Surgery · Medical Literature
Decoding patient preferences: key drivers in selecting thyroid cancer surgery- a discrete choice experiment.
Abstract
With the growing application of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for papillary thyroid carcinoma (PTC), understanding patient preferences is critical to improving communication and supporting informed decision-making. This study aimed to identify key factors influencing surgical choices. A discrete choice experiment was conducted with patients diagnosed with PTC who were scheduled for thyroidectomy. Participants evaluated hypothetical surgical scenarios varying in six attributes: incision location, incision size, recurrence rate, operative duration, complication rate, and cost. Preferences and willingness to pay (WTP) were analyzed using a mixed logit model. A total of 271 patients were included in this study. Patients demonstrated a strong preference for surgical options with lower recurrence rates and scarless approaches. They were willing to pay an additional ¥201,409.60 to reduce the recurrence rate from 10% to 1% and ¥19,141.14 to change the surgical scar location from external to internal. The recurrence rate emerged as the most crucial non-financial factor (β = 8.18, P < 0.001, 95%), followed by incision location (β = 0.78, P < 0.001), and complication rate (β = 0.25, P = 0.030). Demographic factors such as gender, age, education level, marital status, and income exhibited notable differences in postoperative cosmetic concerns. Recurrence risk is the primary driver of surgical preference in PTC patients, followed by cosmetic outcomes. Additionally, postoperative cosmetic concerns varied across different demographic groups. These findings highlight the need for surgeons to consider patient-specific values during preoperative consultations to enhance shared decision-making. https://www.chictr.org.cn/showproj.html?proj=191809, identifier ChiCTR2300069048.
Clinical relevance
Among patients with papillary thyroid carcinoma (PTC) scheduled for thyroidectomy in China, which surgical attributes most strongly drive patient preferences between conventional open thyroidectomy and TOETVA, and what are patients willing to pay for their preferred attributes? __SNAPSHOT__ {"studyDesign":"Cross-sectional discrete choice experiment (DCE) with mixed logit model analysis","setting":"Single tertiary cancer center: Department of Thyroid Surgery, Hunan Cancer Hospital (The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University), Changsha, Hunan, China","sampleSize":"n=271 (298 enrolled; 27 excluded for incomplete questionnaires or failing consistency test)","population":"Adult patients with confirmed PTC scheduled to undergo thyroidectomy; 81.9% female; median age 36.0 years (IQR 30.5–46.0); 78.97% ultimately underwent TOETVA, 21.03% open thyroidectomy; 63.5% with higher education","intervention":"DCE presenting hypothetical surgical scenarios varying across six attributes: incision location (external vs. internal/scarless), incision size, recurrence rate (1%–10%), operative duration, complication rate, and out-of-pocket cost","comparator":"Not applicable (preference elicitation study; no treatment comparator assigned)","primaryOutcome":"Patient preference weights (beta coefficients) and willingness to pay (WTP) for each surgical attribute, derived from a mixed logit model","followUp":"Not reported (cross-sectional preference survey; no longitudinal follow-up)","fundingSource":"Not reported"}
Key findings
Among 271 PTC patients, the mixed logit model identified recurrence rate as the most influential non-financial attribute (β = 8.18, p < 0.001), followed by incision location. Patients were willing to pay an additional ¥201,409.60 (CNY) to reduce the recurrence rate from 10% to 1%, and an additional ¥19,141.14 to change the scar location from external (neck) to internal (scarless/TOETVA). Both WTP estimates are notable in magnitude; however, confidence intervals and standard errors for WTP values are not reported in the available abstract, precluding assessment of their precision. The relative importance of the remaining four attributes—incision size, operative duration, complication rate, and cost—as well as their individual beta coefficients and p-values, are not fully reported in the abstract and therefore cannot be summarized here. No adverse events or safety outcomes were assessed, as this was a preference study rather than a clinical trial. No NNT or NNH is applicable or calculable from these data.
Practice implications
This study establishes that, in a Chinese tertiary cancer center population of predominantly younger, female, well-educated PTC patients, oncologic outcomes (recurrence risk) were the most heavily weighted surgical attribute, substantially outweighing cosmetic preferences in quantitative terms. Nonetheless, willingness to pay for a scarless approach (¥19,141.14) was also substantial, suggesting cosmetic concerns are clinically meaningful and should not be dismissed in preoperative counseling. The high WTP for recurrence reduction (¥201,409.60) should be interpreted cautiously: DCE-derived WTP reflects hypothetical monetary valuation of preferences and does not reflect actual payment capacity or behavior in the Chinese healthcare system. The study population was highly selected—predominantly young women at a high-volume cancer center with an unusually high TOETVA uptake rate (79%)—limiting generalizability to older patients, rural populations, lower-volume centers, and healthcare systems outside China. Patients who declined to participate or were excluded for failing the consistency test are not described; this may introduce selection bias toward patients with more defined preferences. Findings do not establish whether incorporating patient preferences into surgical counseling improves clinical outcomes such as satisfaction, adherence, or recurrence rates. Practice should not change based on this study alone, but findings are highly relevant for structuring shared decision-making conversations, particularly for younger patients where both recurrence anxiety and cosmetic concerns may be prominent. Note: this summary is based solely on the published abstract; the full dataset, subgroup analyses, and complete model outputs were not independently verified. __LIMITATIONS__ Single-center study from one tertiary cancer hospital in China severely limits generalizability to other healthcare systems, surgical volumes, and cultural contexts.,DCE measures stated (hypothetical) preferences, not revealed (actual) preferences; WTP values derived from DCE may not reflect real-world willingness or ability to pay.,Population is demographically skewed (81.9% female, median age 36, high education, 79% TOETVA recipients), which may not represent the broader PTC surgical population.,Exclusion of 24 participants who failed the consistency test (8.1% of enrollees) may introduce selection bias toward more preference-coherent respondents.,Confidence intervals and standard errors for WTP estimates are not reported in the abstract, precluding assessment of statistical precision of monetary valuations.,Only abstract available for this review; complete beta coefficients, model fit statistics, and subgroup analyses for all six attributes could not be independently verified.,Orthogonal design for DCE scenarios may not fully capture real-world multicollinearity of surgical attributes.,Funding source is not disclosed, precluding assessment of potential conflicts of interest.,No assessment of whether patient preferences were actually incorporated into surgical decision-making or whether doing so affected patient outcomes.,The recurrence rate levels used (1%–10%) represent only the low-risk end of the ATA spectrum and may not elicit preferences relevant to intermediate- or high-risk PTC patients. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ In a Chinese single-center DCE of 271 PTC patients, oncologic recurrence risk was the dominant driver of surgical preference, with willingness to pay for recurrence reduction nearly tenfold greater than for achieving a scarless approach (¥201,409 vs. ¥19,141 CNY). Cosmetic concerns were nonetheless independently significant and should be explicitly addressed in preoperative shared decision-making. These findings are hypothesis-generating and context-specific; they should inform counseling frameworks but are not sufficient to alter surgical selection criteria pending external validation in more diverse populations.