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Endoscopy 2009; 41(5): 400-408
DOI: 10.1055/s-0029-1214612
Original article

© Georg Thieme Verlag KG Stuttgart · New York

An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett’s esophagus

A.  Das1 , C.  Wells1 , H.  J.  Kim1 , D.  E.  Fleischer1 , M.  D.  Crowell1 , V.  K.  Sharma1
  • 1Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
Further Information

Publication History

submitted 14 May 2008

accepted after revision 25 February 2009

Publication Date:
05 May 2009 (online)

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Background and aims: Advances have occurred in the development of safe and effective ablative therapies for Barrett’s esophagus. The aim of the current study was to perform an economic analysis evaluating the cost-effectiveness of endoscopic ablation of nondysplastic Barrett’s esophagus.

Methods: A Markov model evaluated three competing strategies in a hypothetical 50-year-old cohort with nondysplastic Barrett’s esophagus from a societal perspective. Strategy I – natural history of Barrett’s disease (without surveillance); Strategy II – surveillance performed according to the American College of Gastroenterology practice guidelines; Strategy III – endoscopic ablative therapy. The model was biased against ablative therapy with a conservative estimate of complete response and continued standard surveillance even after complete ablation. All potential complications were accounted for, and an incomplete histological response after ablation was presumed to have the same risk of progression as untreated Barrett’s. Transitional probabilities, discounted cost, and utility values to estimate quality-adjusted life-years (QALY) were obtained from published information. Direct costs were used in our analysis.

Results: In baseline analysis, the ablative strategy yielded the highest QALY and was more cost-effective than endoscopic surveillance. In a Monte Carlo analysis, the relative risk of developing cancer in the strategy based on endoscopic ablation was decreased compared with the other strategies. In threshold analysis, the critical determinants of cost-effectiveness of the ablative strategy were rate of complete response to ablation, total cost of ablation, and risk of progression to dysplasia.

Conclusions: Within the limits of the model, ablation for nondysplastic Barrett’s esophagus is more cost-effective than endoscopic surveillance. Clinical trials of ablative therapy in nondysplastic Barrett’s esophagus are needed to establish its effectiveness in reducing cancer risk.

