individual comorbid conditions to form a new a head and neck-specific comorbidity instrument, and to compare it with the Modified Kaplan-Feinstein Index to determine if the new disease-specific instrument offers any improvement in survival prediction over a general comorbidity index. DESIGN: Retrospective review of medical records. POPULATION: The study population comprised 1153 patients with biopsy-proven, newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, or larynx. RESULTS: Seven comorbid conditions (congestive heart disease, cardiac arrhythmia, peripheral vascular disease, pulmonary disease, renal disease, cancer controlled, and cancer uncontrolled) were significantly related to survival. These comorbid conditions were assigned integer weights to reflect their relative prognostic importance and combined to create the new Washington University Head and Neck Comorbidity Index (WUHNCI). Survival was significantly related to levels of comorbidity severity as defined by the WUHNCI. The WUHNCI predicted survival better than the Modified Kaplan-Feinstein Index despite containing far fewer ailments. CONCLUSIONS: Comorbidity is an important feature of the patient with head and neck cancer. The WUHNCI can be used for retrospective review or prospective outcomes research.     

Age as a prognostic factor for complications of major head and neck surgery

OBJECTIVE: To determine if age alone is a prognostic indicator of surgical outcomes for major head and neck procedures. DESIGN: Retrospective cohort study over a 4-year period. SETTING: Academic referral center, institutional practice, hospitalized care. PATIENTS: Included in this study were patients who had undergone ablative, reconstructive, and other major surgical procedures of the head and neck, including neck dissection, laryngectomy, maxillectomy, thyroidectomy with lymphadenectomy, and composite resection of the oral cavity with reconstruction, for both malignant and benign disease. MAIN OUTCOME MEASURES: Patient data and intraoperative and postoperative course factors were recorded. Comorbidity was graded using an Adult Comorbidity Evaluation 27 test, Charlson Comorbidity Index, and American Society of Anesthesiology score. Postoperative complications were dichotomized, and multiple logistic regression was used for data analysis. RESULTS: Medical chart review identified 157 cases. Analysis of data revealed that time under general anesthesia was the only factor consistently related to complications (P<.006), and it was the only factor consistently related to length of stay (P<.001). Analysis of major complications (6% incidence) as an outcome using univariate analysis resulted in a strong positive correlation with both comorbidity indexes: Adult Comorbidity Evaluation 27 (P = .002) and Charlson Comorbidity Index (P = .005). Multiple logistic regression showed no significant relationship between age 70 years or older (20% of patients) and either complications or hospital length of stay. CONCLUSIONS: Patient's age alone is not a prognostic indicator of surgical outcome for major head and neck procedures. However, comorbidity is an important predictive factor for postoperative complications in any age group. Time under general anesthesia showed a statistically significant relationship with complication rate and hospital length of stay in multivariate analyses. Consequently, prevention of complications should focus on optimizing preoperative comorbid conditions.     

The economic cost of squamous cell cancer of the head and neck: findings from linked SEER-Medicare data

OBJECTIVE: To evaluate the excess mortality, resource use, and costs associated with squamous cell carcinoma of the head and neck (SCCHN) among elderly Medicare beneficiaries. DESIGN: Retrospective cohort analysis using data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute and Medicare claims. SUBJECTS: Study cohorts included patients aged 65 years and older who were newly diagnosed as having SCCHN in a SEER registry between 1991 and 1993 (N = 4536) and controls matched 1:1 by age and sex. Patients were followed up for 5 years or until death, whichever occurred first. RESULTS: Initial treatment was primarily surgery and/or radiation among patients with early-stage SCCHN, with only modest use of chemotherapy. Patients with SCCHN had significantly (P<.001) higher 5-year mortality (64% vs 25%) and health care costs than controls. Average Medicare payments (1998 US dollars) among patients with SCCHN were $25 542 higher than those of matched comparison patients (P<.001), with monthly payments 3 times as high ($1428 vs $446). Patients diagnosed as having advanced SCCHN had shorter survival times (5-year mortality, 85%, 75%, 47%, and 35% among patients diagnosed as having distant, regional, local, and in situ cancer, respectively) and higher costs (average total Medicare payments, $53 741, $58 387, $42 698, and $37 434, respectively). CONCLUSION: These results suggest that the health economic burden of SCCHN is substantial, with costs that are comparable with or higher than those of other solid tumors.     

