1
|
Hao J, Critchley-Thorne R, Diehl DL, Snyder SR. A Cost-Effectiveness Analysis Of An Adenocarcinoma Risk Prediction Multi-Biomarker Assay For Patients With Barrett's Esophagus. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:623-635. [PMID: 31749626 PMCID: PMC6818671 DOI: 10.2147/ceor.s221741] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/02/2019] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jing Hao
- Department of Epidemiology and Health Services Research, Geisinger, Danville, PA, USA
| | | | - David L Diehl
- Department of Gastroenterology, Geisinger, Danville, PA, USA
| | - Susan R Snyder
- Department of Epidemiology and Health Services Research, Geisinger, Danville, PA, USA
| |
Collapse
|
2
|
Zhou Z, Kalatskaya I, Russell D, Marcon N, Cirocco M, Krzyzanowski PM, Streutker C, Liang H, Litle VR, Godfrey TE, Stein L. Combined EsophaCap cytology and MUC2 immunohistochemistry for screening of intestinal metaplasia, dysplasia and carcinoma. Clin Exp Gastroenterol 2019; 12:219-229. [PMID: 31190949 PMCID: PMC6527096 DOI: 10.2147/ceg.s186958] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 03/30/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose: The incidence of esophageal adenocarcinoma (EAC) has increased by 700% in Western countries over the last 30 years. Although clinical guidelines call for endoscopic surveillance for EAC among high-risk populations, fewer than 5% of new EAC patients are under surveillance at the time of diagnosis. We studied the accuracy of combined cytopathology and MUC2 immunohistochemistry (IHC) for screening of Intestinal Metaplasia (IM), dysplasia and EAC, using specimens collected from the EsophaCap swallowable encapsulated cytology sponge from Canada and United States. Patients and methods: By comparing the EsophaCap cytological diagnosis with concurrent endoscopic biopsies performed on the same patients in 28 cases, we first built up the cytology diagnostic categories and criteria. Based on these criteria, 136 cases were evaluated by both cytology and MUC2 IHC with blinded to patient biopsy diagnosis. Results: We first set up categories and criteria for cytological diagnosis of EscophaCap samples. Based on these, we divided our evaluated cytological samples into two groups: non-IM group and IM or dysplasia or adenocarcinoma group. Using the biopsy as our gold standard to screen IM, dysplasia and EAC by combined cytology and MUC2 IHC, the sensitivity and specificity were 68% and 91%, respectively, which is in the range of clinically useful cytological screening tests such as the cervical Pap smear. Conclusions: Combined EsophaCap cytology and MUC2 IHC could be a good screening test for IM and Beyond.
Collapse
Affiliation(s)
- Zhongren Zhou
- Department of Pathology & Immunology, Washington University, Saint Louis, MO, USA
| | - Irina Kalatskaya
- Department of Adaptive Oncology, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Donna Russell
- Department of Pathology & Immunology, Washington University, Saint Louis, MO, USA
| | - Norman Marcon
- Division of Gastroenterology, Department of Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Maria Cirocco
- Division of Gastroenterology, Department of Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paul M Krzyzanowski
- Department of Adaptive Oncology, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Cathy Streutker
- Division of Gastroenterology, Department of Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Hua Liang
- Department of Statistics, George Washington University, Washington, DC, USA
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Tony E Godfrey
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Lincoln Stein
- Department of Adaptive Oncology, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Thein HH, Jembere N, Thavorn K, Chan KKW, Coyte PC, de Oliveira C, Hur C, Earle CC. Estimates and predictors of health care costs of esophageal adenocarcinoma: a population-based cohort study. BMC Cancer 2018; 18:694. [PMID: 29945563 PMCID: PMC6020438 DOI: 10.1186/s12885-018-4620-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Esophageal adenocarcinoma (EAC) incidence is increasing rapidly. Esophageal cancer has the second lowest 5-year survival rate of people diagnosed with cancer in Canada. Given the poor survival and the potential for further increases in incidence, phase-specific cost estimates constitute an important input for economic evaluation of prevention, screening, and treatment interventions. The study aims to estimate phase-specific net direct medical costs of care attributable to EAC, costs stratified by cancer stage and treatment, and predictors of total net costs of care for EAC. METHODS A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data from 2003 to 2011. The mean net costs of EAC care per 30 patient-days (2016 CAD) were estimated from the payer perspective using phase of care approach and generalized estimating equations. Predictors of net cost by phase of care were based on a generalized estimating equations model with a logarithmic link and gamma