A cost-utility analysis of ablative therapy for Barrett's esophagus

Stratification of Barrett's esophagus surveillance based on p53 immunohistochemistry: a cost-effectiveness analysis by an international collaborative group

BACKGROUND

Surveillance of nondysplastic Barrett's esophagus (NDBE) is recommended to identify progression to dysplasia; however, the most cost-effective strategy remains unclear. Mutation of TP53 or aberrant expression of p53 have been associated with the development of dysplasia in BE. We sought to determine if surveillance intervals for BE could be stratified based on p53 expression.

METHODS

A Markov model was developed for NDBE. Patients with NDBE underwent p53 immunohistochemistry (IHC) and those with abnormal p53 expression underwent surveillance endoscopy at 1 year, while patients with normal p53 expression underwent surveillance in 3 years. Patients with dysplasia underwent endoscopic therapy and surveillance.

RESULTS

On base-case analysis, the strategy of stratifying surveillance based on abnormal p53 IHC was cost-effective relative to conventional surveillance and a natural history model, with an incremental cost-effectiveness ratio (ICER) of $8258 for p53 IHC-based surveillance. Both the conventional and p53-stratified surveillance strategies dominated the natural history model. On probabilistic sensitivity analysis, the p53 IHC strategy ($28 652; 16.78 quality-adjusted life years [QALYs]) was more cost-effective than conventional surveillance ($25 679; 16.17 QALYs) with a net monetary benefit of $306 873 compared with conventional surveillance ($297 642), with an ICER <$50 000 in 96% of iterations. The p53-stratification strategy was associated with a 14% reduction in the overall endoscopy burden and a 59% increase in dysplasia detection.

CONCLUSION

A surveillance strategy for BE based on abnormal p53 IHC is cost-effective relative to a conventional surveillance strategy and is likely to be associated with higher rates of dysplasia diagnosis.

AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia

BACKGROUND & AIMS

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia.

METHODS

The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations.

RESULTS

The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics.

CONCLUSIONS

This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.

Cost-effectiveness Analysis of Radiofrequency Ablation in Patients With Barrett Esophagus and High-Grade Dysplasia or Low-Grade Dysplasia

PURPOSE

Clinical guidelines recommend radiofrequency ablation (RFA) for eradication of Barrett esophagus in patients with low-grade dysplasia (LGD) and high-grade dysplasia (HGD), but evidence on whether RFA provides good value for money is still sparse. This study evaluates the cost-effectiveness of RFA in Italy.

METHODS

A Markov model was used to estimate lifelong costs and consequences of disease progression with different treatments. RFA was compared with esophagectomy in the HGD group or endoscopic surveillance in the LGD group. Clinical and quality-of-life parameters were derived from a review of the literature and expert opinions, whereas Italian national tariffs were used as a proxy for costs.

FINDINGS

RFA dominated esophagectomy in patients with HGD with a probability of 83%. For patients with LGD, RFA was more effective and more costly than active surveillance (incremental cost-effectiveness ratio, €6276 per quality-adjusted life-year). At a cost-effectiveness threshold of €15,272, the probability of RFA being the optimal strategy in this population was close to 100%. Model results were sensitive to the cost of the interventions and utility weights used in the different disease states.

IMPLICATIONS

RFA is likely to be the optimal choice for patients with LGD and HGD in Italy. Italy is discussing the implementation of a national program for the health technology assessment of medical devices, requiring more studies to prove value for money of emerging technologies.

Clinical consequences of nonadherence to Barrett's esophagus surveillance recommendations: a Multicenter prospective cohort study

Half of Barrett's esophagus (BE) surveillance endoscopies do not adhere to guideline recommendations. In this multicenter prospective cohort study, we assessed the clinical consequences of nonadherence to recommended surveillance intervals and biopsy protocol. Data from BE surveillance patients were collected from endoscopy and pathology reports; questionnaires were distributed among endoscopists. We estimated the association between (non)adherence and (i) endoscopic curability of esophageal adenocarcinoma (EAC), (ii) mortality, and (iii) misclassification of histological diagnosis according to a multistate hidden Markov model. Potential explanatory parameters (patient, facility, endoscopist variables) for nonadherence, related to clinical impact, were analyzed. In 726 BE patients, 3802 endoscopies were performed by 167 endoscopists. Adherence to surveillance interval was 16% for non-dysplastic (ND)BE, 55% for low-grade dysplasia (LGD), and 54% of endoscopies followed the Seattle protocol. There was no evidence to support the following statements: longer surveillance intervals or fewer biopsies than recommended affect endoscopic curability of EAC or cause-specific mortality (P > 0.20); insufficient biopsies affect the probability of NDBE (OR 1.0) or LGD (OR 2.3) being misclassified as high-grade dysplasia/EAC (P > 0.05). Better adherence was associated with older patients (OR 1.1), BE segments ≤ 2 cm (OR 8.3), visible abnormalities (OR 1.8, all P ≤ 0.05), endoscopists with a subspecialty (OR 3.2), and endoscopists who deemed histological diagnosis an adequate marker (OR 2.0). Clinical consequences of nonadherence to guidelines appeared to be limited with respect to endoscopic curability of EAC and mortality. This indicates that BE surveillance recommendations should be optimized to minimize the burden of endoscopies.

The Utility of the Marshmallow Barium Swallow Esophagogram for Investigation of Ineffective Esophageal Motility: A Systematic and Narrative Review

Objectives Current gold standard investigations to determine the pathology of ineffective esophageal motility (IEM) are invasive and resource-intensive. Marshmallow barium swallow esophagogram (MBSE) is emerging as a more feasible modality; however, our understanding of its role in the clinical setting is limited. Our aim was to appraise the current literature and describe the effectiveness and limitations of MBSE as a potential diagnostic tool when investigating the pathological cause of IEM.

Methods A search in PubMed was conducted on May 23, 2021. Search terms included “marshmallow” AND “barium.” We included all studies which examined MBSE in the context of esophageal disease. The primary outcome of interest was to characterize the use of MBSE in current literature.

Results A total of 12 studies were retrieved after initial search with 9 studies meeting final inclusion criteria. A total of 375 patients were included, with 296 patients (79%) having a relevant diagnosis or symptom prompting investigation with MBSE. The most common diagnoses included referral to a gastroenterology clinic for a barium swallow (44%), post-Angelchik insertion (23%), and dysphagia (13%). Esophageal disease was identified in both the MBSE and other screening tests in 63% participants, whereas in 27% participants abnormalities were only seen using the MBSE.

Conclusion There is currently limited high-quality evidence on the use of MBSE to diagnose IEM. Further large-scale studies comparing its use in patients with different pathologic causes of IEM and of older age are required to further delineate the optimal delivery of this emerging diagnostic modality.

Management of nondysplastic Barrett’s esophagus: When to survey? When to ablate?

Barrett’s esophagus (BE), a precursor for esophageal adenocarcinoma (EAC), is defined as salmon-colored mucosa extending more than 1 cm proximal to the gastroesophageal junction with histological evidence of intestinal metaplasia. The actual risk of EAC in nondysplastic Barrett’s esophagus (NDBE) is low with an annual incidence of 0.3%. The mainstay in the management of NDBE is control of gastroesophageal reflux disease (GERD) along with enrollment in surveillance programs. The current recommendation for surveillance is four-quadrant biopsies every 2 cm (or 1 cm in known or suspected dysplasia) followed by biopsy of mucosal irregularity (nodules, ulcers, or other visible lesions) performed at 3- to 5-year intervals. Challenges to surveillance include missed cancers, suboptimal adherence to surveillance guidelines, and lack of strong evidence for efficacy. There is minimal role for endoscopic eradication therapy in NDBE. The role for enhanced imaging techniques, artificial intelligence, and risk prediction models using clinical data and molecular markers is evolving.