Age-adjusted Charlson Comorbidity Index predicts prognosis of laryngopharyngeal cancer treated with radiation therapy

Objectives: To examine the ability of comorbidity indices to predict the prognosis of laryngopharyngeal cancer and their association with treatment modalities.

Methods: This retrospective study included 198 patients with laryngeal, hypopharyngeal, and oropharyngeal cancers. The effect of comorbidity indices on overall survival between surgery and (chemo)-radiation therapy ((C)RT) groups was analyzed. The cumulative incidence rates for cancer mortality and other mortalities according to the age-adjusted Charlson Comorbidity Index (ACCI) and Charlson Comorbidity Index (CCI) were compared.

Results: Univariate survival analyses showed a significant association between the ACCI and overall survival in the (C)RT group, but not in the surgery group. The association between the CCI and overall survival was not significant in either group. In multivariate analyses, a high ACCI score was an independent prognostic factor in the (C)RT group (HR 2.89, 95% confidence interval (CI) 1.28–6.49), but not in the surgery group (HR 1.39, 95%CI 0.27–5.43). The higher ACCI group had increased mortality from other causes compared with the lower ACCI group (5-year cumulative incidence, 8.5% and 17.8%, respectively, p?=?.003).

Conclusion: The ACCI was a better prognostic factor than the CCI. Surgery may be more beneficial than radiation for patients with a high ACCI.     

Effect of comorbidity on quality of life and treatment selection in patients with squamous cell carcinoma of the head and neck

OBJECTIVES: Comorbidity is significantly associated with diminished survival and quality of life (QOL) after treatment of head and neck squamous cell carcinoma (HNSCC). We sought to determine whether comorbidity influenced pretreatment QOL scores and treatment selection in patients with HNSCC. METHODS: The medical records of all patients diagnosed with HNSCC who participated in pretreatment QOL analysis over a 15-month period were retrospectively reviewed. Patients with a history of prior treatment for head and neck cancer, unresectable, or distant metastatic disease were excluded. The University of Washington (UW) QOL questionnaire, Performance Status Scale (PSS), and Karnofsky score were used to measure pretreatment QOL. Comorbidity was graded using the Modified Medical Comorbidity Index. RESULTS: Of 75 patients who met study criteria, 33 underwent primary surgical therapy, and 42 underwent nonoperative (radiation or chemoradiation) therapy. Treatment groups did not differ with respect to patient demographics, UW QOL scores, PSS scores, Karnofsky score, or comorbidity. Treatment groups differed significantly by disease stage and primary site. Patients with advanced stage disease (III/IV) or oropharyngeal primary tumors were more likely to undergo nonoperative treatment, compared with patients with early stage disease (I/II) or oral cavity primary tumors (P < .005). No significant association was found between comorbidity and pretreatment QOL scores. CONCLUSIONS: Comorbidity was not significantly associated with treatment selection or pretreatment QOL scores in patients with HNSCC. Location of the primary tumor and disease stage were significantly associated with treatment selection. Further studies are required to determine the effect of comorbidity on patient and tumor responses to treatment.     

The impact of comorbidity and age on survival with laryngeal cancer.

Previous studies have evaluated the effects of comorbidity on survival in patients with cancer. We applied the Charlson comorbidity index (CCI) to a cohort of patients with laryngeal cancer to validate its use and to assess the prognostic impact of age. Our study population consisted of 152 patients with laryngeal cancer who were seen over a 10-year period. Patients were assigned CCI scores and were categorized into low- and high-grade comorbidity groups for comparison. Age adjustments were performed by adding 1 point to the Charlson score for each decade over the median age. Low- vs. high-grade comorbidity was a valid predictor of survival independent of TNM (tumor, nodes, and metastases) stage. Low-grade comorbidity was present in 126 patients; their median survival was 41 months. High-grade comorbidity was present in 26 patients; their median survival was 8 months (p = 0.0002). The addition of the age factor to the CCI did not improve our prognostic ability. There was no difference in CCI groups with respect to tobacco and alcohol use, gender, treatment modality, or mean time to recurrence. The incidence and severity of complications were also similar in the two groups. We conclude that the CCI is a strong predictor of survival in patients with laryngeal cancer. The confounding effects of comorbidity should be considered in the TNM staging of laryngeal cancer to improve our prognostic ability. Further investigations are necessary to assess the validity of this index in patients with other head and neck cancers.     