distribution adjusting for sociodemographic and clinical factors. RESULTS The mean net costs of EAC care per 30 patient-days were $1016 (95% CI, $955-$1078) in the initial phase, $669 (95% CI, $594-$743) in the continuing care phase, and $8678 (95% CI, $8217-$9139) in the terminal phase. Overall, stage IV at diagnosis and surgery plus radiotherapy for EAC incurred the highest cost, particularly in the terminal phase. Strong predictors of higher net costs were receipt of chemotherapy plus radiotherapy, surgery plus chemotherapy, radiotherapy alone, surgery alone, and chemotherapy alone in the initial and continuing care phases, stage III-IV disease and patients diagnosed with EAC later in a calendar year (2007-2011) in the initial and terminal phases, comorbidity in the continuing care phase, and older age at diagnosis (70-74 years), and geographic region in the terminal phase. CONCLUSIONS Costs of care vary by phase of care, stage at diagnosis, and type of treatment for EAC. These cost estimates provide information to guide future resource allocation decisions, and clinical and policy interventions to reduce the burden of EAC.
Collapse
Affiliation(s)
- Hla-Hla Thein
- 0000 0001 2157 2938grid.17063.33Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada ,0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | - Nathaniel Jembere
- 0000 0001 2157 2938grid.17063.33Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Kednapa Thavorn
- 0000 0000 9606 5108grid.412687.eOttawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON Canada ,0000 0001 2182 2255grid.28046.38School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON Canada ,0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences (ICES uOttawa), Ottawa, ON Canada
| | - Kelvin K. W. Chan
- 0000 0001 2157 2938grid.17063.33Department of Medicine, University of Toronto, Toronto, ON Canada ,0000 0000 9743 1587grid.413104.3Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON Canada ,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON Canada
| | - Peter C. Coyte
- 0000 0001 2157 2938grid.17063.33Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada
| | - Claire de Oliveira
- 0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences, Toronto, ON Canada ,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCentre for Addiction and Mental Health, Toronto, ON Canada
| | - Chin Hur
- 0000 0004 0386 9924grid.32224.35Gastroenterology Division, Massachusetts General Hospital, Boston, MA USA ,000000041936754Xgrid.38142.3cHarvard Medical School, Boston, MA USA
| | - Craig C. Earle
- 0000 0000 8849 1617grid.418647.8Institute for Clinical Evaluative Sciences, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Department of Medicine, University of Toronto, Toronto, ON Canada ,0000 0000 9743 1587grid.413104.3Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON Canada ,Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON Canada ,0000 0001 1457 1558grid.484022.8Canadian Partnership Against Cancer, Toronto, ON Canada
| |
Collapse
|
4
|
Kastelein F, van Olphen SH, Steyerberg EW, Spaander MCW, Bruno MJ. Impact of surveillance for Barrett's oesophagus on tumour stage and survival of patients with neoplastic progression. Gut 2016; 65:548-54. [PMID: 25903690 DOI: 10.1136/gutjnl-2014-308802] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 04/01/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Endoscopic surveillance for Barrett's oesophagus (BO) is under discussion given the overall low incidence of neoplastic progression and lack of evidence that it prevents advanced oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the impact of endoscopic BO surveillance on tumour stage and survival of patients with neoplastic progression. DESIGN 783 patients with BO of at least 2 cm were included in a multicentre prospective cohort and followed during surveillance according to the American College of Gastroenterology guidelines. Cases of high-grade dysplasia and OAC were identified during follow-up. OAC staging was performed according to the 7th UICC-AJCC classification. Survival data were collected and crosschecked using death and municipal registries. Data from patients with OAC in the general population were obtained from the Dutch cancer registry. We compared survival of patients with BO with neoplastic progression during surveillance with those of patients without neoplastic progression and patients with OAC in the general population. RESULTS 53 patients with BO developed high-grade dysplasia or OAC during surveillance. Thirty-five (66%) were classified as stage 0, 14 (26%) as stage 1 and 4 (8%) as stage 2. OAC was diagnosed at an earlier stage during BO surveillance than in the general population (p<0.001). Survival of patients with BO with neoplastic progression was not significantly worse than those of patients without neoplastic progression and similar to survival of patients with stage 0 or stage 1 OAC in the general population. CONCLUSIONS OAC is detected at an earlier stage during BO surveillance than in the general population with good survival rates.