A cost-effectiveness modeling study of treatment interventions for stage I to III esophageal squamous cell carcinoma

Background

Esophageal cancer causes considerable costs for health systems. Appropriate treatment options for patients with esophageal squamous cell carcinoma (ESCC) can reduce medical costs and provide more improved outcomes for health systems and patients. This study evaluates the cost-effectiveness of treatment interventions for patients with ESCC according to the Iranian health system.

Material and methods

A five-state Markov model with a 15-year time horizon was performed to evaluate the cost-effectiveness of treatment interventions based on stage for ESCC patients. Costs ($US 2021) and outcomes were calculated from the Iranian health system, with a discount rate of 3%. One-way sensitivity analyses were performed to assess the potential effects of uncertain variables on the model results.

Results

In stage I, the Endoscopic Mucosal Resection (EMR) treatment yielded the lowest total costs and highest total QALY for a total of $1473 per QALY, making it the dominant strategy compared with esophagectomy and EMR followed by ablation. In stages II and III, chemoradiotherapy (CRT) followed by surgery dominated esophagectomy. CRT followed by surgery was also cost-effective with an incremental cost-effectiveness ratio (ICER) of $2172.8 per QALY compared to CRT.

Conclusion

From the Iranian health system’s perspective, EMR was the dominant strategy versus esophagectomy and EMR followed by ablation for ESCC patients in stage I. The CRT followed by surgery was a cost-effective intervention compared to CRT and esophagectomy in stages II and III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00352-5.

Estimated Cost-effectiveness of Endoscopic Screening for Upper Gastrointestinal Tract Cancer in High-Risk Areas in China

IMPORTANCE

Upper gastrointestinal tract cancer, including esophageal and gastric cancers, in China accounts for 50% of the global burden. Endoscopic screening may be associated with a decreased incidence of and mortality from upper gastrointestinal tract cancer.

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic screening for esophageal and gastric cancers among people aged 40 to 69 years in areas of China where the risk of these cancers is high.

DESIGN, SETTING, AND PARTICIPANTS

For this economic evaluation, a Markov model was constructed for initial screening at different ages from a health care system perspective, and 5 endoscopic screening strategies with different frequencies (once per lifetime and every 10 years, 5 years, 3 years, and 2 years) were evaluated. The study was conducted between January 1, 2019, and October 31, 2020. Model parameters were estimated based on this project, government documents, and published literature. For each initial screening age (40-44, 45-49, 50-54, 55-59, 60-64, and 65-69 years), a closed cohort of 100 000 participants was assumed to enter the model and follow the alternative strategies.

MAIN OUTCOMES AND MEASURES

Cost-effectiveness was measured by calculating the incremental cost-effectiveness ratio (ICER), and the willingness-to-pay threshold was assumed to be 3 times the per capita gross domestic product in China (US $10 276). Univariate and probabilistic sensitivity analyses were conducted to assess the robustness of model findings.

RESULTS

The study included a hypothetical cohort of 100 000 individuals aged 40 to 69 years. All 5 screening strategies were associated with improved effectiveness by 1087 to 10 362 quality-adjusted life-years (QALYs) and increased costs by US $3 299 000 to $22 826 000 compared with no screening over a lifetime, leading to ICERs of US $1343 to $3035 per QALY. Screening at a higher frequency was associated with an increase in QALYs and costs; ICERs for higher frequency screening compared with the next-lower frequency screening were between US $1087 and $4511 per QALY. Screening every 2 years would be the most cost-effective strategy, with probabilities of 90% to 98% at 3 times the per capita gross domestic product of China. The model was the most sensitive to utility scores of esophageal cancer- or gastric cancer-related health states and compliance with screening.

CONCLUSIONS AND RELEVANCE

The findings suggest that combined endoscopic screening for esophageal and gastric cancers may be cost-effective in areas of China where the risk of these cancers is high; screening every 2 years would be the optimal strategy. These data may be useful for development of policies targeting the prevention and control of upper gastrointestinal tract cancer in China.

Improving cost-effectiveness of endoscopic surveillance for Barrett's esophagus by reducing low-value care: a review of economic evaluations

BACKGROUND

Individuals with Barrett's esophagus are believed to be at 30-120× risk of developing esophageal adenocarcinoma (EAC). Early detection and endoscopic treatment of dysplasia/early cancer confers a significant advantage to patients under surveillance; however, most do not progress past the non-dysplastic state of Barrett's esophagus (NDBE), which is potentially an inefficient distribution of health care resources.

OBJECTIVES

This article aimed to review the outcomes of cost-effectiveness studies reducing low-value care in the context of endoscopic surveillance for non-dysplastic Barrett's esophagus (NDBE).

METHODS

A systematic search was conducted by two reviewers in accordance with PRISMA guidelines.

INCLUSION CRITERIA

cost-utility analyses of endoscopic surveillance of NDBE patients with at least one treatment strategy focused on reduction of surveillance. A narrative synthesis of economic evaluations was undertaken, along with an in-depth analysis of input parameters contributing to stated Incremental cost-effectiveness ratios (ICER). Study appraisal was performed using the consolidated health economic evaluation reporting standards (CHEERS) tool.

RESULTS

10 Studies met inclusion criteria. There was significant variation in cost-model structures, input parameters, ICER values, and willingness-to-pay thresholds between studies. All studies except one concluded guideline-specified endoscopic surveillance for NDBE patients was not cost-effective. Studies that explored a modified surveillance by deselection of low-risk NDBE patients found it to be a cost-effective strategy.

CONCLUSION

Guideline specified endoscopic surveillance for NDBE was not found to be cost-effective in the studies examined. A modified endoscopic surveillance strategy removing individuals with the lowest risk for progression from NDBE to adenocarcinoma is likely to be cost-effective but is dependent on risk profile of patients excluded from surveillance.

Economic evaluation of Cytosponge®-trefoil factor 3 for Barrett esophagus: A cost-utility analysis of randomised controlled trial data

BACKGROUND

Esophageal adenocarcinoma has a very poor prognosis unless detected early. The Cytosponge-trefoil factor 3 (TFF3) is a non-endoscopic test for Barrett esophagus, a precursor of esophageal adenocarcinoma. Randomised controlled trial data from the BEST3 trial has shown that an offer of Cytosponge-TFF3 in the primary care setting in England to individuals on medication for acid reflux increases detection of Barrett esophagus 10-fold over a year compared with standard care. This is an economic evaluation of Cytosponge-TFF3 screening versus usual care using data from the BEST3 trial which took place between 20th March 2017 and 21st March 2019.

METHODS

A Markov model with a one-year cycle-length and a lifetime time horizon was created, adapting previous modeling work on Cytosponge screening. The impact of one round of Cytosponge screening was modelled in patients with a median age of 69 years (based on BEST3 trial population). Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were conducted on model parameters.

FINDINGS

Per person, one round of Cytosponge-TFF3 screening, including confirmatory endoscopy and treatment, in the intervention arm costed £82 more than usual care and generated an additional 0.015 quality-adjusted life-years (QALYs) at an ICER of £5,500 per QALY gained. Probabilistic sensitivity analysis gave an ICER of £5,405 (95% CI -£6,791 to £17,600). The average QALY gain per person is small because the majority of patients in the model will not develop BE and therefore will have no resulting change in their utility, however the small proportion of patients who are identified with BE dysplasia or cancer derive large benefit. At a willingness-to-pay threshold of £20,000 per QALY, the probability that Cytosponge-TFF3 was cost-effective was over 90%.