Elderly patients with head and neck cancer: the influence of comorbidity on choice of therapy, complication rate, and survival

PURPOSE OF REVIEW: Comorbidity may be an important reason for head and neck surgeons to treat elderly patients less intensively. This article provides an overview of the influence of age and comorbidity on choice of therapy, postoperative complications, and survival. RECENT FINDINGS: Several retrospective studies show that elderly patients can undergo surgery if they do not have severe comorbid disorders. Severe comorbidity influences the rate of postoperative complications, and the higher complication rate in older patients reported in some studies is probably due to a higher level of comorbidity. Comorbidity also affects the survival of cancer patients, but several studies have failed to detect a relation between age and survival after correction for comorbidity. Thus, although severe comorbidity may influence the choice of treatment, patient age as such should not be a reason to exclude patients from intensive therapy. SUMMARY: If severe comorbidity is not present, elderly patients should receive standard treatment for head and neck cancer. Treatment choice should be based on medical findings and patient preference, not on chronologic age.     

Chemoradiation for Metastatic SCCA: Role of Comorbidity

Objectives A previous study of 371 patients with extracapsular spread (ECS) of cervical metastases from squamous cell carcinoma (SCCA) of the head and neck revealed a survival advantage for patients treated with adjuvant chemoradiation, compared with those treated with surgery and radiation or surgery alone. While all patients in the study were offered adjuvant chemotherapy, only 35% selected this option. Comorbidity was identified as a reason for declining chemotherapy. Recently, Piccirillo demonstrated that the Modified Medical Comorbidity Index (MMCI) is a valid instrument to classify and quantify severity of comorbidity. We applied this instrument to previously reported patients with ECS to determine 1) how comorbidity affected treatment selection, 2) whether the survival advantage of adjuvant chemoradiation persisted after controlling for comorbidity, and 3) the impact of comorbidity on outcome. Study Design This was a nonrandomized, retrospective study. Methods Patients in the initial study underwent resection of the primary tumor and neck dissection. Eligible patients elected to receive chemoradiation, radiation, or no further treatment. Comorbidity scores were assigned according to the MMCI. Data were analyzed according to disease‐specific survival and overall survival. Results The study population consisted of 330 patients. More severe comorbidity was related to higher overall mortality rates after controlling for treatment. Adjuvant chemoradiation resulted in improved disease‐specific and overall survival compared with adjuvant radiation after adjusting for severity of comorbidity. Conclusions These results substantiate the benefits of adjuvant chemoradiation for patients with SCCA of the head and neck. Furthermore, these results reinforce the importance of comorbidity as a prognostic indicator for this population of patients.     

Comorbidity in nasopharyngeal carcinoma: a preliminary communication on the prevalence,descriptive distribution and impact on outcome

Objectives: Comorbidity has been shown to be a determinant in treatment selection and survival in squamous cell cancer of the head and neck at various subsites. The objective of this study is to analyse the effect of comorbidity burden on outcome of nasopharyngeal cancer using the Adult Comorbidity Evaluation‐27 (ACE‐27) instrument. Design: Retrospective analysis. Setting: Tertiary care centres. Participants: This study included 59 patients diagnosed with nasopharyngeal carcinoma between 1989–2003 in the North‐East of England. Exclusion criteria included non‐squamous neoplasms of the nasopharynx. Comorbidity was assessed retrospectively from the notes using standard validated techniques described earlier. Tumour, treatment and survival data were obtained from prospective databases. Data was analysed using SPSS for Windows. Main outcome measures: Comorbidity and outcome of treatment. Results: Comorbid burden was evident in 44% of patients, with moderate or severe comorbidity in 19%. The cardiovascular system was the most commonly affected system (27%). Cox's proportional hazard model showed age and stage of tumour to have an impact on disease specific survival. Comorbidity was not seen to predict the outcome independent of other factors. The sample size of this study is powered to detect only medium to large effects. We estimate that 614 subjects will be needed to detect a correlation coefficient of 0.1 with 80% power, assuming a type 1 error rate of 5%. Conclusion: This study shows for the first time that the comorbidity burden seen in nasopharyngeal cancer does not affect prognosis independent of the TNM staging.     