Collapse
Affiliation(s)
- F Kastelein
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S H van Olphen
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
5
|
Kastelein F, van Olphen S, Steyerberg EW, Sikkema M, Spaander MCW, Looman CWN, Kuipers EJ, Siersema PD, Bruno MJ, de Bekker-Grob EW. Surveillance in patients with long-segment Barrett's oesophagus: a cost-effectiveness analysis. Gut 2015; 64:864-71. [PMID: 25037191 DOI: 10.1136/gutjnl-2014-307197] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 07/04/2014] [Indexed: 12/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- F Kastelein
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S van Olphen
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M Sikkema
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - C W N Looman
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E J Kuipers
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E W de Bekker-Grob
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
6
|
Bhat SK, McManus DT, Coleman HG, Johnston BT, Cardwell CR, McMenamin U, Bannon F, Hicks B, Kennedy G, Gavin AT, Murray LJ. Oesophageal adenocarcinoma and prior diagnosis of Barrett's oesophagus: a population-based study. Gut 2015; 64:20-5. [PMID: 24700439 DOI: 10.1136/gutjnl-2013-305506] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Endoscopic surveillance of Barrett's oesophagus (BO) provides an opportunity to detect early stage oesophageal adenocarcinoma (OAC). We sought to determine the proportion of OAC patients with a prior diagnosis of BO on a population basis and to evaluate the influence of a prior diagnosis of BO on survival, taking into account lead and length time biases. DESIGN A retrospective population-based study of all OAC patients in Northern Ireland between 2003 and 2008. A prior BO diagnosis was determined by linkage to the Northern Ireland BO register. Stage distribution at diagnosis and histological grade were compared between patients with and without a prior BO diagnosis. Overall survival, using Cox models, was compared between patients with and without a prior BO diagnosis. The effect of adjusting the survival differences for histological grade and estimates of lead and length time bias was assessed. RESULTS There were 716 OAC cases, 52 (7.3%) of whom had a prior BO diagnosis. Patients with a prior BO diagnosis had significantly lower tumour stage (44.2% vs. 11.1% had stage 1 or 2 disease; p<0.001), a higher rate of surgical resection (50.0% vs. 25.5%; p<0.001) and had a higher proportion of low/intermediate grade tumours (46.2% vs. 26.5%; p=0.011). A prior BO diagnosis was associated with significantly better survival (HR for death 0.39; 95% CI 0.27 to 0.58), which was minimally influenced by adjustment for age, sex and tumour grade (adjusted HR 0.44; 95% CI 0.30 to 0.64). Correction for lead time bias attenuated but did not abolish the survival benefit (HR 0.65; 95% CI 0.45 to 0.95) and further adjustment for length time bias had little effect. CONCLUSIONS The proportion of OAC patients with a prior diagnosis of BO is low; however, prior identification of BO is associated with an improvement in survival in OAC patients.