INTERPRETATION

Using data from a pragmatic randomised trial, one-off Cytosponge-TFF3 screen is cost-effective relative to usual care for patients with gastro-esophageal reflux disease, despite relatively low uptake and an older population in this trial setting than previously modelled. Improving Cytosponge-TFF3 uptake and targeting younger patients is likely to further improve cost-effectiveness.

Massively Parallel Sequencing of Esophageal Brushings Enables an Aneuploidy-Based Classification of Patients With Barrett's Esophagus

BACKGROUND & AIMS

Aneuploidy has been proposed as a tool to assess progression in patients with Barrett's esophagus (BE), but has heretofore required multiple biopsies. We assessed whether a single esophageal brushing that widely sampled the esophagus could be combined with massively parallel sequencing to characterize aneuploidy and identify patients with disease progression to dysplasia or cancer.

METHODS

Esophageal brushings were obtained from patients without BE, with non-dysplastic BE (NDBE), low-grade dysplasia (LGD), high-grade dysplasia (HGD), or adenocarcinoma (EAC). To assess aneuploidy, we used RealSeqS, a technique that uses a single primer pair to interrogate ∼350,000 genome-spanning regions and identify specific chromosome arm alterations. A classifier to distinguish NDBE from EAC was trained on results from 79 patients. An independent validation cohort of 268 subjects was used to test the classifier at distinguishing patients at successive phases of BE progression.

RESULTS

Aneuploidy progression was associated with gains of 1q, 12p, and 20q and losses on 9p and 17p. The entire chromosome 8q was often gained in NDBE, whereas focal gain of 8q24 was identified only when there was dysplasia. Among validation subjects, a classifier incorporating these features with a global measure of aneuploidy scored positive in 96% of EAC, 68% of HGD, but only 7% of NDBE.

CONCLUSIONS

RealSeqS analysis of esophageal brushings provides a practical and sensitive method to determine aneuploidy in BE patients. It identifies specific chromosome changes that occur early in NDBE and others that occur late and mark progression to dysplasia. The clinical implications of this approach can now be tested in prospective trials.

Cost-Effectiveness of Screening, Surveillance, and Endoscopic Eradication Therapies for Managing the Burden of Esophageal Adenocarcinoma

The authors conducted a review of the literature of cost-effectiveness analyses regarding management of Barrett's esophagus, including screening, surveillance, and treatment strategies. Because of the presence of multiple systematic reviews on this topic, they chose to focus on more recent economic analyses, with an emphasis on comparative modeling because these analyses have been demonstrated to achieve greater validity and impact when there are multiple competing strategies that are clinically reasonable to pursue. The authors identified areas of consensus across studies regarding management strategies and also areas that require additional empirical data.

The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia

Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.

Optimizing Management of Patients With Barrett's Esophagus and Low-Grade or No Dysplasia Based on Comparative Modeling

BACKGROUND & AIMS

Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients.

METHODS

We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY).

RESULTS

In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to $17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY).

CONCLUSIONS

Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women.

Overutilization of Endoscopic Surveillance in Barrett's Esophagus: The Perils of Too Much of a Good Thing

A cost-utility analysis in the current issue of AJG examines the ramifications of the overuse of surveillance endoscopy in Barrett's esophagus (BE). This study suggests that excess surveillance is expensive, increasing costs by 50% or more, with only nominal increases in quality-adjusted life expectancy. This study joins a growing literature of cost-utility analyses that suggest that more is not likely better when it comes to surveillance endoscopy. Given the plentiful literature showing overutilization of surveillance endoscopy in BE, the authors argue for a focus on the quality of endoscopy rather than increased frequency of surveillance to improve returns on our healthcare investment.

Cryoballoon ablation for treatment of patients with refractory esophageal neoplasia after first line endoscopic eradication therapy

Background and study aims  Cryoablation with the Cryoballoon device is a novel ablative therapy that uses cycles of freezing and thawing to induce cell death. This single-center prospective study evaluated the feasibility of the focal cryoablation device for the treatment of areas of refractory esophageal neoplasia in patients who had undergone first line endoscopic eradication therapy (EET). Complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia (CR-IM) at first follow-up endoscopy, durability of disease reversal, rates of stenosis and adverse events were studied. Patients and methods  Eighteen cases were treated. At baseline, nine patients had low-grade dysplasia (LGD), six had high-grade dysplasia (HGD) and three had intramucosal carcinoma (IMC). Median length of dysplastic Barrett's esophagus (BE) treated was 3 cm. The median number of ablations per patient was 11. Each selected area of visible dysplasia received 10 seconds of ablation. One session of cryoablation was performed per patient. Biopsies were performed at around 3 months post-ablation. Results  CR-D was achieved in 78 % and CR-IM in 39 % of patients. There were no device malfunction or adverse events. Stenosis was noted in 11 % of cases. At a median follow up of 19-months, CR-D was maintained in 72 % of patients and CR-IM in 33 %. Conclusions  Cryoablation appears to be a viable rescue strategy in patients with refractory neoplasia. It is well tolerated and successful in obtaining CR-D and CR-IM in patients with treatment-refractory BE. Further trials of dosimetry, efficacy and safety in treatment-naïve patients are underway.

Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus

BACKGROUND

Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy).

OBJECTIVES

We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)).

SEARCH METHODS

We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012.

SELECTION CRITERIA

Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately.

TYPES OF PARTICIPANTS

patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent.

DATA COLLECTION AND ANALYSIS

Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9.

MAIN RESULTS

We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies.

AUTHORS' CONCLUSIONS

This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.

AGA Clinical Practice Update on Endoscopic Treatment of Barrett's Esophagus With Dysplasia and/or Early Cancer: Expert Review

DESCRIPTION

The purpose of this best practice advice article is to describe the role of Barrett's endoscopic therapy (BET) in patients with Barrett's esophagus (BE) with dysplasia and/or early cancer and appropriate follow-up of these patients.

METHODS

The best practice advice provided in this document is based on evidence and relevant publications reviewed by the committee. BEST PRACTICE ADVICE 1: In BE patients with confirmed low-grade dysplasia, a repeat examination with high-definition white-light endoscopy should be performed within 3-6 months to rule out the presence of a visible lesion, which should prompt endoscopic resection. BEST PRACTICE ADVICE 2: Both BET and continued surveillance are reasonable options for the management of BE patients with confirmed and persistent low-grade dysplasia. BEST PRACTICE ADVICE 3: BET is the preferred treatment for BE patients with high-grade dysplasia (HGD). BEST PRACTICE ADVICE 4: BET should be preferred over esophagectomy for BE patients with intramucosal esophageal adenocarcinoma (T1a). BEST PRACTICE ADVICE 5: BET is a reasonable alternative to esophagectomy in patients with submucosal esophageal adenocarcinoma (T1b) with low-risk features (<500-μm invasion in the submucosa [sm1], good to moderate differentiation, and no lymphatic invasion) especially in those who are poor surgical candidates. BEST PRACTICE ADVICE 6: In all patients undergoing BET, mucosal ablation should be applied to 1) all visible esophageal columnar mucosa; 2) 5-10 mm proximal to the squamocolumnar junction and 3) 5-10 mm distal to the gastroesophageal junction, as demarcated by the top of the gastric folds (ie, gastric cardia) using focal ablation in a circumferential fashion. BEST PRACTICE ADVICE 7: Mucosal ablation therapy should only be performed in the presence of flat BE without signs of inflammation and in the absence of visible abnormalities. BEST PRACTICE ADVICE 8: BET should be performed by experts in high-volume centers that perform a minimum of 10 new cases annually. BEST PRACTICE ADVICE 9: BET should be continued until there is an absence of columnar epithelium in the tubular esophagus on high-definition white-light endoscopy and preferably optical chromoendoscopy. In case of complete endoscopic eradication, the neosquamous mucosa and the gastric cardia are sampled by 4-quadrant biopsies. BEST PRACTICE ADVICE 10: If random biopsies obtained from the neosquamous epithelium demonstrate intestinal metaplasia/dysplasia or subsquamous intestinal metaplasia, a repeat endoscopy should be performed and visible islands or tongues should undergo targeted focal ablation. BEST PRACTICE ADVICE 11: Intestinal metaplasia of the gastric cardia (without residual columnar epithelium in the tubular esophagus) should not warrant additional ablation therapy. BEST PRACTICE ADVICE 12: When consenting patients for BET, the most common complication of therapy to be quoted is post-procedural stricture formation, occurring in about 6% of cases. Bleeding and perforation occur at rates <1%. BEST PRACTICE ADVICE 13: After complete eradication (endoscopic and histologic) of intestinal metaplasia has been achieved with BET, surveillance endoscopy with biopsies should be performed at the following intervals: for baseline diagnosis of HGD/esophageal adenocarcinoma: at 3, 6, and 12 months and annually thereafter; and baseline diagnosis of low-grade dysplasia: at 1 and 3 years. BEST PRACTICE ADVICE 14: Endoscopic surveillance post therapy should be performed with high-definition white-light endoscopy, including careful inspection of the neosquamous mucosal and retroflexed inspection of the gastric cardia. BEST PRACTICE ADVICE 15: The approach to recurrent disease is similar to that of the initial therapy; visible recurrent nodular lesions require endoscopic resection, whereas flat areas of columnar mucosa in the tubular esophagus can be treated with mucosal ablation. BEST PRACTICE ADVICE 16: Patients should be counseled on cancer risk in the absence of BET, as well as after BET, to allow for informed decision-making between the patient and the physician.

