Medical decision analysis of endoscopic surveillance of Barrett’s oesophagus to prevent oesophageal adenocarcinoma

Abstract

INTRODUCTIONIn a subgroup of patients with gastro-oesophageal re¯ux disease, the normal squamous epithelium of the distal oesophagus is replaced by columnar lined epithelium with intestinal metaplasia. The condition of intestinal metaplasia in the distal oesophagus is known as Barrett's oesophagus. Barrett's oesophagus carries a more than 30-fold increased risk of developing oesophageal adenocarcinoma. 1 Estimates for the annual incidence rate of adenocarcinoma range between 0.2% and 2% in patients with Barrett's oesophagus. 1,2 Because of this increased risk, the majority of gastroenterologists recommend frequent surveillance of patients with Barrett's oesophagus. 3 It is very dif®cult to validate the usefulness of endoscopic surveillance in a randomized clinical trial because a large number of patients with Barrett's oesophagus need to be followed over a prolonged period of time. In addition to the costs and logistic problems involved in the follow-up of a large group of patients over a prolonged time period, only a few patients are available for recruitment at individual gastroenterology centres. 4 To overcome the dearth of prospective clinical data, the feasibility of endoscopic surveillance to intervene in the development of oesophageal adenocarcinoma was tested by cost± utility analyses. 5,6 These studies suggested that the cost of endoscopic surveillance is in the range $26 000± 98 000 per quality-adjusted life-year saved. The underlying decision models were not described in suf®cient detail to replicate and expand the original SUMMARY Background: Barrett's oesophagus is associated with an increased risk of the development of oesophageal adenocarcinoma. Endoscopic surveillance every 2±5 years has been recommended to prevent death from adenocarcinoma. Aim: To assess the cost-effectiveness of this strategy. Methods: The incremental cost-effectiveness of surveillance (as compared to no surveillance) was analysed with a computer model of a Markov process. Results: Compared to no surveillance, the incremental cost-effectiveness of bi-annual endoscopy is $16 695 per life-year saved. Surveillance is less cost-effective if

Optical Coherence Tomography to Identify Intramucosal Carcinoma and High-Grade Dysplasia in Barrett’s Esophagus

“…Of the 177 remaining images, 49 corresponded to a diagnosis of IMC/HGD, 15 to LGD, 8 to IGD, 100 to SIM, and 5 to gastric mucosa. Of the 65 discarded images, 20 corresponded to a diagnosis of IMC/HGD, 13 LGD, 2 IGD, 29 SIM, and 1 gastric mucosa. The agreement between pathologists' diagnoses of IMC/HGD was excellent (κ = 0.89).…”

Barrett's Esophagus

“…Some computer-modeling studies have concluded that screening and surveillance can be cost-effective under certain circumstances, but such studies are not definitive. 43,44 Despite the lack of high-quality evidence to support the practice, medical societies currently recommend endoscopic screening for Barrett's esophagus in patients with chronic GERD symptoms who have at least one additional risk factor for esophageal adenocarcinoma, such as an age of 50 years or older, male sex, white race, hiatal hernia, elevated body-mass index, intraabdominal body-fat distribution, or tobacco use. 2,12,13,45 If the screening examination does not reveal Barrett's esophagus, no further endoscopic screening for the condition is recommended.…”

Screening and surveillance for Barrett’s esophagus

“…A number of computer models have supported the practice of endoscopic screening and surveillance for Barrett's esophagus [34][35][36][37][38][39][40][41]. Table 1 summarizes the results of five Markov models that examined the issue of screening middle-aged patients with GERD symptoms for Barrett's esophagus.…”