Collapse
Affiliation(s)
- Shivaram K Bhat
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Damian T McManus
- Department of Pathology, Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, Northern Ireland
| | - Helen G Coleman
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Brian T Johnston
- Department of Gastroenterology, Royal Victoria Hospital, Belfast Health & Social Care Trust, Belfast, Northern Ireland
| | - Christopher R Cardwell
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Una McMenamin
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Finian Bannon
- Northern Ireland Cancer Registry, Queens University Belfast, Belfast, Northern Ireland
| | - Blanaid Hicks
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Grace Kennedy
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queens University Belfast, Belfast, Northern Ireland
| | - Liam J Murray
- Centre for Public Health, Institute of Clinical Sciences - Block B, Queens University Belfast, Royal Victoria Hospital, Belfast, Northern Ireland
| |
Collapse
|
7
|
The case for ablating nondysplastic Barrett's esophagus. Gastrointest Endosc 2014; 80:866-72. [PMID: 25436398 DOI: 10.1016/j.gie.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/03/2014] [Indexed: 02/08/2023]
|
8
|
Comparison of cancer-associated genetic abnormalities in columnar-lined esophagus tissues with and without goblet cells. Ann Surg 2014; 260:72-80. [PMID: 24509200 DOI: 10.1097/sla.0000000000000424] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine and compare the frequency of cancer-associated genetic abnormalities in esophageal metaplasia biopsies with and without goblet cells. BACKGROUND Barrett's esophagus is associated with increased risk of esophageal adenocarcinoma (EAC), but the appropriate histologic definition of Barrett's esophagus is debated. Intestinal metaplasia (IM) is defined by the presence of goblet cells whereas nongoblet cell metaplasia (NGM) lacks goblet cells. Both have been implicated in EAC risk but this is controversial. Although IM is known to harbor genetic changes associated with EAC, little is known about NGM. We hypothesized that if NGM and IM infer similar EAC risk, then they would harbor similar genetic aberrations in genes associated with EAC. METHODS Ninety frozen NGM, IM, and normal tissues from 45 subjects were studied. DNA copy number abnormalities were identified using microarrays and fluorescence in situ hybridization. Targeted sequencing of all exons from 20 EAC-associated genes was performed on metaplasia biopsies using Ion AmpliSeq DNA sequencing. RESULTS Frequent copy number abnormalities targeting cancer-associated genes were found in IM whereas no such changes were observed in NGM. In 1 subject, fluorescence in situ hybridization confirmed loss of CDKN2A and amplification of chromosome 8 in IM but not in a nearby NGM biopsy. Targeted sequencing revealed 11 nonsynonymous mutations in 16 IM samples and 2 mutations in 19 NGM samples. CONCLUSIONS This study reports the largest and most comprehensive comparison of DNA aberrations in IM and NGM genomes. Our results show that IM has a much higher frequency of cancer-associated mutations than NGM.
Collapse
|
9
|
|
10
|
Grant KS, DeMeester SR, Kreger V, Oh D, Hagen JA, Chandrasoma P, DeMeester TR. Effect of Barrett's esophagus surveillance on esophageal preservation, tumor stage, and survival with esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2013; 146:31-7. [PMID: 23312980 DOI: 10.1016/j.jtcvs.2012.12.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Revised: 11/29/2012] [Accepted: 12/12/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Surveillance endoscopy has been recommended for patients with Barrett's esophagus; however, recent studies have questioned the importance owing to the new, lower, estimates of the rate of progression of Barrett's esophagus to cancer. The aim of the present study was to compare the tumor stage, survival, and frequency of esophageal preservation in patients who presented with progression of Barrett's esophagus within a surveillance program versus those who presented with prevalent disease. METHODS A retrospective chart review was performed of all patients treated for high-grade dysplasia or esophageal adenocarcinoma from 2005 to 2010. The surveillance group included patients who had had at least 1 endoscopy and biopsy confirming intestinal metaplasia (with or without low-grade dysplasia) 6 months or more before the endoscopy showing progression. RESULTS A total of 224 patients were included in the present study, 36 in the surveillance group and 188 in the prevalence group. The surveillance patients had significantly earlier stage tumors (P < .0001) and were more likely to undergo endoscopic therapy and to keep their esophagus (44% vs 11%, P < .0001) than were patients with prevalent disease. Furthermore, the patients in the surveillance group were less likely to have lymph node metastases and had better overall and disease-free survival. No patient with high-grade dysplasia or an intramucosal tumor died of cancer. CONCLUSIONS Patients within a surveillance program for Barrett's esophagus had better survival and were less likely to have an esophagectomy than those who presented with prevalent disease. Treatment of intramucosal cancer was curative, and improved survival with surveillance was not secondary to lead time bias. Surveillance endoscopy remains important in patients with Barrett's esophagus.