A Cost-Effectiveness Analysis Of An Adenocarcinoma Risk Prediction Multi-Biomarker Assay For Patients With Barrett's Esophagus

PURPOSE

This study evaluates the cost-effectiveness of a quantitative multi-biomarker assay (the Assay) that stratifies patients with Barrett's Esophagus (BE) by risk of progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) and can be used to guide clinical decisions, versus the current guidelines (standard of care [SOC]) for surveillance and treatment of BE.

PATIENTS AND METHODS

Markov decision modeling and simulation were used to compare cost and quality-adjusted life-years (QALYs) from the perspective of a US health insurer with care delivered by an integrated health system. Model assumptions and disease progression probabilities were derived from the literature. Performance metrics for the Assay were from an independent clinical validation study. Cost of the Assay was based on reimbursement rates from multiple payers. Other costs were derived from Geisinger payment data.

RESULTS

Base-case model results for a 5-year period comparing the Assay-directed care to the SOC estimated an incremental cost-effectiveness ratio (ICER) of $52,483/QALY in 2012 US dollars. Assay-directed care increased the use of endoscopic treatments by 58.4%, which reduced the progression to HGD, EAC and reduced EAC-related deaths by 51.7%, 47.1%, and 37.6%, respectively, over the 5-year period. Sensitivity analysis indicated that the probability of the Assay being cost-effective compared to the SOC was 57.3% at the $100,000/QALY acceptability threshold.

CONCLUSION

Given the model assumptions, the new Assay would be cost-effective after 5 years and improves patient outcomes due to improvement in the effectiveness of surveillance and treatment protocols resulting in fewer patients progressing to HGD and EAC and fewer EAC-related deaths.

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

BACKGROUND AND AIMS

Endoscopic eradication therapy (EET) is the first line approach for treating Barrett's oesophagus (BE) related neoplasia globally. The British Society of Gastroenterology (BSG) recommend EET with combined endoscopic resection (ER) for visible dysplasia followed by endoscopic ablation in patients with both low and high grade dysplasia (LGD and HGD). The aim of this study is to perform a cost-effectiveness analysis for EET for treatment of all grades of dysplasia in BE patients.

METHODS

A Markov cohort model with a lifetime time horizon was used to undertake a cost-effectiveness analysis. A hypothetical cohort of UK patients diagnosed with BE entered the model. Patients in the treatment arm with LGD and HGD received EET and patients with non-dysplastic BE (NDBE) received endoscopic surveillance only. In the comparator arm, patients with LGD, HGD and NDBE received endoscopic surveillance only. A UK National Health Service (NHS) perspective was adopted and the incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analysis was conducted on key input parameters.

RESULTS

EET for patients with LGD and HGD arising in BE is cost-effective compared to endoscopic surveillance alone (lifetime ICER £3006 per quality adjusted life year [QALY] gained). The results show that, as the time horizon increases, the treatment becomes more cost-effective. The 5 year financial impact to the UK NHS of introducing EET is £7.1m.

CONCLUSIONS

EET for patients with low and high grade BE dysplasia, following updated guidelines from the BSG, has been shown to be cost-effective for patients with BE in the UK.

Screening for Barrett's Esophagus: Balancing Clinical Value and Cost-effectiveness

In predisposed individuals with long standing gastroesophageal reflux disease (GERD), esophageal squamous mucosa can transform into columnar mucosa with intestinal metaplasia, commonly called Barrett’s esophagus (BE). Barrett’s mucosa can develop dysplasia, which can be a precursor for esophageal adenocarcinoma (EAC). However, most EAC cases are identified when esophageal symptoms develop, without prior BE or GERD diagnoses. While several gastrointestinal societies have published BE screening guidelines, these vary, and many recommendations are not based on high quality evidence. These guidelines are concordant in recommending targeted screening of predisposed individuals (eg, long standing GERD symptoms with age > 50 years, male sex, Caucasian race, obesity, and family history of BE or EAC), and against population based screening, or screening of GERD patients without risk factors. Targeted endoscopic screening programs provide earlier diagnosis of high grade dysplasia and EAC, and offer potential for endoscopic therapy, which can improve prognosis and outcome. On the other hand, endoscopic screening of the general population, unselected GERD patients, patients with significant comorbidities or patients with limited life expectancy is not cost-effective. New screening modalities, some of which do not require endoscopy, have the potential to reduce costs and expand access to screening for BE.

Endosheath ultrathin transnasal endoscopy is a cost-effective method for screening for Barrett's esophagus in patients with GERD symptoms

BACKGROUND AND AIMS

Barrett's esophagus (BE) screening is currently not considered to be cost effective in the general population but may be effective in high-risk subgroups, such as 50-year-old white men with chronic reflux disease (GERD). A new modality for screening is unsedated transnasal endoscopy using endosheath technology (uTNE), which has been shown to be safe and effective in clinical practice. In this study, we determined the cost-utility of uTNE in a high-risk subgroup compared with no screening or screening with standard endoscopy.

METHODS

A Markov model was used to simulate screening of 50-year-old white men with symptoms of GERD with either uTNE or standard endoscopy compared with no screening, over a lifetime horizon. Input variables were based on the literature and recent data on uTNE screening for BE. The study was designed from a healthcare payer perspective by using direct costs. Primary outcome measures were costs, quality-adjusted life years (QALYs), and the incremental cost-utility ratio (ICUR) of uTNE and standard endoscopy compared with no screening. Sensitivity analysis was performed for several factors, such as prevalence of BE.

RESULTS

Costs of uTNE, standard endoscopy, and no screening were estimated at, $2495, $2957, and $1436, respectively. Compared with no screening, uTNE screening resulted in an overall QALY increase of 0.039 (95% percentile 0.018; 0.063) and an ICUR of $29,446 per QALY gained (95% confidence interval [CI], 18.516-53.091), whereas standard endoscopy compared with no screening resulted in a QALY increase of 0.034 (95% CI, 0.015-0.056) and an ICUR of $47,563 (95% CI, 31,036-82,970).

