Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Esophagogastric  Junction

  Browse by Author
  Browse by Movies
Volume: The Esophagogastric Junction
Chapter: Esophageal columnar metaplasia (Barrett s esophagus)

Should quality of life influence the decision for esophagectomy in high grade dysplasia?

D. Provenzale (Durham)

There is an increased risk of esophageal adenocarcinoma in patients with Barrett's esophagus. Patients with Barrett's esophagus develop adenocarcinoma of the esophagus at a rate of 1/75 patient-years, an incidence that is 30-125 times that of the general population [1-7]. Patients with high grade dysplasia are at greatest risk.

Current recommendations for patients with high grade dysplasia include immediate esophagectomy [2], and continued endoscopic surveillance with esophagectomy for those diagnosed with cancer [6].

Our previously published decision model suggested that surveillance of patients with Barrett's esophagus is effective; increasing life expectancy and preventing cancer deaths [8].

The objective of this study was to examine the effectiveness of the alternative management strategies for Barrett's patients diagnosed with high grade dysplasia, and to determine their impact on quality of life.

We modified our previously published decision model [8] to compare the alternative indications for esophagectomy in patients diagnosed with high grade dysplasia.


We used a Markov model [9] and constructed a computer cohort simulation of 10,000, hypothetical men with Barrett's esophagus. A Markov model is a mathematical model for estimating life expectancy that can be used for determining prognosis in medical applications. It is particularly useful for simulating clinical situations that involve an ongoing risk over time (such as the risk for developing adenocarcinoma in patients with Barrett's esophagus), because it considers the consequences of ongoing risk, namely, that the times that events will occur are uncertain, and that an event may occur more than once [10]. For example, certain members of the hypothetical cohort with high grade dysplasia might develop cancer within a year, while others might not develop cancer for several years.

Structure of the analysis

We evaluated the following strategies:

- A: immediate esophagectomy (for those who are surgical candidates);

- B1-5: surveillance every 3, 6, 12, 18 and 24 months with esophagectomy for cancer;

- C: no surveillance.

Endoscopy is performed for dysphagia, and esophagectomy is performed if cancer is diagnosed.

Our simulation begins at the point at which an endoscopic biopsy demonstrates Barrett's esophagus and high grade dysplasia. Over time, patients with high grade dysplasia may remain in this health state, they may develop cancer or they may die. Our model also includes long-term post-surgical states for the prognosis of patients following surgery, an inoperable state for patients with cancer who are inoperable due to other illnesses [11], and a dead state. The likelihood of entering each of these states, each year, depends on annual transition probabilities derived from published literature [5, 6, 12] Because the current therapy for patients with high grade dysplasia is controversial, patients detected to have high grade dysplasia in strategy A undergo esophagectomy, while those in strategies B1-B5 undergo endoscopic surveillance with biopsy every three months and undergo esophagectomy only if carcinoma is diagnosed.

The analysis continues until all members of the cohort have died, either from esophageal cancer or from other causes, based on age, gender and race-specific mortality rates taken from life tables for the general population [13]. The simulation permits calculation of the average life expectancy, and the cumulative incidence of cancer.


All parameters used in the model are shown in Table I. Estimates were obtained from published reports. When published data were not available, we consulted experts in the field to obtain estimates [11, 13-20].


Table II shows the baseline results using the values in Table I.
Table I. Parameters-Markov surveillance model.
Table II. Results.    Cumulative Life-years   in

Cumulative incidence of cancer

Our model predicts that 96% of patients with high grade dysplasia who do not undergo surveillance will develop cancer over their lifetime. Endoscopic surveillance and esophagectomy for cancer decreases the lifetime cumulative incidence to 49-81% (a 16-49% reduction). The shortest surveillance interval results in the greatest reduction in cancer incidence.

Life expectancy

For reference, 55 year old men from the general population have an average life expectancy of 24.5 years. For patients with high grade dysplasia who do not undergo surveillance, our model predicts an average life expectancy of 5.3 years. Surveillance with esophagectomy for cancer adds 5.4-9.7 years to life expectancy compared to no surveillance. The optimal surveillance interval is every 3 months. For those who are surgical candidates, immediate esophagectomy for high grade dysplasia extends life expectancy by an additional 5.5-9.8 years.