Collapse
Affiliation(s)
- Kimberly S Grant
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, Calif 90033, USA
| | | | | | | | | | | | | |
Collapse
|
11
|
Mayne GC, Bright T, Hussey DJ, Watson DI. Ablation of Barrett's oesophagus: towards improved outcomes for oesophageal cancer? ANZ J Surg 2012; 82:592-8. [PMID: 22901306 DOI: 10.1111/j.1445-2197.2012.06151.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2011] [Indexed: 11/28/2022]
Abstract
Barrett's oesophagus is the major risk factor for the development of oesophageal adenocarcinoma. The management of Barrett's oesophagus entails treating reflux symptoms with acid-suppressing medication or surgery (fundoplication). However, neither form of anti-reflux therapy produces predictable regression, or prevents cancer development. Patients with Barrett's oesophagus usually undergo endoscopic surveillance, which aims to identify dysplastic changes or cancer at its earliest stage, when treatment outcomes should be better. Alternative endoscopic interventions are now available and are suggested for the treatment of early cancer and prevention of progression of Barrett's oesophagus to cancer. Such treatments could minimize the risks associated with oesophagectomy. The current status of these interventions is reviewed. Various endoscopic interventions have been described, but with long-term outcomes uncertain, they remain somewhat controversial. Radiofrequency ablation of dysplastic Barrett's oesophagus might reduce the risk of cancer progression, although cancer development has been reported after this treatment. Endoscopic mucosal resection (EMR) allows a 1.5-2 cm diameter piece of oesophageal mucosa to be removed. This provides better pathology for diagnosis and staging, and if the lesion is confined to the mucosa and fully excised, EMR can be curative. The combination of EMR and radiofrequency ablation has been used for multifocal lesions, but long-term outcomes are unknown. The new endoscopic interventions for Barrett's oesophagus and early oesophageal cancer have the potential to improve clinical outcomes, although evidence that confirms superiority over oesphagectomy is limited. Longer-term outcome data and data from larger cohorts are required to confirm the appropriateness of these procedures.
Collapse
Affiliation(s)
- George C Mayne
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.
| | | | | | | |
Collapse
|
12
|
Caillol F, Bories E, Pesenti C, Poizat F, Monges G, Guiramand J, Esterni B, Giovannini M. Radiofrequency ablation associated to mucosal resection in the oesophagus: experience in a single centre. Clin Res Hepatol Gastroenterol 2012; 36:371-7. [PMID: 22361442 DOI: 10.1016/j.clinre.2012.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 11/07/2011] [Accepted: 01/02/2012] [Indexed: 02/04/2023]
Abstract
UNLABELLED Endoscopic resection (EMR) and radiofrequency ablation (RFA) form part of the treatment of Barrett's oesophagus (BO), dysplasia, superficial adenocarcinoma (OAC) associated with BO. PATIENTS AND METHODS Between June 2008 and April 2011, 34 patients underwent treatment with RFA (HALO system(®)), in a tertiary centre. For the study, patients were divided into two groups. Group 1 (16 patients of average 60 years old; 14 men, two women) received EMR and RFA. Group 2 (18 patients averaging 59 years age; 14 men, four women) received RFA without EMR in the year preceding the RFA. RESULTS In group 1, high grade dysplasia (HGD) was eradicated in 12 cases (92%), low grade dysplasia (LGD) in three cases (100%). Complete response occurred in nine cases (56%), partial response in 100% of cases. Mean follow-up was 15 months. In group 2, HGD was eradicated in one patient (100%), LGD in three patients (64%). A complete response was achieved in eight patients, partial response in four cases (77%). Mean follow-up was 10 months. The complication rate for groups 1 and 2 was of 18% and 10% respectively. No complication prevented completion of treatment or continued monitoring. Recurrence was evaluated to 5% in both groups. CONCLUSION RFA associated with EMR is feasible, offering probably better results and a very important advantage: a more complete histology before follow-up. Our results show effective treatment of BO and associated dysplasia with a low rate of complication. Nevertheless, when new techniques of BO ablation are used, the need to obtain histology before treatment should not be forgotten.