References

  • 1 Spechler S. Clinical practice. Barrett’s esophagus.  N Engl J Med. 2002;  346 836-842
    CrossrefPubMedGoogle Scholar
  • 2 Fitzgerald R C, Saeed I T, Khoo D. et al . Rigorous surveillance protocol increases detection of curable cancers associated with Barrett’s esophagus.  Dig Dis Sci. 2001;  46 1892-1898
    CrossrefPubMedGoogle Scholar
  • 3 Corley D A, Levin T R, Habel L A. et al . Surveillance and survival in Barrett’s adenocarcinomas: a population-based study.  Gastroenterology. 2002;  122 633-640
    CrossrefPubMedGoogle Scholar
  • 4 Sampliner R E. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus.  Am J Gastroenterol. 2002;  97 1888-1895
    CrossrefPubMedGoogle Scholar
  • 5 Boyer J, Laugier R, Chemali M. et al . French Society of Digestive Endoscopy SFED guideline: monitoring of patients with Barrett’s esophagus.  Endoscopy. 2007;  39 840-842
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Playford R J. New British Society of Gastroenterology (BSG) guidelines for the diagnosis and management of Barrett’s oesophagus.  Gut. 2006;  55 442
    CrossrefPubMedGoogle Scholar
  • 7 Inadomi J M, Sampliner R, Lagergren J. et al . Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis.  Ann Intern Med. 2003;  138 176-186
    CrossrefPubMedGoogle Scholar
  • 8 Sampliner R E. Endoscopic ablative therapy for Barrett’s esophagus: current status.  Gastrointest Endosc. 2004;  59 66
    CrossrefPubMedGoogle Scholar
  • 9 Johnston M H. Technology insight: ablative techniques for Barrett’s esophagus – current and emerging trends.  Nat Clin Pract Gastroenterol Hepatol. 2005;  2 323-330
    CrossrefPubMedGoogle Scholar
  • 10 Dulai G S, Jensen D M, Cortina G. et al . Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus.  Gastrointest Endosc. 2005;  61 232-240
    CrossrefPubMedGoogle Scholar
  • 11 Sharma V K, Wang K K, Overholt B F. et al . Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett’s esophagus: 1-year follow-up of 100 patients.  Gastrointest Endosc. 2007;  65 185-195
    CrossrefPubMedGoogle Scholar
  • 12 Peters F P, Krishnadath K K, Rygiel A M. et al . Stepwise radical endoscopic resection of the complete Barrett’s esophagus with early neoplasia successfully eradicates pre-existing genetic abnormalities.  Am J Gastroenterol. 2007;  102 1853-1861
    CrossrefPubMedGoogle Scholar
  • 13 Sonnenberg F A, Beck J R. Markov models in medical decision making: a practical guide.  Med Decis Making. 1993;  13 322-338
    CrossrefPubMedGoogle Scholar
  • 14 Weinstein M C, Siegel J E, Gold M R. et al . Recommendations of the Panel on Cost-effectiveness in Health and Medicine.  JAMA. 1996;  276 1253-1258
    CrossrefPubMedGoogle Scholar
  • 15 Shaheen N J, Inadomi J M, Overholt B F, Sharma P. What is the best management strategy for high grade dysplasia in Barrett’s oesophagus? A cost effectiveness analysis.  Gut. 2004;  53 1736-1744
    CrossrefPubMedGoogle Scholar
  • 16 Gerson L B, Groeneveld P W, Triadafilopoulos G. Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease.  Clin Gastroenterol Hepatol. 2004;  2 868-879
    CrossrefPubMedGoogle Scholar
  • 17 Vij R, Triadafilopoulos G, Owens D K. et al . Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett’s esophagus.  Gastrointest Endosc. 2004;  60 739-756
    CrossrefPubMedGoogle Scholar
  • 18 Hur C, Nishioka N S, Gazelle G S. Cost-effectiveness of aspirin chemoprevention for Barrett’s esophagus.  J Natl Cancer Inst. 2004;  96 316-325
    CrossrefPubMedGoogle Scholar
  • 19 Sonnenberg A, Fennerty M B. Medical decision analysis of chemoprevention against esophageal adenocarcinoma.  Gastroenterology. 2003;  124 1758-1766
    CrossrefPubMedGoogle Scholar