Measuring comorbidity in patients with head and neck cancer

BACKGROUND: Comorbidities are diseases or conditions that coexist with a disease of interest. The importance of comorbidities is that they can alter treatment decisions, change resource utilization, and confound the results of survival analysis. OBJECTIVE: The objective of this study was to determine the best comorbidity index to use in survival analysis of patients with squamous cell carcinoma of the head and neck. METHOD: Four validated indexes, with very different methodologies (i.e., the Charlson Index, the Cumulative Illness Rating Scale, the Kaplan-Feinstein Classification, the Index of Co-existent Disease), were tested using data from 379 unselected consecutive patients with complete 3-year follow-up from the Kingston Regional Cancer Center. Kaplan-Meier analysis and Cox Proportional Hazards Regression were used to stratify patients into three levels of increasing severity of comorbidity for each index. The Proportion of Variance Explained and Receiver Operating Characteristics curves were used to compare the performance of the indexes. CONCLUSION: The Kaplan-Feinstein Classification was the most successful in stratifying patients in this population.     

Applicability of the adult comorbidity evaluation - 27 and the Charlson indexes to assess comorbidity by notes extraction in a cohort of United Kingdom patients with head and neck cancer: a retrospective study

The term comorbidity stands for disease processes that co-exist and are not related to the index disease being studied. Comorbidity in cancer has been shown to be a major determinant in treatment selection and survival. Patients with head and neck cancer can have significant comorbidity owing to the high incidence of tobacco and alcohol abuse. No studies to date have addressed this problem in head and neck cancer patients in the United Kingdom. The applicability of the adult comorbidity evaluation - 27 index (ACE-27) and the Charlson index (CI) to assess the comorbidity burden by retrospective notes review is studied here. Retrospective data collection and completion of a comorbidity index in a United Kingdom setting is feasible. We conclude that the pre-assessment visit is a useful time to record comorbidity and as a significant amount of information required for grading relates to historical items, this is best done using a self-administered patient questionnaire.     

Cost-effectiveness of two types of dysphagia care in head and neck cancer: a preliminary report

We conducted a prospective, preliminary study to compare the cost-effectiveness of two different instrument-based techniques for diagnosing and managing dysphagia in 30 consecutive hospitalized patients with head and neck cancer. The two techniques are videofluoroscopy via modified barium swallow (MBS) and videoendoscopy via flexible endoscopic evaluation of swallowing with sensory testing (FEESST). Medicare was the primary insurer of all patients. Fifteen of these patients had their dysphagia diagnosed and managed by MBS and the other 15 by FEESST. Cost-effectiveness was assessed by determining the average Medicare reimbursement for each procedure. We found that the mean reimbursements were $451.01 (+/- $50.55) for MBS and $321.23 (+/- $3.01) for FEESST. The mean reimbursement for FEESST was significantly lower than that for MBS (p < 0.0001; Mann-Whitney U test). We conclude that FEESST appears to be more cost-effective than MBS for the inpatient management of dysphagia in patients with head and neck cancer.     

General health measures and long-term survival in patients with head and neck cancer

OBJECTIVE: To determine whether a self-reported, subjective general health assessment tool can provide prognostic information about survival in patients with head and neck cancer. DESIGN: Prospective observational cohort study. SETTING: Tertiary care center. PATIENTS: Five hundred seventy-one patients with squamous cell carcinoma of the upper aerodigestive tract who were enrolled in the institution's longitudinal Outcomes Assessment Project between January 1, 1995, and November 30, 2004. MAIN OUTCOME MEASURES: Actuarial 5-year observed and disease-specific survival. RESULTS: The physical component summary obtained from the SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey) was significantly associated with ACE-27 (Adult Comorbidity Evaluation-27) comorbidity ratings. The mental component summary was not associated with ACE-27 scores or survival. Although the comorbidity rating was an independent predictor of observed survival (P = .002) only, the physical component summary was independently predictive of both observed (P<.001) and disease-specific (P = .001) survival. These associations continued to be independently significant when site and stage were included in the analysis (P = .003, P<.001, and P = .004, respectively). CONCLUSION: The physical component summary generated by the SF-36, a self-reported, subjective measure of general physical health, is predictive of both observed and disease-specific survival.     

