Cost–effectiveness analysis of endoscopic eradication therapy for treatment of high-grade dysplasia in Barrett’s esophagus

Abstract

Aim:The aim was to evaluate the cost-effectiveness of endoscopic eradication therapy (EET) with combined endoscopic mucosal resection and radiofrequency ablation for the treatment of high-grade dysplasia (HGD) arising in patients with Barrett's esophagus compared with endoscopic surveillance alone in the UK. Materials & methods:The cost-effectiveness model consisted of a decision tree and modified Markov model. A lifetime time horizon was adopted with the perspective of the UK healthcare system. Results: The base case analysis estimates that EET for the treatment of HGD is cost-effective at a GB£20,000 cost-effectiveness threshold compared with providing surveillance alone for HGD patients (incremental cost-effectiveness ratio: GB£1272). Conclusion: EET is likely to be a cost-effective treatment strategy compared with surveillance alone in patients with HGD arising in Barrett's esophagus in the UK. Barrett's esophagus (BE) is a precancerous state that can develop into esophageal adenocarcinoma (OAC). BE exists in most patients in a metaplastic state and carries a very low risk of progression to invasive neoplasia and OAC in the region of 0.12-0.5% per year [1,2]. The 2013 British Society of Gastroenterology (BSG) guidelines advise that, in those patients with BE in whom there is no neoplasia, surveillance is recommended for those fit for endoscopy [3]. This is based on existing evidence from published studies which show that surveillance correlates with early-stage cancer diagnosis and likely improved survival from other cancers [4][5][6]. Recent work from the ProBar study group examined data from the Dutch cancer registry. They compared survival of patients with BE with neoplastic progression during surveillance with those of patients without neoplastic progression and patients with OAC in the general population. They found that OAC was diagnosed at an earlier stage during BE surveillance than in the general population. However, the survival of patients with BE with neoplastic progression was not significantly worse than those of patients without neoplastic progression, and was similar to survival of patients with stage 0 or stage 1 OAC in the general population [7]. In patients with OAC, the prognosis is poor with just over 15% patients being alive at 5 years [8].Current UK surveillance guidelines [3] recommend that patients with BE undergo endoscopy every 2-5 years. In some patients, no surveillance is recommended due to the negligible risk for cancer progression. The intervals are dependent on the length of BE and presence of intestinal metaplasia at the index endoscopy. However, in a minority of patients with BE there is a molecular and pathological transformation through various dysplastic stages to mucosal dysplasia and cancer and then finally invasive disease where it Cost-effectiveness analysis of endoscopic eradication therapy for treatment of highgrade dysplasia in Barrett's esophagus

A cost-effectiveness analysis of endoscopic eradication therapy for management of dysplasia arising in patients with Barrett’s oesophagus in the United Kingdom

“…The results of this study align with the previous literature which has shown RFA to be cost effective for LGD and HGD separately [22,25,39]. Although the previous analysis of RFA for only HGD patients resulted in a marginally lower ICER (£1,272) [39], the current analysis highlights that use of RFA for both LGD and HGD patients remains significantly cost-effective (ICER: £3,006). Although, NICE clinical guidelines reported ICERs far in A c c e p t e d M a n u s c r i p t excess of the current results (£24,829 [3]).…”

National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett’s oesophagus and stage I oesophageal adenocarcinoma

“…In addition to the clinical studies, four cost–utility analyses were identified. 68 76–78 They reported that at a threshold of £20 000 per QALY gained, EMR combined with RFA was cost effective versus endoscopic surveillance 77 ; EMR plus RFA plus surveillance, EMR plus APC plus surveillance and surgery were all cost effective versus no surveillance 78 ; RFA followed by endoscopic surveillance was cheaper and more effective than oesophagectomy 76 ; and RFA alone was cheaper and more effective than oesophagectomy. 68 …”

“…In addition to the clinical studies, four cost-utility analyses were identified. 68 76-78 They reported that at a threshold of £20 000 per QALY gained, EMR combined with RFA was cost effective versus endoscopic surveillance 77 ; EMR plus RFA plus surveillance, EMR plus APC plus surveillance and surgery were all cost effective versus no surveillance 78 ; RFA followed by endoscopic surveillance was cheaper and more effective than oesophagectomy 76 ; and RFA alone was cheaper and more effective than oesophagectomy. 68 Based on clinical experience the committee recommended that high-grade dysplasia should be endoscopically resected, when oesophageal lesions are visible at endoscopy, and the residual Barrett's oesophagus should be treated with endoscopic ablation.…”

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

“…The endpoint of surveillance is the detection of dysplasia or intramucosal carcinoma (IMCa). Endoscopic eradication therapy (EET) for high‐grade dysplastic (HGD) lesions and early neoplasia within BE has been shown to be cost‐effective and eliminates the need for esophagectomy 9,10 . Expert agreement on quality indicators for EET for BE has been published and outlines some guidance for those wishing to establish such a service 11 .…”

“…Endoscopic eradication therapy (EET) for high-grade dysplastic (HGD) lesions and early neoplasia within BE has been shown to be cost-effective and eliminates the need for esophagectomy. 9,10 Expert agreement on quality indicators for EET for BE has been published and outlines some guidance for those wishing to establish such a service. 11 The statements are supported by evidence and give direction to those treating BE associated dysplasia and malignancy, while affording operators latitude on their approach to endoscopic resection (ER) and ablation.…”