CONCLUSION

Both uTNE and standard endoscopy seem to be cost-effective screening methods in a screening cohort of 50-year-old white men with GERD at a willingness-to-pay cutoff of $50,000.

Radiofrequency ablation compared with argon plasma coagulation after endoscopic resection of high-grade dysplasia or stage T1 adenocarcinoma in Barrett's esophagus: a randomized pilot study (BRIDE)

BACKGROUND AND AIMS

Endoscopic resection (ER) is safe and effective for Barrett's esophagus (BE) containing high-grade dysplasia (HGD) or mucosal adenocarcinoma (T1A). The risk of metachronous neoplasia is reduced by ablation of residual BE by using radiofrequency ablation (RFA) or argon plasma coagulation (APC). These have not been compared directly. We aimed to recruit up to 100 patients with BE and HGD or T1A confirmed by ER over 1 year in 6 centers in a randomized pilot study.

METHODS

Randomization was 1:1 to RFA or APC (4 treatments allowed at 2-month intervals). Recruitment, retention, dysplasia clearance, clearance of benign BE, adverse events, healthcare costs, and quality of life by using EQ-5D, EORTC QLQ-C30, or OES18 were assessed up to the end of the trial at 12 months.

RESULTS

Of 171 patients screened, 76 were randomized to RFA (n = 36) or APC (n = 40). The mean age was 69.7 years, and 82% were male. BE was <5 cm (n = 27), 5 to 10 cm (n = 45), and >10 cm (n = 4). Sixty-five patients completed the trial. At 12 months, dysplasia clearance was RFA 79.4% and APC 83.8% (odds ratio [OR] 0.7; 95% confidence interval [CI], 0.2-2.6); BE clearance was RFA 55.8%, and APC 48.3% (OR 1.4; 95% CI, 0.5-3.6). A total of 6.1% (RFA) and 13.3% (APC) had buried BE glands. Adverse events (including stricture rate after starting RFA 3/36 [8.3%] and APC 3/37 [8.1%]) and quality of life scores were similar, but RFA cost $27491 more per case than APC.

CONCLUSION

This pilot study suggests similar efficacy and safety but a cost difference favoring APC. A fully powered non-inferiority trial is appropriate to confirm these findings. (Clinical trial registration number: NCT01733719.).

Cost Effectiveness of Gastric Cancer Screening According to Race and Ethnicity

BACKGROUND & AIMS

There are marked racial and ethnic differences in non-cardia gastric cancer prevalence within the United States. Although gastric cancer screening is recommended in some regions of high prevalence, screening is not routinely performed in the United States. Our objective was to determine whether selected non-cardia gastric cancer screening for high-risk races and ethnicities within the United States is cost effective.

METHODS

We developed a decision analytic Markov model with the base case of a 50-year-old person of non-Hispanic white, non-Hispanic black, Hispanic, or Asian race or ethnicity. The cost effectiveness of a no-screening strategy (current standard) for non-cardia gastric cancer was compared with that of 2 endoscopic screening modalities initiated at the time of screening colonoscopy for colorectal cancer: upper esophagogastroduodenoscopy with biopsy examinations and continued surveillance only if intestinal metaplasia or more severe pathology is identified or esophagogastroduodenoscopy with biopsy examinations continued every 2 years even in the absence of identified pathology. We used prevalence rates, transition probabilities, costs, and quality-adjusted life years (QALYs) from publications and public data sources. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/QALY.

RESULTS

Compared with biennial and no screening, screening esophagogastroduodenoscopy with continued surveillance only when indicated was cost effective for non-Hispanic blacks ($80,278/QALY), Hispanics ($76,070/QALY), and Asians ($71,451/QALY), but not for non-Hispanic whites ($122,428/QALY). The model was sensitive to intestinal metaplasia prevalence, transition rates from intestinal metaplasia to dysplasia to local and regional cancer, cost of endoscopy, and cost of resection (endoscopic or surgical).

CONCLUSIONS

Based on a decision analytic Markov model, endoscopic non-cardia gastric cancer screening for high-risk races and ethnicities could be cost effective in the United States.

Screening and Surveillance for Barrett's Esophagus: Is It Cost-Effective?

The cost-effectiveness of screening and surveillance for Barrett's esophagus continues to evolve as the incidence of esophageal adenocarcinoma increases, biomarkers enhance the identification of individuals at highest risk for developing cancer, and endoscopic eradication of Barrett's esophagus improves. Screening to detect Barrett's esophagus may be cost-effective in selected high-risk groups based on age, race, sex and other factors such as symptoms of heartburn. Currently, endoscopic eradication therapy for Barrett's esophagus and high-grade dysplasia is a cost-effective intervention, while endoscopic therapy for non-dysplastic Barrett's esophagus is not a cost-effective strategy. As diagnosis of low-grade dysplasia improves, endoscopic eradication therapy may also prove to be a cost-effective intervention.

Recent Advances in Screening for Barrett's Esophagus

OPINION STATEMENT

PURPOSE OF REVIEW: There is a pressing need for effective strategies to halt the increase in both the incidence and mortality of esophageal adenocarcinoma (EAC). Screening for Barrett's esophagus, which is the only known precursor of EAC, remains a ripe area for research, particularly with regard to identifying the target population, screening tools, and management of screen-detected populations. This review aims to explore in depth the rationale for screening for Barrett's esophagus, recent biotechnological advances which may have the potential of making screening feasible, and also highlight the challenges which will have to be overcome in order make screening for BE a realistic prospect.

RECENT FINDINGS

Imaging techniques such as portable transnasal endoscopy have the advantage of providing an immediate diagnosis of Barrett's esophagus as well as other significant pathologies such as reflux esophagitis and cancer; however, larger studies in non-enriched community screening populations are required to evaluate their feasibility. The capsule sponge is a cell-sampling device coupled with a biomarker, which has been most extensively evaluated with very promising results as regards feasibility, acceptability, accuracy, and cost-effectiveness. Its effectiveness in increasing the detection of Barrett's esophagus in primary care is currently being evaluated. Several Barrett's esophagus risk prediction scores have been developed with variable degrees of accuracy. Several minimally and non-invasive screening techniques have been studied including imaging and cell-sampling devices. Barrett's risk assessment models need to be further validated in independent, relevant screening populations with clear cut-offs for recommending screening to be defined.

Costs associated with Barrett's esophagus screening in the community: an economic analysis of a prospective randomized controlled trial of sedated versus hospital unsedated versus mobile community unsedated endoscopy

BACKGROUND AND AIMS

Data on the economic impact associated with screening for Barrett's esophagus (BE) are limited. As part of a comparative effectiveness randomized trial of unsedated transnasal endoscopy (uTNE) and sedated EGD (sEGD), we assessed costs associated with BE screening.

METHODS

Patients were randomly allocated to 3 techniques: sEGD or uTNE in a hospital setting (huTNE) versus uTNE in a mobile research van (muTNE). Patients were called 1 and 30 days after screening to assess loss of work (because of the screening procedure) and medical care sought after procedure. Direct medical costs were extracted from billing claims databases. Indirect costs (loss of work for subject and caregiver) were estimated using patient reported data. Statistical analyses including multivariable analysis accounting for comorbidities were conducted to compare costs.

RESULTS

Two hundred nine patients were screened (61 sEGD, 72 huTNE, and 76 muTNE). Thirty-day direct medical costs and indirect costs were significantly higher in the sEGD than the huTNE and muTNE groups. Total costs (direct medical + indirect costs) were also significantly higher in the sEGD than in the uTNE group. The muTNE group had significantly lower costs than the huTNE group. Adjustment for age, sex, and comorbidities on multivariable analysis did not change this conclusion.

