A Cost-Utility Analysis of Ablative Therapy for Barrett's Esophagus

Division of Gastroenterology, San Francisco General Hospital, San Francisco, California 94110, USA.
Gastroenterology (Impact Factor: 16.72). 03/2009; 136(7):2101-2114.e1-6. DOI: 10.1053/j.gastro.2009.02.062
Source: PubMed


Recommendations for patients with Barrett's esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost utility of ablation with that of endoscopic surveillance strategies.
A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted; and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation, and photodynamic therapy.
Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of <$6,000 compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates >or=28% of LGD or 40% of nondysplastic metaplasia, ablation would be preferred to surveillance.
Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued after successful ablation. As further postablation data become available, the optimal management strategy will be clarified.

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Available from: Ryan D Madanick, Nov 26, 2014
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    • "In contrast, ablative treatment ensures that all neoplastic cells are eradicated. Further, cost-utility models show that ablation is the dominant or preferred strategy for managing dysplastic BE and that alternative management strategies for dysplastic Barrett’s are less optimal [19–21]. Esophagectomy is curative in that it removes the entire organ, yet is fraught with a high rate of morbidity and mortality. "
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    ABSTRACT: Barrett's esophagus (BE) is a well-established pre-malignant lesion for esophageal adenocarcinoma, a condition that carries a dismal five-year overall survival rate of less than 15%. Among several available methods to eliminate BE, radiofrequency ablation (RFA) provides the most efficient modality, since it has been demonstrated to successfully eradicate BE with or without dysplasia with acceptable safety, efficacy and durability profiles. In conjunction with proton pump therapy, this new technology has quickly become the standard care for patients with dysplastic BE. However, several technical questions remain about how to deploy RFA therapy for maximum effectiveness and long-term favorable outcomes for all stages of the disease. These include how to select patient for therapy, what the best protocol for RFA is, when to use other modalities, such as endoscopic mucosal resection, and what should be considered for refractory BE. This review addresses these questions with the perspective of the best available evidence matched with the authors' experience with the technology.
    09/2013; 1(2):95-104. DOI:10.1093/gastro/got009
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    • "High inter-observer variability among the pathologists in diagnosis LGD seems to affect the natural history of LGD and its rate of progression to HGD and cancer [52]. High rates of eradication of intestinal metaplasia (IM) and LGD, using RFA as reported, is enticing [54]. However, the survival benefits and cost-effectiveness of ablation over surveillance are not clear as estimated from a modeling study [55]. "
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    ABSTRACT: Barrett's esophagus (BE) is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium. Endoscopy with systemic biopsy protocols plays a vital role in diagnosis. Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia. These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy. A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa, followed by long-term surveillance improves the outcomes of BE. Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy, radiofrequency ablation and cryotherapy. Debatable issues such as durability of response, recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further. Development of safer wide field resection techniques, which would effectively remove all BE and obviate the need for long-term surveillance, is another research goal. Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.
    07/2013; 1(1):9-18. DOI:10.1093/gastro/got015
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    • "Sparse data exists to inform physicians’ outcome expectancies for surveillance and ablative therapy. Some clinical and decision science experts have even advocated against surveillance (while still supporting screening) due to the significant limitations, uncertain benefits, and potential costs [25-27]. Better evidence is needed to clarify how physicians perceive the quantitative and qualitative benefits/risks of surveillance and therapeutic endoscopy and how such information is communicated to patients to arrive at informed decisions. "
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    ABSTRACT: Background The comparative effectiveness (CE) of endoscopic screening (versus no screening) for Barrett’s esophagus (BE) in patients with GERD symptoms, or among different endoscopic surveillance strategies in patients with BE, for the early detection of esophageal adenocarcinoma (EA) is unknown. Furthermore, it is unclear if patients or providers have or will adopt any of these strategies (screening only, screening and surveillance, vs. none), irrespective of their effectiveness. Endoscopic screening and surveillance is expensive and can be risky. Therefore, it is imperative to establish the CE and acceptability about the risks and outcomes related to these practices to better inform expert recommendations and provider-patient decisions. Methods/Results We propose a mixed methods study which will involve: (1) an analysis of secondary databases (VA and VA-Medicare linked datasets for 2004–09) to examine CE of endoscopic screening and surveillance in an observational study cohort (an estimated 680,000 patients with GERD; 25,000–30,000 with BE; and 3,000 with EA); (2) a structured electronic medical record (EMR) review on a national sample of patients using VA EMRs to verify all EA cases, identify cancer stage, cancer-targeted therapy, and validate the screening and surveillance endoscopy; and (3) qualitative in depth interviews with patients and providers to elicit preferences, norms, and behaviors to explain clinical contexts of these findings and address gaps arising from the CE study. Conclusion This study will compare clinical strategies for detecting and monitoring BE, a pre-cancerous lesion. Additionally, by eliciting acceptability of these strategies for patients and providers, we will be able to propose effective and feasible strategies that are likely to be implemented in routine use. Findings will inform recommendations for clinical practice guidelines. Our innovative approach is consistent with the methodological standards of patient-centered outcomes research, and our findings will offer a significant contribution to the literature on cancer surveillance. Trial Registration Not applicable
    BMC Health Services Research 08/2012; 12(1):288. DOI:10.1186/1472-6963-12-288 · 1.71 Impact Factor
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