Comorbidity as a major risk factor for mortality and complications in head and neck surgery

OBJECTIVE: To describe the impact of comorbidity on complications of surgery and mortality in patients with head and neck squamous cell carcinoma (HNSCC). DESIGN: A total of 120 consecutive patients with HNSCC, treated surgically between January 1999 and December 2001, were included. The Adult Comorbidity Evaluation 27 index (ACE-27) and the American Society of Anesthesiologists (ASA) risk classification system were used to describe comorbidity. Major complications were defined and scored by review of the medical records. Univariate and multivariate analyses were performed to determine the impact of 17 clinical variables, including the ACE-27 grade and the ASA class. RESULTS: Twenty-five patients (21.4%) had 1 or more major complications. In the univariate analysis, ACE-27 grade, ASA class, T stage, surgical procedure used for the primary tumor, type of neck dissection, and duration of anesthesia had a significant relation with major complications. In the multivariate analysis, duration of anesthesia and comorbidity reflected by the ACE-27 grade or the ASA class remained significant. The odds ratios (95% confidence intervals) associated with ACE-27 grades of 1 and 2 were 1.9 (0.6-6.8) and 4.6 (1.4-15.2), respectively; with ASA classes 2 and 3, 2.0 (0.5-8.2) and 10.0 (2.2-45.1), respectively. Duration of anesthesia longer than 360 minutes was characterized by an odds ratio of 7.8 (1.8-12.9). CONCLUSIONS: Duration of anesthesia and comorbidity reflected by the ACE-27 grade and the ASA class are important predictors of major complications in head and neck surgery. Optimizing the general condition of patients with HNSCC might reduce morbidity and treatment-related costs.     

Comorbidity measurement in patients with laryngeal squamous cell carcinoma

INTRODUCTION: The evaluation of a cancer patient can be affected by many factors. Cancer patients often have other diseases or medical conditions in addition to their cancer. These conditions are referred to as comorbidities. They can influence the treatment option, the rate of complications, the outcome, and can confound the survival analysis. OBJECTIVE: It was the aim of this study to measure comorbidities in patients with laryngeal squamous cell carcinoma. PATIENTS AND METHODS: Ninety adult patients treated for newly diagnosed laryngeal squamous cell carcinoma were studied. We measured comorbid illness applying the following validated scales: the Cumulative Illness Rating Scale (CIRS), the Kaplan-Feinstein Classification (KFC), the Charlson index, the Index of Coexistent Disease (ICED), the Adult Comorbidity Evaluation-27 (ACE-27), the Alcohol-Tobacco-Related Comorbidities Index (ATC), and the Washington University Head and Neck Comorbidity Index (WUHNCI). Survival analysis was performed using the Kaplan-Meier method (with the log-rank test value being used to compare groups). The Cox proportional hazards model was chosen to identify independent prognostic factors. RESULTS: The mean age was 62.3 years. The majority of patients (36.7%) had early tumors. Forty patients were treated by surgery only, while the remaining 49 patients also received postoperative radiation therapy. Only 5 patients (5.6%) were lost to follow-up. Median follow-up time was 42.5 months. The 4-year overall survival was 63%. There was a statistically significant difference between survival rates according to clinical stage (CS I 87.3%, CS II 48.9%, CS III 74.7%, CS IV 23.9%; p < 0.001). Patients treated by surgery only presented a better survival rate (79.6%) than those receiving postoperative radiation therapy (48.9%; p = 0.001). A statistically significant difference in survival rates was also noted when patients were analyzed according to the type of surgical procedure. In a univariate analysis, comorbidity had impact on prognosis, no matter which scale was utilized: CIRS (p = 0.008), ACE-27 (p = 0.010), ATC (p = 0.004), WUHNCI (p = 0.003), Charlson index (p = 0.020), KFC (p = 0.001), and ICED (p = 0.010). However, in the multivariate analysis, only CIRS and TNM staging were identified as independent prognostic factors. CONCLUSION: The comorbidity is an independent prognostic factor in patients with surgically treated laryngeal cancer. In the univariate analysis, all indexes were able to stratify patients. However, in the multiple analysis, only the CIRS was predictive of death. Comorbidities are an important factor in the analysis of overall survival.     

A cross-comparison of retrospective notes extraction and combined notes extraction and patient interview in the completion of a comorbidity index (ACE-27) in a cohort of United Kingdom patients with head and neck cancer

Co-existent comorbidity is a major determinant of treatment outcome in head and neck cancer. Most of the work pertaining to this topic has been done in the United States, where the standard practice is for trained cancer registrars to grade comorbidity using validated indexes by retrospective notes review. The adult comorbidity evaluation-27 index (ACE-27) is a validated instrument that has been widely used in head and neck cancer. Although the required clinical data may be available in the notes, a significant amount of historical information is required to grade comorbidity. The aim of this study was to assess the accuracy and inter-rater reliability of the retrospective notes review process, in a typical setting in the United Kingdom (UK), by comparing the information obtained on notes review alone by a physician to that available after a structured patient interview. The study concludes that the retrospective notes review is an accurate and reliable technique for grading comorbidity whose completeness can be improved by the use of patient questionnaire as part of a structured interview.     