CONCLUSIONS

Short-term direct, indirect, and total costs of screening are significantly lower with uTNE compared with sEGD. Mobile uTNE costs were lower than huTNE costs, raising the possibility of mobile screening as a novel method of screening for BE and esophageal adenocarcinoma.

Economic evaluation of endoscopic radiofrequency ablation for the treatment of dysplastic Barrett's esophagus in Spain

BACKGROUND AND STUDY AIMS

To assess the cost-effectiveness of introducing endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection in selected patients into the standard of care of Barrett's esophagus patients with high-grade dysplasia or low-grade dysplasia in Spain.

METHODS

The disease evolution was modeled via a semi-Markov model. The treatment strategies compared included endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection and the Standard of Care (esophagectomy or palliative chemoradiotherapy according to disease status for high-grade dysplasia and endoscopic surveillance for low-grade dysplasia). Efficacy rates, transition probabilities and utility values were obtained from the literature. Clinical management patterns and resource use were modeled according to Spanish clinical expert opinion. Costs were expressed in euros (€) from 2016 reflecting the Spanish National Health System perspective. Sensitivity analyses were performed to assess the robustness of the model.

RESULTS

With respect to the Spanish Standard of Care, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection was a dominant strategy for high-grade dysplasia patients. When a willingness-to-pay threshold of €30,000 per quality-adjusted life-years gained was considered, this was cost-effective for low-grade dysplasia patients (€12,865 per quality-adjusted life-years gained). The sensitivity analyses supported the base case analysis results and pointed towards the main drivers of uncertainty in the model.

CONCLUSIONS

From a health care decision-maker, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection is the intervention of choice for dysplasic Barrett's esophagus patients in Spain.

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

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.

The cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia: results from a randomized controlled trial (SURF trial)

BACKGROUND AND AIMS

The Surveillance versus Radiofrequency Ablation (SURF) trial randomized 136 patients with Barrett's esophagus (BE) containing low-grade dysplasia (LGD), to receive radiofrequency ablation (ablation, n = 68) or endoscopic surveillance (control, n = 68). Ablation reduced the risk of neoplastic progression to high-grade dysplasia and esophageal adenocarcinoma (EAC) by 25% over 3 years (1.5% for ablation vs 26.5% for control). We performed a cost-effectiveness analysis from a provider perspective alongside this trial.

METHODS

Patients were followed for 3 years to quantify their use of health care services, including therapeutic and surveillance endoscopies, treatment of adverse events, and medication. Costs for treatment of progression were analyzed separately. Incremental cost-effectiveness ratios (ICER) were calculated by dividing the difference in costs (excluding and including the downstream costs for treatment of progression) by the difference in prevented events of progression. Bootstrap analysis (1000 samples) was used to construct 95% confidence intervals (CIs).

RESULTS

Patients who underwent ablation generated mean costs of U.S.$13,503 during the trial versus $2236 for controls (difference $11,267; 95% CI, $9996-$12,378), with an ICER per prevented event of progression of $45,066. Including the costs for treatment of progression, ablation patients generated mean costs of $13,523 versus $4,930 for controls (difference $8593; 95% CI, $6881-$10,153) with an ICER of $34,373. Based on the various ICER estimates derived from the bootstrap analysis, one can be reasonably certain (>75%) that ablation is efficient at a willingness to pay of $51,664 per prevented event of progression or $40,915 including downstream costs of progression.

CONCLUSIONS

Ablation for patients with confirmed BE-LGD is more effective and more expensive than endoscopic surveillance in reducing the risk of progression to high-grade dysplasia/EAC. The increase in costs of ablation can be justified to avoid a serious event such as neoplastic progression. At a willingness to pay of $40,915 per prevented event of progression, one can be reasonably certain that ablation is efficient. (www.trialregister.nl number: NTR 1198.).

Alternatives to Traditional Per-Oral Endoscopy for Screening

Barrett's esophagus (BE) predisposes patients to esophageal adenocarcinoma. 3 to 6% of individuals with gastro-esophageal reflux disease are estimated to have BE but only 20 to 25% of BE patients are currently diagnosed. The current gold standard for diagnosis of BE is per-oral upper GI endoscopy. As this is not suitable for large-scale screening, a number of alternative methods are currently being investigated: transnasal and video capsule endoscopy, endomicroscopy, cell collection devices like the cytosponge and biomarkers. Some of these are promising, however, well powered studies carried out in relevant screening populations are needed.

Effectiveness and Cost-Effectiveness of Endoscopic Screening and Surveillance

Guidelines for the screening and surveillance of Barrett's esophagus continue to evolve as the incidence of esophageal adenocarcinoma increases, identification of individuals at highest risk for cancer improves, and management of dysplasia evolves. This article reviews related studies and economic analyses. Advances in diagnosis offer promising strategies to help focus screening efforts on those individuals who are most likely to develop esophageal adenocarcinoma.

Current Endoscopic Approaches for the Treatment of Barrett Esophagus

Barrett esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer associated with a poor 5-year survival rate. The stepwise pathologic progression of BE to invasive cancer provides an opportunity to halt progression and potentially decrease incidence and ultimately the morbidity and mortality related to this lethal cancer. Endoscopic eradication therapy (EET) in patients at increased risk of progression to invasive EAC (intramucosal EAC, high-grade dysplasia, and low-grade dysplasia) is a practice that is endorsed by multiple societies and has replaced esophagectomy as the standard of care for these patients. Although the effectiveness, safety, and durability of EET have been demonstrated in several studies, this review addresses the several challenges with EET that need to be considered to optimize patient outcomes. Finally, the critical role of training, competence, and quality indicators in EET are emphasized in this era of value-based health care practice.

Cost effectiveness of surveillance for GI cancers

Gastrointestinal (GI) diseases are among the leading causes of death in the world. To reduce the burden of GI diseases, surveillance is recommended for some diseases, including for patients with inflammatory bowel diseases, Barrett's oesophagus, precancerous gastric lesions, colorectal adenoma, and pancreatic neoplasms. This review aims to provide an overview of the evidence on cost-effectiveness of surveillance of individuals with GI conditions predisposing them to cancer, specifically focussing on the aforementioned conditions. We searched the literature and reviewed 21 studies. Despite heterogeneity of studies in terms of settings, study populations, surveillance strategies and outcomes, most reviewed studies suggested at least some surveillance of patients with these GI conditions to be cost-effective. For some high-risk conditions frequent surveillance with 3-month intervals was warranted, while for other conditions, surveillance may only be cost-effective every 10 years. Further studies based on more robust effectiveness evidence are needed to inform and optimise surveillance programmes for GI cancers.

Recurrent intestinal metaplasia at the gastroesophageal junction following endoscopic eradication of dysplastic Barrett's esophagus may not be benign

BACKGROUND AND STUDY AIMS

Radiofrequency ablation (RFA) combined with endoscopic mucosal resection (EMR) is effective for eradicating dysplastic Barrett's esophagus. The durability of response is reported to be variable. We aimed to determine the effectiveness and durability of RFA with or without EMR for patients with dysplastic Barrett's esophagus.

PATIENTS AND METHODS

Patients with dysplastic Barrett's esophagus referred to two academic hospitals were assessed with high definition white-light endoscopy, narrow-band imaging, and Seattle protocol biopsies. EMR was performed in visible lesions. RFA was performed at 3-month intervals until complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM) was achieved.

