Introduction High grade dysplasia (HGD) in Barrett's oesophagus (BO) has been regarded as an indication for oesophagectomy. However, the introduction of endoscopic mucosal resection (EMR), radiofrequency ablation (RFA) and photodynamic therapy (PDT) is changing practice. The cost-effectiveness of these strategies was compared with oesophagectomy.
Methods Decision analysis (Markov) models were developed to examine EMR, RFA and PDT in managing HGD in BO. Two separate models were developed for endoscopically visible HGD and flat HGD. The models assumed that HGD was present at two separate endoscopies, that intramucosal cancer had been excluded and that staging modalities (EUS and CT) had been performed. Competing clinical strategies included a baseline strategy of oesophagectomy and other strategies involving EMR only (up to two resections were modelled), EMR followed by RFA and EMR followed by PDT, respectively, for visible HGD and RFA or PDT for flat HGD. Cost-effectiveness was expressed as net amount per quality adjusted life year (QALY) and base-costs for treatment were obtained from the Department of Health HRG tariffs for 2007/8. A cohort of 1000 50-year-old Caucasian males with BO and HGD followed until 75 years old was modelled. All patients were assumed to be fit for oesophagectomy. Monte Carlo simulation and sensitivity analysis were carried out.
Results Treatment of visible HGD utilising EMR followed by RFA to ablate residual BO yielded a total cost per patient of £12 424 for 26 QALYs and was the most cost-effective strategy (Abstract 018). The incremental cost-effectiveness ratio (ICER) for this strategy compared to oesophagectomy was £7554.
A strategy of treating flat HGD with RFA was more cost-effective than PDT or oesophagectomy (Abstract 10) and yielded an ICER of £4596 compared to oesophagectomy.
All variables in the model were tested in a one-way sensitivity analyses and strategies involving EMR and RFA for visible HGD and RFA for flat HGD remained superior to competing strategies in the model.
Conclusion A combination of EMR and RFA to treat visible HGD and RFA for flat HGD appear to be the most cost-effective strategies to treat HGD due to lower mortality and morbidity than oesophagectomy and less morbidity than PDT. This combination remained more cost-effective even if mortality due to oesophagectomy were to fall from 5 to 0%.