Collapse
Affiliation(s)
- F Caillol
- Endoscopy unit, Paoli Calmette institute, 232, boulevard Ste-Marguerite, 13009 Marseille, France.
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Boardman CR, Sonnenberg A. A watched pot can boil: interval cancer in tightly surveyed Barrett's esophagus. Am J Gastroenterol 2012; 107:793-4. [PMID: 22552249 DOI: 10.1038/ajg.2012.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
14
|
Shields HM, Nardone G, Zhao J, Wang W, Xing Z, Fang D, Jacobson BC, Romero Y, Dvorak K, Goldman A, Pellegrini CA, Wiley EL, Peura DA, Tatum RP, Schnell TG. Barrett's esophagus: prevalence and incidence of adenocarcinomas. Ann N Y Acad Sci 2011; 1232:230-47. [DOI: 10.1111/j.1749-6632.2011.06054.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
15
|
Kisiel JB, Yab TC, Taylor WR, Chari ST, Petersen GM, Mahoney DW, Ahlquist DA. Stool DNA testing for the detection of pancreatic cancer: assessment of methylation marker candidates. Cancer 2011. [PMID: 22083596 DOI: 10.1002/cncr/26558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic cancer (PanC) presents at late stage with high mortality. Effective early detection methods are needed. Aberrantly methylated genes are unexplored as markers for noninvasive detection by stool testing. The authors aimed to select discriminant methylated genes and to assess accuracy of these and mutant KRAS in stool to detect PanC. METHODS Nine target genes were assayed by real-time methylation-specific polymerase chain reaction (MSP) in bisulfite-treated DNA from microdissected frozen specimens of 24 PanC cases and 30 normal colon controls. Archived stools from 58 PanC cases and 65 controls matched on sex, age, and smoking were analyzed. Target genes from fecal supernatants were enriched by hybrid capture, bisulfite-treated, and assayed by MSP. KRAS mutations were assayed using the QuARTS technique. RESULTS Areas under the receiver operating characteristics curves (AUCs) for tissue BMP3, NDRG4, EYA4, UCHL1, MDFI, Vimentin, CNTNAP2, SFRP2, and TFPI2 were 0.90, 0.79, 0.78, 0.78, 0.77, 0.77, 0.69, 0.67, and 0.66, respectively. The top 4 markers and mutant KRAS were evaluated in stool. BMP3 was the most discriminant methylation marker in stool. At 90% specificity, methylated BMP3 alone detected 51% of PanCs, mutant KRAS detected 50%, and combination detected 67%. AUCs for methylated BMP3, mutant KRAS, and combination in stool were 0.73, 0.75, and 0.85, respectively. CONCLUSIONS This study demonstrates that stool assay of a methylated gene marker can detect PanC. Among candidate methylated markers discriminant in tissue, BMP3 alone performed well in stool. Combining methylated BMP3 and mutant KRAS increased stool detection over either marker alone.