Quality of life

These life expectancy gains, however, are associated with procedures and symptoms which some patients might prefer to avoid. Endoscopic procedures may be inconvenient and uncomfortable, and esophagectomy may be associated with life long symptoms. In order to determine the impact of quality of life after esophagectomy on the decision for immediate esophagectomy versus continued surveillance, we performed sensitivity analysis. In sensitivity analysis, the quality of life with an esophagectomy is varied over a broad range to determine its impact on the preferred strategy. In our analysis we varied quality of life from 0.00 (equivalent to being dead) to 1.00 (equivalent to a state of perfect health). The results are shown in Figure 1 and suggest that if the quality of life with an esophagectomy is greater than 0.28, immediate esophagectomy is the preferred strategy for high grade dysplasia patients who are surgical candidates, providing an increase in quality-adjusted life expectancy of up to 15.2 years compared to no surveillance and of up to 9.8 years compared to surveillance with esophagectomy for cancer. If the quality of life is between 0.01 and 0.28, then continued surveillance is preferred providing an increase in quality-adjusted life expectancy of approximately 3.9 years compared to immediate esophagectomy and of up to 1.5 years compared to no surveillance. If the quality of life with an esophagectomy is less than 0.01, then no surveillance is preferred.

In order to evaluate the quality of life of Barrett's patients who undergo esophagectomy, we performed a pilot study of patients with a history of Barrett's esophagus who had undergone esophagectomy for high grade dysplasia or cancer at Duke University and the Durham Veterans Affairs Medical Center [21]. We used the time trade-off technique [22] to measure quality of life. The time trade-off is a form of utility assessment, in which a set of dimensions is described in a scenario, and a score is assigned to reflect the overall assessment. Health state utilities are numeric values assigned to a particular health state. These values reflect the quality of the health states and allow morbidity and mortality estimates to be combined into a single weighted measure, a "QALY" or quality-adjusted life year gained [22]. Preference values are derived implicitly, based on individual responses to decision situations, e.g.: "Would you rather live 10 years with an esophagectomy or 5 years in excellent health?" The time trade-off is a valid, reliable measure of quality of life that has been administered to diverse populations including post-colectomy patients with a history of ulcerative colitis [23], and patients on long-term home TPN [24]. Measured values are reported as reliable and stable [25]. Our results suggested that the quality of life post-esophagectomy is excellent. The mean (range) for quality of life was 0.9 (0.6, 1.0). We incorporated this value for quality of life into our decision model. Using a quality-adjustment for esophagectomy of 0.9, the analysis suggests that for those who are surgical candidates, immediate esophagectomy will increase quality-adjusted life expectancy by up to 13.3 years compared to no surveillance and by up to 8.5 years compared to surveillance strategies with esophagectomy performed for the development of cancer. For those who choose continued surveillance as a management strategy, surveillance every 3 months would increase quality-adjusted life expectancy, on average, by approximately 8.5 years compared to no surveillance.

Figure 1. Preferred strategy based on quality of life.


Quality of life is a critical component in the decision for immediate esophagectomy or continued surveillance among Barrett's patients with high grade dysplasia. Our results suggest that either immediate esophagectomy (for surgical candidates), or frequent surveillance (every 3 months), should increase both length and quality of life. Our decision analysis suggests that the benefits of immediate esophagectomy in preventing cancer outweigh the morbidity and chronic symptoms associated with esophagectomy for most values of quality of life. Although the gains are not as great, surveillance will also increase both length and quality of life.

Our study of quality of life post esophagectomy was the first to use the time trade-off in this group. The results suggest that quality of life is excellent post-esophagectomy. To provide a prospective for these results, the quality of life of patients who have been treated for benign esophageal disease including achalasia and gastroesophageal reflux ranges from 0.74-0.96, and the quality of life of patients who have undergone colectomy for ulcerative colitis is 0.96 (mean). Thus, the quality of life post-esophagectomy compares favorably with other post-surgical groups.

Our results provide a guide for decision making with patients with high grade dysplasia. Clinicians and patients can use these results to determine the expected outcomes with alternative management strategies. Those who make health policy can use these results to develop programs that optimize both length and quality of life of Barrett's patients with high grade dysplasia.


1. Talley NJ, Zinsmeister AR, Schleck C, et al. The natural history of gastroesophageal reflux. Gastroenterology 1992;102:A28.

2. Spechler J. Barrett's esophagus: What's new and what to do. Am J Gastroenterol 1989;84:220-223.

3. Sjogren RW Jr, Johnson LF. Barrett's esophagus:a review. Am J Med 1983;74:313-321.

4. U.S. Bureau of the Census, Statistical Abstract of the United States:1991 (111th edition.) Washington, DC, 1991.

5. Robertson CS, Mayberry JF, Nicholson DA, et al. Value of endoscopic surveillance in the detection of neoplastic change in Barrett's oesophagus. Br J Surg 1988;75:760-763.