  • 20 E A rias. United States life tables, 2003. National vital statistic reports; vol 54 no. 4. Hyattsville, MD; National Center for Health Statistics 2006
    Google Scholar
  • 21 Schnell T G, Sontag S J, Chejfec G. et al . Long-term nonsurgical management of Barrett’s esophagus with high-grade dysplasia.  Gastroenterology. 2001;  120 1607-1619
    CrossrefPubMedGoogle Scholar
  • 22 Weston A P, Sharma P, Topalovski M. et al . Long-term follow-up of Barrett’s high-grade dysplasia.  Am J Gastroenterol. 2000;  95 1888-1893
    CrossrefPubMedGoogle Scholar
  • 23 Hameeteman W, Tytgat G N, Houthoff H J. et al . Barrett’s esophagus: development of dysplasia and adenocarcinoma.  Gastroenterology. 1989;  96 1249-1256
    PubMedGoogle Scholar
  • 24 Sharma P, Morales T G, Bhattacharyya A. et al . Dysplasia in short-segment Barrett’s esophagus: a prospective 3-year follow-up.  Am J Gastroenterol. 1997;  92 2012-2016
    PubMedGoogle Scholar
  • 25 Weston A P, Badr A S, Hassanein R S. Prospective multivariate analysis of clinical, endoscopic, and histological factors predictive of the development of Barrett’s multifocal high-grade dysplasia or adenocarcinoma.  Am J Gastroenterol. 1999;  94 3413-3419
    CrossrefPubMedGoogle Scholar
  • 26 Cameron A J, Ott B J, Payne W S. The incidence of adenocarcinoma in columnar-lined (Barrett’s) esophagus.  N Engl J Med. 1985;  313 857-859
    CrossrefPubMedGoogle Scholar
  • 27 Drewitz D J, Sampliner R E, Garewal H S. The incidence of adenocarcinoma in Barrett’s esophagus: a prospective study of 170 patients followed 4.8 years.  Am J Gastroenterol. 1997;  92 212-215
    PubMedGoogle Scholar
  • 28 Spechler S J, Lee E, Ahnen D. et al . Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial.  JAMA. 2001;  285 2331-2338
    CrossrefPubMedGoogle Scholar
  • 29 O’Connor J B, Falk G W, Richter J E. The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus: report on the Cleveland Clinic Barrett’s Esophagus Registry.  Am J Gastroenterol. 1999;  94 2037-2042
    PubMedGoogle Scholar
  • 30 Shaheen N J, Crosby M A, Bozymski E M. et al . Is there publication bias in the reporting of cancer risk in Barrett’s esophagus?.  Gastroenterology. 2000;  119 333-338
    CrossrefPubMedGoogle Scholar
  • 31 Katz D, Rothstein R, Schned A. et al . The development of dysplasia and adenocarcinoma during endoscopic surveillance of Barrett’s esophagus.  Am J Gastroenterol. 1998;  93 536-541
    CrossrefPubMedGoogle Scholar
  • 32 Spechler S J, Robbins A H, Rubins H B. et al . Adenocarcinoma and Barrett’s esophagus. An overrated risk?.  Gastroenterology. 1984;  87 927-933
    PubMedGoogle Scholar
  • 33 Weston A P, Badr A S, Hassanein R S. Prospective multivariate analysis of factors predictive of complete regression of Barrett’s esophagus.  Am J Gastroenterol. 1999;  94 3420-346
    CrossrefPubMedGoogle Scholar
  • 34 Winters Jr C, Spurling T J, Chobanian S J. et al . Barrett’s esophagus. A prevalent, occult complication of gastroesophageal reflux disease.  Gastroenterology. 1987;  92 118-124
    CrossrefPubMedGoogle Scholar
  • 35 Streitz J MJ, Andrews C WJ, Ellis F H, Jr. E ndoscopic. Does it help?.  J Thorac Cardiovasc Surg. 1993;  105 383-387
    PubMedGoogle Scholar
  • 36 Menke-Pluymers M B, Schoute N W, Mulder A H. et al . Outcome of surgical treatment of adenocarcinoma in Barrett’s oesophagus.  Gut. 1992;  33 1454-1458
    CrossrefPubMedGoogle Scholar
  • 37 Pera M, Trastek V F, Carpenter H A. et al . Barrett’s esophagus with high-grade dysplasia: an indication for esophagectomy?.  Ann Thorac Surg. 1992;  54 199-204
    CrossrefPubMedGoogle Scholar
  • 38 Peters J H, Clark G W, Ireland A P. et al . Outcome of adenocarcinoma arising in Barrett’s esophagus in endoscopically surveyed and nonsurveyed patients.  J Thorac Cardiovasc Surg. 1994;  108 813-821
