OESOPHAGUS

What is the best management strategy for high grade dysplasia in Barrett’s oesophagus? A cost effectiveness analysis

N J Shaheen¹, J M Inadomi², B F Overholt³, P Sharma⁴

¹ Center for Esophageal Diseases and Swallowing, University of North Carolina Schools of Medicine and Public Health, Chapel Hill, NC, USA
² Veterans’ Administration Center for Practice Management and Outcomes Research, University of Michigan School of Medicine, Ann Arbor, MI, USA
³ Gastrointestinal Associates, PA, Knoxville, TN, USA
⁴ University of Kansas School of Medicine, Kansas City, MO, USA

Correspondence to:
Correspondence to:
Dr N Shaheen
CB#7080, UNC-CH, Chapel Hill, NC 27599-7080, USA; nshaheen{at}med.unc.edu

Background: Multiple treatment strategies for subjects with high grade dysplasia (HGD) in Barrett’s oesophagus (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.

Aim: To compare the efficacy and cost effectiveness of competing management strategies for BO with HGD.

Methods: We 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 oesophagectomy, (3) endoscopic ablation, and (4) surveillance endoscopy. The base case 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 modelled after reported rates. Estimates were derived 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 modelled as photodynamic therapy. Sensitivity analyses were performed over a wide range of cancer incidences, complication rates, and procedure costs.

Results: 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 oesophagectomy. 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 oesophagectomy, being both less costly and more effective. The condition of extended dominance occurred when comparing endoscopic ablation to endoscopic surveillance because, 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 (21 009/dQALY). Sensitivity analysis demonstrated that when yearly rates of progression to cancer from HGD exceeded 30%, oesophagectomy became the most cost effective option.

Conclusions: A strategy of endoscopic ablation provided the longest quality adjusted life expectancy for BO with HGD. Although endoscopic surveillance was less expensive than endoscopic ablation, it was associated with shorter survival. Optimal utilisation of healthcare resources may be achieved with endoscopic ablative therapy for BO with HGD.

Abbreviations: BO, Barrett’s oesophagus; HGD, high grade dysplasia; dQALYs, discounted quality adjusted life years; PDT, photodynamic therapy; ICER, incremental cost effectiveness ratio

Keywords: Barrett’s oesophagus; oesophageal adenocarcinoma; cost effectiveness; endoscopic ablation; high grade dysplasia

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This article has been cited by other articles:

• Smith, M. S., Lightdale, C. J. (2008). Review: Barrett's esophagus and the increasing role of endoluminal therapy. Therapeutic Advances in Gastroenterology 1: 121-142 [Abstract]  
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• Cassidy, J., Bissett, D., Spence OBE, R. A.J., Payne, M. (2006). Further reading. Oxford Handbook of Oncology 2: med-9780198567875-div1-68-med-9780198567875-div1-68 [Full Text]  

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A letter in response to “What is the best management strategy for high grade dysplasia in Barrett’s

Chin Hur, et al.

Gut Online, 8 Dec 2004 [Full text]

Author's reply

Nicholas J. Shaheen

Gut Online, 15 Dec 2004 [Full text]