Bioelectrical impedance analysis of head and neck cancer patients at presentation

Abstract

Conclusion: Finnish head and neck cancer (HNC) patients show signs of severe malnutrition already at presentation, measured by bioelectric impedance analysis (BIA). BIA may be a practical method to detect malnutrition, analyze body composition, and to identify high-risk patients in this population.

Objectives: BIA is a validated method for evaluating body composition and detecting malnutrition. Low phase angle (PA) is associated with increased mortality and morbidity. Vector analysis (BIVA) provides a qualitative measure for hydration and cell mass, independent of body size. This study describes BIA results in Finnish HNC patients at presentation.

Methods: Forty-one newly-diagnosed HNC patients at the Helsinki University Hospital were included. BIA measures (resistance, reactance, PA, fat-free mass index [FFMI], and fat mass index [FMI]), body mass index (BMI), and Charlson Comorbidity Index (CCI) were determined.

Results: The majority of patients were men (78%), with a normal average BMI of 25.2. Low FFMI was seen in 44% of women and 28% of men. The PA (median?=?4.6; IQ range?=?4–5) was lower than the reference values in 76% (n?=?31) of cases. In BIVA, only 13 (32%) of the patients were within normal range and 15 (37%) were plotted in the quadrant indicating malnutrition.     

Care of the terminal head and neck cancer patient in the hospice setting

The ratio of incidence to mortality is somewhat less than 3:1 for head and neck cancer, and the 5-year relative survival rate is 50%. Despite the high mortality rate, few reports have focused on patients with terminal head and neck cancer. A growing number of these patients end their lives in a hospice facility. A retrospective analysis was undertaken of 67 patients with terminal head and neck cancer who were admitted to the Tel Hashomer Hospice between 1988 and 1992. Patient data were reviewed and analyzed, and the particular characteristics of this population were defined. This study found that terminal head and neck cancer patients seem to receive better support in a hospice than in a general hospital or some family settings.     

Cost-effective management of low-risk papillary thyroid carcinoma

OBJECTIVE: To compare the 20-year cost-effectiveness of initial hemithyroidectomy vs total thyroidectomy in the management of small papillary thyroid cancer in the low-risk patient. DESIGN: Pooled data from the published literature were used to determine key statistics for decision analysis such as rates of recurrence, rates of complications for all interventions undertaken, and rates of death. The 2005 costs were obtained from the US Department of Health and Human Services, as well as from Medicare reimbursement schedules. Future costs were discounted at 6%. SETTING: Decision analysis study. PATIENTS: Data from the published literature. MAIN OUTCOME MEASURES: A state-transition (Markov) decision model was constructed based on the most recent American Thyroid Association recommendations. A cost-effectiveness analysis was performed using fixed probability estimates and Monte Carlo microsimulation, with effectiveness defined as cause-specific mortality or recurrence-free survival. After identifying initial results, sensitivity and threshold analyses were performed to assess the strength of the recommendations. RESULTS: Initial probability estimates were determined from a review of 940 abstracts and 31 relevant studies examining outcomes in patients with low-risk thyroid cancer undergoing thyroidectomy or neck dissection. During 20 years, cost estimates (including initial surgery, follow-up, and treatment of recurrence) were between $13,896.81 and $14,241.24 for total thyroidectomy and between $15,037.58 and $15,063.75 for hemithyroidectomy. Cause-specific mortality was similar for both treatment strategies, but recurrence-free survival was higher in the total thyroidectomy group. Sensitivity and threshold analyses demonstrated that these results were sensitive to rates of recurrence and cost of follow-up but remained robust when compared with willingness to pay. CONCLUSIONS: Total thyroidectomy dominates over hemithyroidectomy as initial treatment for low-risk papillary thyroid cancer. However, in sensitivity analyses, these results varied by institution because of heterogeneity in long-term treatment outcomes. With changing protocols of management, it is possible that hemithyroidectomy will emerge as being more cost-effective. Long-term prospective trials are necessary to validate our findings.