    PubMedGoogle Scholar
  • 39 Overholt B F, Panjehpour M, Halberg D L. Photodynamic therapy for Barrett’s esophagus with dysplasia and/or early stage carcinoma: long-term results.  Gastrointest Endosc. 2003;  58 183-188
    CrossrefPubMedGoogle Scholar
  • 40 Sharma P, Wani S, Weston A P. et al . A randomised controlled trial of ablation of Barrett’s oesophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid suppression: long term results.  Gut. 2006;  55 1233-1239
    CrossrefPubMedGoogle Scholar
  • 41 Zaninotto G, Parenti A R, Ruol A. et al . Oesophageal resection for high-grade dysplasia in Barrett’s oesophagus.  Br J Surg. 2000;  87 1102-1105
    CrossrefPubMedGoogle Scholar
  • 42 Patti M G, Corvera C U, Glasgow R E. et al . A hospital’s annual rate of esophagectomy influences the operative mortality rate.  J Gastrointest Surg. 1998;  2 186-192
    CrossrefPubMedGoogle Scholar
  • 43 Bousamra M, Haasler G B. A decade of experience with transthoracic and transhiatal esophagectomy.  Am J Surg. 2002;  183 162-167
    CrossrefPubMedGoogle Scholar
  • 44 Lerut T, Coosemans W, Van Raemdonck D. et al . Surgical treatment of Barrett’s carcinoma. Correlations between morphologic findings and prognosis.  J Thorac Cardiovasc Surg. 1994;  107 1059-1065
    PubMedGoogle Scholar
  • 45 McLarty A J, Deschamps C, Trastek V F. et al . Esophageal resection for cancer of the esophagus: long-term function and quality of life.  Ann Thorac Surg. 1997;  63 1568-1572
    Google Scholar
  • 46 Chan M F. Complications of upper gastrointestinal endoscopy.  Gastrointest Endosc Clin N Am. 1996;  6 287-303
    PubMedGoogle Scholar
  • 47 Kavic S M, Basson M D. Complications of endoscopy.  Am J Surg. 2001;  181 319-332
    CrossrefPubMedGoogle Scholar
  • 48 Arrowsmith J B, Gerstman B B, Fleischer D E. et al . Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy.  Gastrointest Endosc. 1991;  37 421-427
    Google Scholar
  • 49 Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy.  Endoscopy. 1990;  22 229-233
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Hernandez L J, Jacobson J W, Harris M S. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures.  Gastrointest Endosc. 2000;  51 460-462
    CrossrefPubMedGoogle Scholar
  • 51 Iannettoni M D, Vlessis A A, Whyte R I. et al . Functional outcome after surgical treatment of esophageal perforation.  Ann Thorac Surg. 1997;  64 1606-1609
    CrossrefPubMedGoogle Scholar
  • 52 Ormsby A H, Petras R E, Henricks W H. et al . Observer variation in the diagnosis of superficial oesophageal adenocarcinoma.  Gut. 2002;  51 671-676
    CrossrefPubMedGoogle Scholar
  • 53 Montgomery E, Bronner M P, Goldblum J R. et al . Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation.  Hum Pathol. 2001;  32 368-378
    CrossrefPubMedGoogle Scholar
  • 54 Provenzale D, Schmitt C, Wong J B. Barrett’s esophagus: a new look at surveillance based on emerging estimates of cancer risk.  Am J Gastroenterol. 1999;  94 2043-2053
    CrossrefPubMedGoogle Scholar
  • 55 Provenzale D, Kemp J A, Arora S. et al . A guide for surveillance of patients with Barrett’s esophagus.  Am J Gastroenterol. 1994;  89 670-680
    PubMedGoogle Scholar
  • 56 Alikhan M, Rex D, Khan A. et al . Variable pathologic interpretation of columnar lined esophagus by general pathologists in community practice.  Gastrointest Endosc. 1999;  50 23-26
    CrossrefPubMedGoogle Scholar
  • 57 Zaman R, Hapke G, Sahagun G, Katon R M. Unsedated peroral endoscopy with a video ultrathin endoscope: patient acceptance, tolerance, and diagnostic accuracy.  Am J Gastroenterol. 1998;  93 1260-1263
    CrossrefPubMedGoogle Scholar
