Elsevier

Gastrointestinal Endoscopy

Volume 60, Issue 5, November 2004, Pages 739-756
Gastrointestinal Endoscopy

Original Article
Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus

https://doi.org/10.1016/S0016-5107(04)02167-4Get rights and content

Background

Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities.

Methods

By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer.

Results

Esophagectomy cost $24,045, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost ($47,310) for an incremental cost-effectiveness of $47,410/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%.

Conclusions

Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.

Section snippets

Patient population

Our hypothetical cohort consisted of 55-year-old white men diagnosed with HGD in Barrett's esophagus, the demographic subgroup at highest risk of developing Barrett's esophagus and esophageal adenocarcinoma. Our assumption is that patients were candidates for all 3 options: surgery, PDT, or endoscopic surveillance.

Results

Table 4 provides the health and economic outcomes by using baseline assumptions. Initial esophagectomy was the least expensive but also had the lowest quality-adjusted length of life (Table 4). PDT followed by surveillance for patients with residual HGD was the most effective strategy, yielding an additional half year of quality-adjusted life, although at a higher incremental cost of $23,250 compared with esophagectomy (Appendix 5). Thus, the incremental cost-effectiveness (the ratio of the

Discussion

Our study demonstrates that PDT is potentially a cost-effective option compared with surgery for the management of patients diagnosed with HGD in Barrett's esophagus and is associated with an incremental cost of $47,410 per QALY saved (Table 4). A key determinant of the benefit of PDT is the averted post-surgical reduction in quality of life. If life after surgery were equivalent to perfect health, then surgery would be the only cost-effective treatment. Even a small decrement in quality of

Acknowledgments

We would like to thank Dr. B. F. Overholt for sharing his 4-year follow-up data after PDT with us before publication. His results appeared in the August 2003 issue of Gastrointestinal Endoscopy.9

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    This work was presented in abstract form at Digestive Diseases Week, May 18-21, 2003, Orlando, Florida (Gastrointest Endosc 2003;57:AB79) and at the 25th Annual Meeting of the Society for Medical Decision Making, October 18-22, 2003, Chicago Illinois (Med Decis Making 2003;23:585).

    Grant Support: Dr. Vij's research was supported by the National Institutes of Health Training Grant DK07056 and the National Research Service Award 5 T32 HS00028-17 from the Agency for Healthcare Research and Quality. Dr. Triadafilopoulos's research was supported in part by the National Institutes of Health Grant R01 DK063624-03.

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    Copyright © 2004 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.