Ablative Technologies for Thyroid Nodules: A Health Technology Assessment.

Background: Thyroid nodules are common, but most are benign and do not require treatment. However, intervention is warranted in people who experience compressive symptoms or hyperthyroidism, or based on risk of malignancy. Ablative technologies may offer a minimally invasive option for those in whom surgery is being considered. We conducted a health technology assessment of ablative technologies for adults with symptomatic benign thyroid nodules, cystic thyroid nodules, autonomously functioning thyroid nodules (AFTNs), or small, low-risk papillary thyroid cancer, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding ablative technologies, and patient preferences and values. Methods: We performed a systematic literature search of the clinical evidence to retrieve systematic reviews; we then complemented the chosen systematic reviews with a literature search to identify primary studies published from January 2022. We assessed the risk of bias of each included study using the Risk of Bias in Systematic Reviews tool for systematic reviews and the Cochrane Risk-of-Bias Tool 2 for primary studies. We assessed the quality of the body of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted cost-utility analyses with a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding radiofrequency ablation (RFA) in adults with symptomatic benign thyroid nodules, AFTNs, and small, low-risk papillary thyroid cancer in Ontario. To contextualize the potential value of RFA, we spoke with people who had thyroid nodules. Results: We included 4 systematic reviews and 1 randomized controlled trial in the clinical evidence review. In patients with symptomatic benign thyroid nodules, thermal ablations (including RFA, microwave ablation, and high-intensity focused ultrasound ablation) may be as effective as surgery in reducing nodule volume and improving symptoms, and they may result in better quality of life (GRADEs: Very low to Low). In patients with cystic thyroid nodules, RFA may be as effective as ethanol ablation in reducing nodule volume and improving symptoms (GRADEs: Low). In patients with AFTNs, RFA may reduce nodule volume, improve symptoms, and normalize thyroid-stimulating hormone levels (GRADEs: Low). In patients with small, low-risk papillary thyroid cancer, thermal ablations may be as effective as surgery in terms of tumour disappearance but have a lower tumour recurrence rate; they may require less surgical time and a shorter length of hospital stay, and they may be associated with less postprocedural pain and better postprocedural quality of life than surgery (GRADEs: Low to Very low). The effectiveness of the different thermal ablations may be similar, but the evidence is very uncertain. Compared with surgery, thermal ablations may not result in hypothyroidism and may lead to fewer adverse events (GRADEs: Low to Very low). Thermal ablations are reasonably safe, and their safety profiles are comparable (GRADEs: Low to Very low).In patients with symptomatic benign thyroid nodules and AFTNs, RFA is more effective and less costly than surgery. In patients with small, low-risk papillary thyroid cancer, RFA is more effective and less costly than surgery and cost-effective compared with active surveillance at an incremental cost-effectiveness ratio of $1,574 per QALY gained. Publicly funding RFA for patients with symptomatic benign thyroid nodules, AFTNs, and small, low-risk papillary thyroid cancer in Ontario would lead to cost savings of $5.42 million, $0.64 million, and $4.03 million over 5 years, respectively.The quantitative preference evidence demonstrated that physicians preferred interventions that were safe and effective, and patients placed more value on quality of life after interventions. Patient preferences for interventions for papillary thyroid microcarcinoma were driven by aversion to complications rather than by interest in a particular treatment pathway. The people we interviewed noted their preference for minimally invasive options such as RFA for the treatment of thyroid nodules. Those who had experience with RFA noted benefits such as improvement of their symptoms, shorter recovery time, and less scarring. Conclusions: Ablative technologies may be as effective as surgery for patients with symptomatic benign thyroid nodules or small, low-risk papillary thyroid cancer, and they may also be safer. Effectiveness and safety among the different ablative technologies may be similar, but the evidence was inconclusive. In patients with symptomatic thyroid nodules and AFTNs, RFA is more effective and less costly than surgery. In patients with small, low-risk papillary thyroid cancer, RFA is more effective and less costly than surgery and cost-effective compared with active surveillance. We estimate that publicly funding RFA for patients with symptomatic benign thyroid nodules, AFTNs, and small, low-risk papillary thyroid cancer in Ontario would result in cost savings of $5.42 million, $0.64 million, and $4.03 million over the next 5 years, respectively. Thyroid nodules have a negative impact on people's physical and emotional well-being, affecting daily activities, work, and overall quality of life. The people we interviewed expressed a preference for minimally invasive treatment options such as RFA, noting benefits such as shorter recovery times and less reliance on lifelong medication as a result of preserved thyroid function.