Collapse
Affiliation(s)
- John B Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | |
Collapse
|
16
|
Kisiel JB, Yab TC, Taylor WR, Chari ST, Petersen GM, Mahoney DW, Ahlquist DA. Stool DNA testing for the detection of pancreatic cancer: assessment of methylation marker candidates. Cancer 2011; 118:2623-31. [PMID: 22083596 DOI: 10.1002/cncr.26558] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 08/10/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pancreatic cancer (PanC) presents at late stage with high mortality. Effective early detection methods are needed. Aberrantly methylated genes are unexplored as markers for noninvasive detection by stool testing. The authors aimed to select discriminant methylated genes and to assess accuracy of these and mutant KRAS in stool to detect PanC. METHODS Nine target genes were assayed by real-time methylation-specific polymerase chain reaction (MSP) in bisulfite-treated DNA from microdissected frozen specimens of 24 PanC cases and 30 normal colon controls. Archived stools from 58 PanC cases and 65 controls matched on sex, age, and smoking were analyzed. Target genes from fecal supernatants were enriched by hybrid capture, bisulfite-treated, and assayed by MSP. KRAS mutations were assayed using the QuARTS technique. RESULTS Areas under the receiver operating characteristics curves (AUCs) for tissue BMP3, NDRG4, EYA4, UCHL1, MDFI, Vimentin, CNTNAP2, SFRP2, and TFPI2 were 0.90, 0.79, 0.78, 0.78, 0.77, 0.77, 0.69, 0.67, and 0.66, respectively. The top 4 markers and mutant KRAS were evaluated in stool. BMP3 was the most discriminant methylation marker in stool. At 90% specificity, methylated BMP3 alone detected 51% of PanCs, mutant KRAS detected 50%, and combination detected 67%. AUCs for methylated BMP3, mutant KRAS, and combination in stool were 0.73, 0.75, and 0.85, respectively. CONCLUSIONS This study demonstrates that stool assay of a methylated gene marker can detect PanC. Among candidate methylated markers discriminant in tissue, BMP3 alone performed well in stool. Combining methylated BMP3 and mutant KRAS increased stool detection over either marker alone.
Collapse
Affiliation(s)
- John B Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | |
Collapse
|
17
|
Gisbert JP. [Ten major publications in 2010 with implications for clinical practice in gastroenterology]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:289-304. [PMID: 21474205 DOI: 10.1016/j.gastrohep.2011.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 02/28/2011] [Indexed: 05/30/2023]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| |
Collapse
|
18
|
Fleischer DE, Odze R, Overholt BF, Carroll J, Chang KJ, Das A, Goldblum J, Miller D, Lightdale CJ, Peters J, Rothstein R, Sharma VK, Smith D, Velanovich V, Wolfsen H, Triadafilopoulos G. The case for endoscopic treatment of non-dysplastic and low-grade dysplastic Barrett's esophagus. Dig Dis Sci 2010; 55:1918-31. [PMID: 20405211 DOI: 10.1007/s10620-010-1218-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 03/22/2010] [Indexed: 12/24/2022]
Abstract
Non-dysplastic mucosa (ND-) in Barrett's esophagus (BE) shows clonal molecular aberrations, loss of cell cycle control, and other features of "neoplasia." These changes occur prior to morphologic expression of neoplasia (dysplasia). Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-positive diagnoses. Early "crypt dysplasia" is difficult to detect, and is often missed in routine biopsy specimens. Some studies show substantial progression rates of low-grade dysplasia (LGD), and crypt dysplasia, to esophageal adenocarcinoma (EAC). Dysplasia, even when fully developed, may, in certain circumstances, be difficult to differentiate from non-dysplastic (regenerating) BE. Radiofrequency ablation (RFA) is a safe and effective method for removing mucosa at risk of cancer. Given the difficulties of dysplasia assessment in mucosal biopsies, and the molecular characteristics of ND-BE, this technique should be considered for treatment of all BE patients, including those with ND or LGD. Post-ablation neo-squamous epithelium reveals no molecular abnormalities, and is biologically stable. Given that prospective randomized controlled trials of ablative therapy for ND-BE aiming at reducing EAC incidence and mortality are unlikely to be completed in the near future, endoscopic ablation is a valid management option. The success of RFA in achieving safe, uniform, reliable, and predictable elimination of BE allows surgeons to combine fundoplication with RFA. Currently, there is no type of treatment for dysplastic or non-dysplastic BE that achieves a complete response in 100% of patients, eliminates all risk of developing cancer, results in zero adverse events, is less expensive in terms of absolute costs than surveillance, is durable for 20+ years, or eliminates the need for surveillance. Regardless, RFA shows established safety, efficacy, durability, and cost-effective profiles that should be considered in the management of patients with non-dysplastic or low-grade dysplastic BE.
