Objective To compare the cost-effectiveness of endoscopic submucosal dissection (ESD) and wide-field endoscopic mucosal resection (WF-EMR) for removing large sessile and laterally spreading colorectal lesions (LSLs) >20 mm.
Design An incremental cost-effectiveness analysis using a decision tree model was performed over an 18-month time horizon. The following strategies were compared: WF-EMR, universal ESD (U-ESD) and selective ESD (S-ESD) for lesions highly suspicious for containing submucosal invasive cancer (SMIC), with WF-EMR used for the remainder. Data from a large Western cohort and the literature were used to inform the model. Effectiveness was defined as the number of surgeries avoided per 1000 cases. Incremental costs per surgery avoided are presented. Sensitivity and scenario analyses were performed.
Results 1723 lesions among 1765 patients were analysed. The prevalence of SMIC and low-risk-SMIC was 8.2% and 3.1%, respectively. Endoscopic lesion assessment for SMIC had a sensitivity and specificity of 34.9% and 98.4%, respectively. S-ESD was the least expensive strategy and was also more effective than WF-EMR by preventing 19 additional surgeries per 1000 cases. 43 ESD procedures would be required in an S-ESD strategy. U-ESD would prevent another 13 surgeries compared with S-ESD, at an incremental cost per surgery avoided of US$210 112. U-ESD was only cost-effective among higher risk rectal lesions.
Conclusion S-ESD is the preferred treatment strategy. However, only 43 ESDs are required per 1000 LSLs. U-ESD cannot be justified beyond high-risk rectal lesions. WF-EMR remains an effective and safe treatment option for most LSLs.
Trial registration number NCT02000141.
- endoscopic polypectomy
- colorectal adenomas
- therapeutic endoscopy
- colorectal cancer
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Contributors FFB designed the study, collected data, analysed data, drafted the manuscript and revised the manuscript after review by the coauthors. SJH Designed the economic model, analysed data and codrafted the manuscript. KNR collected data. HM performed histological analysis. DML performed histological analysis. EYTL performed procedures and collected data. SJW performed procedures and collected data. MJB initiated, designed and led the study, performed procedures, collected data, cowrote the manuscript and critically reviewed the manuscript.
Funding FFB was supported by a grant from the National Health and Medical Research Council of Australia (NHMRC). There was no influence from the NHMRC on study design or conduct, data collection and management, analysis,interpretation, preparation and review or approval of the manuscript. SJH was supported by the N.B. Hershfield Professorship in therapeutic endoscopy.
Competing interests None declared.
Ethics approval Western Sydney Local Health District Human Ethics Research Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are no additional unpublished data from this study.
Correction notice This article has been corrected since it published Online First. Figure 1 has been updated.