Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Mucosa
 The
 Esophagogastric  Junction
 Barrett's
 Esophagus

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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Dysplasia
 

Is immediate esophagectomy a cost-effective strategy for Barrett's patients with high-grade dysplasia?

D. Provenzale (Durham)

Patients with Barrett's esophagus and high-grade dysplasia (HGD) are at greatest risk for developing adenocarcinoma of the esophagus. Because of their cancer risk, current recommendations are either for immediate esophagectomy or continued surveillance at frequent intervals [1]. Because there are no controlled trials that examine this question, we modified our previously published cohort simulation to consider 60 year old patients with Barrett's esophagus and HGD. From published literature we used an incidence of cancer of 30% in a 5 year period and according to standard economic methodology, we employed an annual discount rate of 3%.

The strategies we included in this model are shown in Figure 1. For patients with Barrett's esophagus and HGD, we considered immediate esophagectomy or continued surveillance, every 3 months, every 6 months, every year, and every 1.5 years and compared this to no surveillance in which esophagectomy was performed only for the development of cancer. The costs we used in this model are shown in Table I.

Figure 1. Strategies.

The results are shown on Figure 2. The vertical axis displays the average lifetime cost per patient for each strategy and the horizontal axis displays the discounted quality-adjusted life expectancy in years. Each of the circles represents the results of an alternative management strategy. No surveillance costs approximately $ 25,700 and is associated with living an additional 7 years after the diagnosis of HGD. Surveillance every 1.5 years costs approximately $ 47,700 and is associated with living an additional 10 years. The change in cost divided by the change in quality-adjusted life expectancy to move from no surveillance to surveillance every 1.5 years, which is the incremental cost-utility ratio, is at $ 9,400 per quality-adjusted life year gained. The line connects surveillance every 1.5 years to immediate esophagectomy. The alternative surveillance intervals every 3 and 6 months and every year are not connected by the line because they have higher incremental cost-utility ratios and are less effective than immediate esophagectomy for preventing cancer and reducing cancer deaths. The intervening surveillance intervals are all dominated or are inferior when compared to immediate esophagectomy. Immediate esophagectomy is the most effective strategy. The incremental cost-utility ratio for immediate esophagectomy is at $ 10,100 per quality-adjusted life year gained. On the same figure, the published incremental cost-effectiveness ratios for accepted medical practices are listed: surveillance or immediate esophagectomy with cost-effectiveness ratios ranging from approximately $ 9,000 to $ 10,000 per quality-adjusted life year gained would be considered cost effective compared to these other strategies such as evaluation for chest pain with an incremental

Figure 2. Is immediate esophagectomy a cost-effective strategy for Barrett's patients with high-grade dysplasia?

cost-effectiveness ratio of $ 57,700/LY [2] gained or heart transplantation at $ 160,000/LY [3] because their incremental cost-utility ratios are lower.

We conclude that for patients with high-grade dysplasia, immediate esophagectomy is the most effective strategy, providing the greatest gain in life expectancy compared to common medical practices and it is also cost-effective compared to the other practices listed earlier. Continued frequent surveillance is less effective, but is also cost-effective compared to common practices. The decision for immediate esophagectomy or continued surveillance should consider quality life after esophagectomy and patient preferences for the alternative management strategies.

References

1. Sampliner RE, The Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines on the diagnosis, surveillance, and therapy of Barrett's esophagus. Am J Gastroenterol 1998;93:1028-1032.

2. Kuntz KM, Fleischmann KE, Hunink MG, et al. Cost-effectiveness of diagnostic strategies for patients with chest pain. Ann Intern Med 1999;130:709-718.

3. Pennock JL, Oyer PE, Reitz BA, et al. Cardiac transplantation in perspective for the future:survival complications, rehabilitation, and cost. J Thorac Cardiovasc Surg 1982;83:18-77.

4. El-Serag HB, Inadomi JM, Kowdley KV. Screening for hereditary hemochromatosis in siblings and children of affected patients: a cost-effectiveness analysis. Ann Int Med 2000;132:261-269.

5. Eddy DM. Screening for cervical cancer. Ann Intern Med 1990;113:214-226.


Publication date: August 2003 OESO©2015