Multiple treatment strategies for subjects with high grade dysplasia (HGD) in Barrett’s esophagus (BO) have been suggested.
However, it is unclear which of these strategies provides the greatest life expectancy, and the costs associated with the management strategies are unknown.
Dr Shaheen and colleagues from America undertook a study to compare the efficacy and cost effectiveness of competing management strategies for BO with HGD.
The researchers created a decision analysis model in Data 4.0 to assess possible treatment strategies for BO with HGD.
The strategies included: (1) no preventative strategy, (2) elective surgical esophagectomy, (3) endoscopic ablation, and (4) surveillance endoscopy.
The researchers decided on a base case that was a healthy 50 year old White male with an initial diagnosis of BO with HGD.
The model allowed for complications of surgery, including death. Ablative therapy could cause stricture or perforation.
Pathological misinterpretation was allowed, and modeled after reported rates.
|Endoscopic ablation was the most effective strategy, yielding 15.5 discounted quality adjusted life years|
The research team derived estimates from the literature for the rate of progression of HGD to cancer and for complication rates for the various treatment modalities.
The endoscopic ablation arm was modeled as photodynamic therapy.
The researchers carried out sensitivity analyses over a wide range of cancer incidences, complication rates, and procedure costs.
The research team found that endoscopic ablation was the most effective strategy, yielding 15.5 discounted quality adjusted life years (dQALY), compared with 15.0 for endoscopic surveillance and 14.9 for esophagectomy.
In addition, the researchers found that no preventative strategy was the most inexpensive option, yielding an average cost per quality adjusted life year of $54 (44) per dQALY, but resulted in high rates of cancer.
Endoscopic surveillance dominated esophagectomy, being both less costly and more effective.
Although the total costs of ablation were greater than those of surveillance, it was less expensive to buy an additional life year using endoscopic ablation than endoscopic surveillance.
The incremental cost effectiveness ratio when moving from no therapy to ablative therapy was a reasonable $25 621/dQALY.
Sensitivity analysis demonstrated that when yearly rates of progression to cancer from HGD exceeded 30%, esophagectomy became the most cost effective option.
Dr Shaheen concluded, "A strategy of endoscopic ablation provided the longest quality adjusted life expectancy for BO with HGD."
Dr Shaheen added, "Although endoscopic surveillance was less expensive than endoscopic ablation, it was associated with shorter survival."
"Optimal utilization of healthcare resources may be achieved with endoscopic ablative therapy for BO with HGD."