6. Hameeteman W, Tytgat GNJ, Houthoff HJ, et al. Barrett's esophagus: Development of dysplasia and adenocarcinoma. Gastroenterology 1989;96:1249-1256.

7. Spechler SJ, Robbins AH, Rubins HB, et al. Adenocarcinoma and Barrett's esophagus: an overrated risk? Gastroenterology 1984;87:927-933.

8. Provenzale D, Kemp JA, Arora S, Wong JB. A guide for surveillance of patients with Barrett's esophagus. Am J Gastroenterol 1994;89(5):670-680.

9. Beck JR, Pauker SG. The Markov process in medical prognosis. Med Decis Making 1983;3:419-458.

10. Sonnenberg FA, Beck JR. Markov models in medical decision making: A practical guide. Med Decis Making 1993;13:322-328.

11. van Andel JG, Dees J, Dijkhuis CM, et al. Carcinoma of the esophagus: Results of treatment. Ann Surg 1979;190:684-689.

12. Spechler SJ. Endoscopic surveillance for patients with Barrett's esophagus: Does the cancer risk justify the practice? Ann Intern Med 1987;106:902-904.

13. National Center for Health Statistics. Vital Statistics of the United States, 1987. Vol. II, mortality, Part A. Public Health Service, Washington, DC, U.S. Government Printing Office, 1990.

14. Skinner DB. En bloc resection for neoplasms of the esophagus and cardia. J Thorac Cardiovasc Surg 1983;85:59-71.

15. Ellis FH, Gibb SP, Watkins E. Esophagogastrectomy - A safe, widely applicable and expeditious form of palliation for patients with carcinoma of the esophagus and cardia. Ann Surg 1983;198:531-540.

16. Galandiuk S, Hermann RE, Gassman JJ, et al. Cancer of the esophagus. The Cleveland Clinic experience. Ann Surg 1986;198:101-108.

17. DeMeester TR, Zaninotto G, Johansson KE. Selective therapeutic approach to cancer of the lower esophagus and cardia. J Thorac Cardiovasc Surg 1988;95:42-54.

18. Wu YK, Huang KC. Chinese experience in the surgical treatment of carcinoma of the esophagus. Ann Surg 1979;190:361-365.

19. Earlam R. Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67:381-390.

20. Williamson WA, Ellis FH, Gibb SP, et al. Barrett's esophagus: prevalence and incidence of adenocarcinoma. Arch Intern Med 1991;151:2212-2216.

21. Schmitt CM, Provenzale D, Brazer SR, Davis D, Phillips B, Wolfe WG. Quality of life in esophageal disorders. Gastroenterology 1994;106(4):A26.

22. Boyd NF, Sutherland HJ, Heasman KZ, et al. Whose utilities for decision analysis? Med Decis Making 19990;10:58-67.

23. Provenzale D, Shearin M, Tillinger W, Phillips B, Bollinger R, Koruda M, Drossman D, Wong JB. The effect of patient preferences on policy recommendations for prophylactic colectomy or surveillance in patients with ulcerative colitis. Gastroenterology 1994;106(4)A:22.

24. Detsky AS, McLaughlin JR, Abrams HB, L'Abbe KA, Whitwell J, Bombadier C, Jeejeebhoy KN. Quality of life of patients on long-term total parenteral nutrition at home. J Gen Intern Med 1986;1:26-33.

25. Llewellyn-Thomas H, Sutherland HJ, Ciampi A, et al. The assessment of values in laryngeal cancer: Reliability of measurement methods. J Chron Dis 1984;37:283-291.

26. Guanrei Y, Songliang Q, He H, et al. Natural history of early esophageal squamous carcinoma and early adenocarcinoma of the gastric cardia in the People's Republic of China. Endoscopy 1988;20:95-98.

27. Silvis SE, Nebel O, Rogers G, et al. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy survey. JAMA 1976;235:928-930.

28. Sabiston DC. Textbook of surgery. Thirteenth Edition. New York, Philadelphia: WB Saunders Co., 1986:749-753.

29. Cedarquist C, Nielsen J, Berthelsen A, et al. Cancer of the esophagus, II. Therapy and outcome. Acta Chir Scand 1978;144:233-240.

Publication date: May 1998 OESO©2015