RESULTS

In total, 137 patients received RFA (78 with EMR); 75 with over 12 months follow-up since commencing RFA. Pretreatment histology was intramucosal cancer (IMC) 21 %, high grade dysplasia (HGD) 54 %, low grade dysplasia (LGD) 25 %. CR-D rates were 88 %, 92 %, and 100 % at 1, 2, and 3 years; CR-IM rates were 69 %, 74 %, and 81 %. Kaplan-Meier analysis showed increasing probability of achieving CR-D/CR-IM over time. Of 26 patients maintaining CR-IM for > 12 months, five relapsed with intestinal metaplasia (19 %), and three with dysplasia (12 %). Recurrences occurred in patients with prior HGD/IMC, predominantly at the gastroesophageal junction (GEJ). None relapsed with cancer. Adverse events occurred in 4 % of RFA and 6.5 % of EMR procedures.

CONCLUSIONS

RFA combined with EMR is effective in achieving CR-D/CR-IM in the majority of patients with dysplastic Barrett's esophagus, with an incremental response over time. While durable in the majority, recurrent intestinal metaplasia and dysplasia, frequently occurring at the GEJ, suggest long-term surveillance is warranted in high risk groups.

Comparative Effectiveness of Esophagectomy Versus Endoscopic Treatment for Esophageal High-grade Dysplasia

OBJECTIVE

The purpose of this study is to determine the comparative effectiveness of esophagectomy versus endoscopic mucosal resection followed by radiofrequency ablation (EMR-RFA) for the treatment of Barrett esophagus with high-grade dysplasia (HGD).

BACKGROUND

HGD of the esophagus may be managed by surgical resection or EMR-RFA. National guidelines suggest that EMR-RFA is effective at eradicating HGD. The comparative effectiveness and cost-effectiveness of EMR-RFA versus esophagectomy for HGD remains unclear.

METHODS

A decision-analysis model was constructed to represent 3 management strategies for HGD: (1) esophagectomy, (2) EMR-RFA, and (3) endoscopic surveillance. Estimates for model variables were obtained from literature review, and costs were estimated from Medicare fee schedules. Costs and utilities were discounted at an annual rate of 3%. The baseline model was adjusted for alternative age groups and high-risk dysplastic variants. One-way and multivariable probabilistic sensitivity analyses were conducted.

RESULTS

For a 65-year-old patient, compared to esophagectomy, EMR-RFA yields equivalent utility (11.5 vs 11.4 discounted quality-adjusted life years) with lower total cost ($52.5K vs $74.3K) over the first 20 years. Dominance of EMR-RFA over esophagectomy persists for all age groups. Patients with diffuse or ulcerated HGD are more effectively treated with esophagectomy. Model outcomes are sensitive to estimated rates of disease progression and postintervention utility parameters.

CONCLUSIONS

Existing evidence supports EMR-RFA over esophagectomy for the treatment of esophageal HGD. Long-term outcomes and more definitive quality-of-life studies for both interventions are crucial to better inform decision-making.

Post-ablation surveillance in Barrett's esophagus: A review of the literature

Barrett’s esophagus (BE) is a pre-malignant condition affecting up to 15% of patients with gastroesophageal reflux disease. Neoplastic Barrett’s mucosa is defined as harboring high grade dysplasia or intra-mucosal cancer, and carries a high risk of progression to esophageal adenocarcinoma. The rising incidence of Barrett’s lesions along with the high morbidity of surgical approaches has led to the development of numerous validated endoscopic techniques capable of eradicating neoplastic mucosa in a minimally invasive manner. While there has been widespread adoption of these techniques, less is known about optimal surveillance intervals in the post-therapy period. This is due in part to limitations in current surveillance methods, questions about durability of treatment response and the risk of subendothelial progression. As we are now able to achieve organ sparing eradication of superficial neoplasia in BE, we need to also then focus our attention on how best to manage these patients after eradication is achieved. Implementing optimal surveillance practices requires additional understanding of the biology of the disease, appreciation of the limits of current tools and treatments, and exploration of the role of adjunctive technologies. The aim of this article is to provide a comprehensive review of current literature surrounding post-ablation surveillance in neoplastic BE.

Update on management of Barrett's esophagus

Barrett's esophagus (BE) is a common condition that develops as a consequence of gastroesophageal reflux disease. The significance of Barrett's metaplasia is that predisposes to cancer development. This article provides a current evidence-based review for the management of BE and related early neoplasia. Controversial issues that impact the management of patients with BE, including definition, screening, clinical aspects, diagnosis, surveillance, and management of dysplasia and early cancer have been assessed.

Managing incidental pancreatic cystic neoplasms with integrated molecular pathology is a cost-effective strategy

BACKGROUND AND STUDY AIMS

Current guidelines recommend using endoscopic ultrasound (EUS), carcinoembryonic antigen (CEA) testing and cytology to manage incidental pancreatic cystic neoplasms (PCN); however, studies suggest a strategy including integrated molecular pathology (IMP) of cyst fluid may further aid in predicting risk of malignancy. Here, we evaluate several strategies for diagnosing and managing asymptomatic PCN using healthcare economic modeling.

PATIENTS AND METHODS

A third-party-payer perspective Markov decision model examined four management strategies in a hypothetical cohort of 1000 asymptomatic patients incidentally found to have a 3 cm solitary pancreatic cystic lesion. Strategy I used cross-sectional imaging, recommended surgery only if symptoms or risk factors emerged. Strategy II considered patients for resection without initial EUS. Strategy III (EUS + CEA + Cytology) referred only those with mucinous cysts (CEA > 192 ng/mL) for resection. Strategy IV implemented IMP; a commercially available panel provided a "Benign," "Mucinous," or "Aggressive" classification based on the level of mutational change in cyst fluid. "Benign" and "Mucinous" patients were followed with surveillance; "Aggressive" patients were referred for resection. Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated.

RESULTS

Strategy IV provided the greatest increase in QALY at nearly identical cost to the cheapest approach, Strategy I. Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 - 0.53) with an NNT of 56 (95 %CI 34 - 120).

CONCLUSIONS

Use of IMP was the most cost-effective strategy, supporting its routine clinical use.

An Accurate Cancer Incidence in Barrett's Esophagus: A Best Estimate Using Published Data and Modeling

BACKGROUND & AIMS

Published estimates for the rate of progression from Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC) vary. We used simulation modeling to reconcile published data and more accurately estimate the incidence of EAC among people with BE.

METHODS

We calibrated the ERASMUS/UW model (a collaboration between Erasmus Medical Center, Rotterdam, the Netherlands and the University of Washington, Seattle) for EAC to match the 0.18% annual rate of progression from population-based studies. This model was then used to simulate the design of prospective studies, introducing more endoscopic surveillance. We used the model to predict rates of progression for both types of studies and for different periods of follow-up, and compared the predicted rates with published data.

RESULTS

For the first 5 years of follow-up, the model reproduced the 0.19% mean annual rate of progression observed in population-based studies; the same disease model predicted a 0.36% annual rate of progression in studies with a prospective design (0.41% reported in published articles). After 20 years, these rates each increased to 0.63% to 0.65% annually, corresponding with a 9.1% to 9.5% cumulative cancer incidence. Between these periods, the difference between the progression rates of both study designs decreased from 91% to 5%.

CONCLUSIONS

In the first 5 years after diagnosis, the rate of progression from BE to EAC is likely to more closely approximate the lower estimates reported from population-based studies than the higher estimates reported from prospective studies in which EAC is detected by surveillance. Clinicians should use this information to explain to patients their short-term and long-term risks if no action is taken, and then discuss the risks and benefits of surveillance.

Salvage cryotherapy after failed radiofrequency ablation for Barrett's esophagus-related dysplasia is safe and effective

BACKGROUND

Radiofrequency ablation (RFA) is an effective treatment for Barrett's esophagus (BE) dysplasia. For patients with dysplasia refractory to RFA, data are limited regarding efficacy of endoscopic therapy.