  • 58 de Boer A G, Stalmeier P F, Sprangers M A. et al . Transhiatal vs extended transthoracic resection in oesophageal carcinoma: patients’ utilities and treatment preferences.  Br J Cancer. 2002;  86 851-857
    CrossrefPubMedGoogle Scholar
  • 59 Doubilet P, Begg C B, Weinstein M C. et al . Probabilistic sensitivity analysis using Monte Carlo simulation: a practical approach.  Med Decis Making. 1985;  5 157-177
    CrossrefPubMedGoogle Scholar
  • 60 Stinnett A A, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis.  Med Decis Making. 1998;  18 (Suppl. 2) S68-S80
    CrossrefPubMedGoogle Scholar
  • 61 Heitjan D F. Fieller’s method and net health benefit.  Health Econ. 2000;  9 327-335
    CrossrefPubMedGoogle Scholar
  • 62 Ganz R A, Overholt B F, Sharma V K. et al . Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry.  Gastrointest Endosc. 2008;  68 35-40
    CrossrefPubMedGoogle Scholar
  • 63 Gondrie J J, Pouw R E, Sondermeijer C M. et al . Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system.  . 2008;  40 370-379
    Article in Thieme ConnectPubMedGoogle Scholar
  • 64 Sharma V K, Kim H J, Das A. et al . Circumferential and focal ablation of Barrett esophagus containing dysplasia.  Am J Gastroenterol. 2009;  104 310-317
    CrossrefPubMedGoogle Scholar
  • 65 Gondrie J J, Pouw R E, Sondermeijer C M. et al . Stepwise circumferential and focal ablation of Barrett’s esophagus with high-grade dysplasia: results of the first prospective series of 11 patients.  Endoscopy. 2008;  40 359-369
    Article in Thieme ConnectPubMedGoogle Scholar
  • 66 Sharma V K, Kim H J, Das A. et al . A prospective pilot trial of ablation of Barrett’s esophagus with low-grade dysplasia using stepwise circumferential and focal ablation (HALO system).  Endoscopy. 2008;  40 380-387
    Article in Thieme ConnectPubMedGoogle Scholar
  • 67 Fleischer D E, Overholt B F, Sharma V K. et al . Endoscopic ablation of Barrett’s esophagus: a multicenter study with 2.5-year follow-up.  . 2008;  68 867-876
    CrossrefPubMedGoogle Scholar
  • 68 Shaheen N J, Sharma P, Overholt B F. et al . A randomized, multicenter, sham-controlled trial of radiofrequency ablation (RFA) for subjects with Barrett’s esophagus (BE) containing dysplasia: interim results of the AIM Dysplasia Trial.  Gastroenterology. 2008;  134 A37
    PubMedGoogle Scholar
  • 69 Arguedas M R, Eloubeidi M A. Barrett’s esophagus: a review of costs of the illness.  Pharmacoeconomics. 2001;  19 1003-1011
    CrossrefPubMedGoogle Scholar
  • 70 Weston A P. Automated circumferential Barrett’s ablation by using radiofrequency energy: a welcome step in the right direction.  Gastrointest Endosc. 2007;  65 196-199
    PubMedGoogle Scholar
  • 71 Bergman J J. Radiofrequency energy ablation of Barrett’s esophagus: the best is yet to come!.  Gastrointest Endosc. 2007;  65 200-202
    CrossrefPubMedGoogle Scholar
  • 72 Inadomi J M, Madanick R D, Somsouk M. et al . Radiofrequency ablation is more cost-effective than endoscopic surveillance or esophagectomy among patients with Barrett’s esophagus and low-grade dysplasia [abstract].  Gastroenterology. 2007;  132 A53
    PubMedGoogle Scholar
  • 73 Craig B A, Black M A, Sendi P P. Uncertainty in decision models analyzing cost-effectiveness.  Med Decis Making. 2000;  20 135-137
    CrossrefPubMedGoogle Scholar
  • 74 Sampliner R E. The better burn.  Gastrointest Endosc. 2005;  61 241-242
    CrossrefPubMedGoogle Scholar
  • 75 Krishnadath K K, Reid B J, Wang K K. Biomarkers in Barrett esophagus.  Mayo Clin Proc. 2001;  76 438-446
    PubMedGoogle Scholar

A. Das, MD

Division of Gastroenterology
Mayo Clinic Arizona

Scottsdale
AZ 85259
USA

Fax: +1-480-301-6867

Email: Das.ananya@mayo.edu

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