A Cost-Utility Analysis of Ablative Therapy for Barrett's Esophagus

Background & Aims

Recommendations for patients with Barrett's esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost utility of ablation with that of endoscopic surveillance strategies.

Methods

A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted; and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation, and photodynamic therapy.

Results

Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of <$6,000 compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates ≥28% of LGD or 40% of nondysplastic metaplasia, ablation would be preferred to surveillance.

Conclusions

Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued after successful ablation. As further postablation data become available, the optimal management strategy will be clarified.

Abbreviations used in this paper: BE, Barrett's esophagus, CMS, Center for Medicare and Medicaid Services, CR, complete remission, dQALY, discounted quality-adjusted life-years, EGD, esophagogastroduodenoscopy, HGD, high-grade dysplasia, ICER, incremental cost-effectiveness ratio, LGD, low-grade dysplasia, ND BE, nondysplastic Barrett's esophagus, PDT, photodynamic therapy, QALYs, quality-adjusted life-years, RFA, radiofrequency ablation, WTP, willingness to pay