OBJECTIVE

To assess the efficacy and safety of cryotherapy in patients with BE dysplasia who failed RFA.

DESIGN

Single-center, retrospective, cohort study.

SETTING

Tertiary-care center between 2006 and 2013.

PATIENTS

Patients with BE and low-grade dysplasia (LGD), high-grade dysplasia (HGD), or intramucosal carcinoma (IMC) were referred for RFA every 2 to 3 months. Response was determined by complete eradication of dysplasia (CE-D).

INTERVENTIONS

Patients without CE-D or those with recurrent dysplasia after initial eradication were offered cryotherapy.

MAIN OUTCOME MEASUREMENTS

Eradication of dysplasia and/or cancer. Secondary outcome, eradication of intestinal metaplasia.

RESULTS

A total of 121 patients underwent RFA for BE dysplasia (55% HGD, 26% LGD, 17% IMC, 2% indefinite dysplasia). After a median of 3 RFA sessions, 75% (n = 91) had CE-D. Patients without CE-D were more likely to have a longer BE length (7 cm vs 4 cm; P = .004) and a hiatal hernia (83% vs 55%; P = .005). Sixteen patients (14 with failed CE-D and 2 with recurrent dysplasia) were offered cryotherapy and had endoscopic follow-up. Seven (57%) had HGD before cryotherapy (6 with LGD, 2 with IMC, and 1 with indefinite dysplasia). After cryotherapy, 12 (75%) had CE-D, and 5 (31%) had eradication of intestinal metaplasia. Of patients with IMC, 100% had CE-D. Three patients developed strictures that responded to dilation.

LIMITATIONS

Single center, retrospective nature of study.

CONCLUSION

For patients with refractory dysplasia or recurrent dysplasia after RFA, salvage cryotherapy is a safe and effective endoscopic therapy.

Surveillance in patients with long-segment Barrett's oesophagus: a cost-effectiveness analysis

OBJECTIVE

Surveillance is recommended for Barrett's oesophagus (BO) to detect early oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the cost-effectiveness of surveillance.

DESIGN

We included 714 patients with long-segment BO in a multicentre prospective cohort study and used a multistate Markov model to calculate progression rates from no dysplasia (ND) to low-grade dysplasia (LGD), high-grade dysplasia (HGD) and OAC. Progression rates were incorporated in a decision-analytic model, including costs and quality of life data. We evaluated different surveillance intervals for ND and LGD, endoscopic mucosal resection (EMR), radiofrequency ablation (RFA) and oesophagectomy for HGD or early OAC and oesophagectomy for advanced OAC. The incremental cost-effectiveness ratio (ICER) was calculated in costs per quality-adjusted life-year (QALY).

RESULTS

The annual progression rate was 2% for ND to LGD, 4% for LGD to HGD or early OAC and 25% for HGD or early OAC to advanced OAC. Surveillance every 5 or 4 years with RFA for HGD or early OAC and oesophagectomy for advanced OAC had ICERs of €5.283 and €62.619 per QALY for ND. Surveillance every five to one year had ICERs of €4.922, €30.067, €32.531, €41.499 and €75.601 per QALY for LGD. EMR prior to RFA was slightly more expensive, but important for tumour staging.

CONCLUSIONS

Based on a Dutch healthcare perspective and assuming a willingness-to-pay threshold of €35.000 per QALY, surveillance with EMR and RFA for HGD or early OAC, and oesophagectomy for advanced OAC is cost-effective every 5 years for ND and every 3 years for LGD.

Ablative Endoscopic Therapies for Barrett's-Esophagus-Related Neoplasia

Barrett's esophagus (BE) is more common in developed countries. Endoscopic therapy is an effective treatment method in management of dysplastic BE. Ablation by thermal energy, freezing, or photochemical injury completely eradicates dysplasia and specialized intestinal metaplasia resulting in neosquamation of esophagus. Among the ablative modalities, radiofrequency ablation (RFA) is the most studied with safe, effective, and durable long-term outcomes. Cryotherapy, argon plasma coagulation, and photodynamic therapy can be offered in select patients when RFA is unavailable, has failed, or is contraindicated. Future research on natural disease progression, biomarkers, advanced imaging, and application of endoscopic techniques will lead to better clinical outcomes for BE-associated neoplasia.

Cost-Analyses Studies in Barrett's Esophagus: What Is Their Utility?

Approximately 10% to 15% of the chronic gastroesophageal reflux disease population is at risk for the development of Barrett's esophagus, particularly in the setting of other risk factors, including male gender, Caucasian race, age more than 50, and central obesity. The risk of cancer progression for patients with nondysplastic BE has been estimated to be approximately 0.2% to 0.5% per year. Given these low progression rates and the high cost of endoscopic surveillance, cost-effectiveness analyses in this area are useful to determine appropriate resource allocation.

Recurrent intestinal metaplasia after radiofrequency ablation for Barrett's esophagus: endoscopic findings and anatomic location

BACKGROUND

Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett's esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described.

OBJECTIVE

Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence.

DESIGN

Retrospective cohort.

SETTING

Single referral center.

PATIENTS

A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM.

INTERVENTIONS

RFA, EMR, surveillance endoscopy.

MAIN OUTCOME MEASUREMENTS

The anatomic location and histologic grade of recurrence.

RESULTS

In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval [CI], 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence>1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%).

LIMITATIONS

Single-center study.

CONCLUSION

Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies>1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.

High-resolution microendoscopy for esophageal cancer screening in China: A cost-effectiveness analysis

AIM

To study the cost-effectiveness of high-resolution microendoscopy (HRME) in an esophageal squamous cell carcinoma (ESCC) screening program in China.

METHODS

A decision analytic Markov model of ESCC was developed. Separate model analyses were conducted for cohorts consisting of an average-risk population or a high-risk population in China. Hypothetical 50-year-old individuals were followed until age 80 or death. We compared three different strategies for both cohorts: (1) no screening; (2) standard endoscopic screening with Lugol's iodine staining; and (3) endoscopic screening with Lugol's iodine staining and an HRME. Model parameters were estimated from the literature as well as from GLOBOCAN, the Cancer Incidence and Mortality Worldwide cancer database. Health states in the model included non-neoplasia, mild dysplasia, moderate dysplasia, high-grade dysplasia, intramucosal carcinoma, operable cancer, inoperable cancer, and death. Separate ESCC incidence transition rates were generated for the average-risk and high-risk populations. Costs in Chinese currency were converted to international dollars (I$) and were adjusted to 2012 dollars using the Consumer Price Index.

RESULTS

The main outcome measurements for this study were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). For the average-risk population, the HRME screening strategy produced 0.043 more QALYs than the no screening strategy at an additional cost of I$646, resulting in an ICER of I$11808 per QALY gained. Standard endoscopic screening was weakly dominated. Among the high-risk population, when the HRME screening strategy was compared with the standard screening strategy, the ICER was I$8173 per QALY. For both the high-risk and average-risk screening populations, the HRME screening strategy appeared to be the most cost-effective strategy, producing ICERs below the willingness-to-pay threshold, I$23500 per QALY. One-way sensitivity analysis showed that, for the average-risk population, higher specificity of Lugol's iodine (> 40%) and lower specificity of HRME (< 70%) could make Lugol's iodine screening cost-effective. For the high-risk population, the results of the model were not substantially affected by varying the follow-up rate after Lugol's iodine screening, Lugol's iodine test characteristics (sensitivity and specificity), or HRME specificity.

CONCLUSION

The incorporation of HRME into an ESCC screening program could be cost-effective in China. Larger studies of HRME performance are needed to confirm these findings.