Collapse
Affiliation(s)
- David E Fleischer
- Department of Internal Medicine, Mayo Clinic in Arizona, Scottsdale, AZ 85259, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
Biomarkers are needed to screen multiple stages in the clinical pathway of Barrett's oesophagus patients; from disease diagnosis to risk stratification and predicting response to therapy. Routes to the identification of biomarkers have been recognized by known molecular features of the disease and more recently through transcriptomic, methylation and proteomic screening approaches. The majority of Barrett's oesophagus patients remain undiagnosed in the general population. In order to develop a tool to screen for Barrett's oesophagus in the primary care setting, minimally invasive sampling methods coupled with immunocytology-based biomarkers are currently being assessed. Biomarkers may also have utility in surveillance programmes by allowing endoscopic interval to be adjusted according to individual neoplastic risk. Many individual biomarkers have been proposed in this regard, but have frequently been assessed in studies of limited power, or have lacked sufficient sensitivity or specificity when assessed in wider population-based studies. Biomarker panels may provide a route forward. In this regard, a panel of methylation markers has shown promise in a multicentre, double-blind, validation study. Biomarkers are also being developed to improve detection of high-grade dysplasia and oesophageal adenocarcinoma, utilizing brush cytology combined with FISH (fluorescence in situ hybridization), and to assess therapeutic success and risk of complication during photodynamic therapy. Finally, we outline progress in identifying alternative sources of biomarkers for this condition.
Collapse
|
20
|
Abstract
OBJECTIVES Surveillance endoscopy aims to identify progression to high-grade dysplasia (HGD) or oesophageal adenocarcinoma (OA) at an early stage in patients with Barrett's metaplasia (BM). There are variations in surveillance practice, clinical outcomes and economic analyses. The study examined long-term survival and financial impact in patients undergoing annual surveillance of BM. METHODS Patients with BM and considered fit for curative treatment between January 1994 and July 2001 were studied. Surveillance was scheduled as annual endoscopy with quadrantic biopsies every 2 cm. Financial analysis was based on standard National Health Service costs to death or follow-up to 5 years. Comparison was made with patients presenting with OA over the same time period. RESULTS Three hundred and two patients were identified with BM. Minimum follow-up was 5 years with a total follow-up of 654 patient-years. Two patients developed HGD and six OA. Median time between last nondysplastic biopsy and development of OA or HGD was 16 months (range 9-55). Five underwent potentially curative treatment. The remaining patients were unfit (n=1), refused surgery (n=1) or had metastatic disease (n=1). Four of five treated patients survived up to 5 years. The total cost of the surveillance programme including subsequent surgical or palliative treatment was euro240 682, euro30 085 per patient who progressed and for the prevalent cancer group (n=74) euro630 480 or euro8520 per patient. Only two patients in this group survived beyond 5 years. The additional cost of surveillance was euro4493 per life year gained. CONCLUSION A surveillance programme leads to improved 5-year survival. It is cost-effective compared with dealing with unselected patients.
Collapse
|
21
|
MicroRNAs in Barrett's esophagus and esophageal adenocarcinoma. Curr Opin Pharmacol 2009; 9:727-32. [PMID: 19773200 DOI: 10.1016/j.coph.2009.08.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 08/19/2009] [Accepted: 08/24/2009] [Indexed: 01/02/2023]
Abstract
The molecular genetics of Barrett's esophagus (BE) and its evolution to esophageal adenocarcinoma (EAC) have been widely studied; however, the molecular mechanism of BE-EAC carcinogenesis has not been completely understood. MicroRNA (miRNA) is now essential to understand the molecular mechanism of cancer progression. Recent findings include the following: firstly, miRNA expression profiles can distinguish between BE and EAC; secondly, miR-196a is upregulated in EAC tissues targeting annexin A1, thereby exerting antiapoptotic effects and contributing to EAC cell survival; miR-196a may also constitute a good biomarker of progression during BE-EAC carcinogenesis; and thirdly, The miR-106b-25 polycistron is activated by genomic amplification and is involved in esophageal neoplastic progression and proliferation via the suppression of two target genes, p21 and Bim.
Collapse
|