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Menon S, Norman R, Iyer PG, Ragunath K. Stratification of Barrett's esophagus surveillance based on p53 immunohistochemistry: a cost-effectiveness analysis by an international collaborative group. Endoscopy 2024; 56:727-736. [PMID: 38698618 DOI: 10.1055/a-2317-8184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
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.
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Affiliation(s)
- Shyam Menon
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom of Great Britain and Northern Ireland
| | - Richard Norman
- Health Economist, School of Population Health, Curtin University, Perth, Australia
| | - Prasad G Iyer
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | - Krish Ragunath
- Curtin Medical School, Curtin University, Perth, Australia
- Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Australia
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Lin YT, Zhou CC, Xu K, Zhang MD, Li X. Cost-effectiveness analysis of serplulimab in combination with cisplatin plus 5-fluorouracil chemotherapy compared to cisplatin plus 5-fluorouracil chemotherapy as first-line treatment for advanced or metastatic esophageal squamous cell carcinoma in China. Ther Adv Med Oncol 2023; 15:17588359231213621. [PMID: 38028139 PMCID: PMC10666699 DOI: 10.1177/17588359231213621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background This study evaluated the cost-effectiveness of serplulimab plus chemotherapy versus chemotherapy alone in treating advanced/metastatic esophageal squamous cell carcinoma (ESCC) within the Chinese health care system. Methods A partitioned survival model based on ASTRUM-007 trial patient characteristics was developed. Efficacy, safety, and medical/economic data were obtained from the trial and real-world clinical practice. Costs, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs) were calculated for both treatment strategies. Sensitivity, subgroup, and scenario analyses were performed to assess the uncertainty impact. Results Serplulimab combined with chemotherapy yielded an ICER of US$ 53,538.27/QALY. Deterministic sensitivity analysis identified patient survival and serplulimab price as influential parameters. Probabilistic sensitivity analysis showed a 47.33% probability of cost-effectiveness at a willingness-to-pay (WTP) threshold of US$ 53,541/QALY and 0.05% at three times China's GDP per capita. Subgroup analysis revealed that patients with a programmed death-ligand 1 (PD-L1) expression combined positive score (CPS) ⩾10 had a lower hazard ratio (0.59) and ICER (US$ 29,935.23/QALY), with a 95.36% probability of cost-effectiveness. Scenario analysis demonstrated that the drug donation discount policy significantly increased the likelihood of cost-effective serplulimab-chemotherapy combinations in Jiangsu, Fujian, and Guangdong at 99.99%, 99.90%, and 94.16%, respectively. Conclusion Compared to chemotherapy alone, serplulimab combined with chemotherapy is currently not a cost-effective first-line treatment for advanced/metastatic ESCC in China. However, as serplulimab plus chemotherapy regimens evolve and price competition among programmed death 1 (PD-1) inhibitors intensifies, this combination may become a cost-effective treatment option.
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Affiliation(s)
- Ying-Tao Lin
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Drug Clinical Trial Institution, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chong-Chong Zhou
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kai Xu
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meng-Die Zhang
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xin Li
- Center for Global Health, School of Public Health, Nanjing Medical University, No.101 Longmian Avenue, Nanjing, Jiangsu 210029, China
- Department of Pharmaceutical Regulatory Science and Pharmacoeconomics, School of Pharmacy, Nanjing Medical University, No.101 Longmian Avenue, Nanjing, Jiangsu, China
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Palmieri L, Giacomo TD, Quaresima S, Balla A, Diso D, Mottola E, Ruberto F, Paganini AM. Minimally Invasive Esophagectomy for Esophageal Cancer. GASTROINTESTINAL CANCERS 2022:111-124. [PMID: 36343154 DOI: 10.36255/exon-publications-gastrointestinal-cancers-esophagectomy] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Rubenstein JH, Omidvari AH, Lauren BN, Hazelton WD, Lim F, Tan SX, Kong CY, Lee M, Ali A, Hur C, Inadomi JM, Luebeck G, Lansdorp-Vogelaar I. Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis. Gastroenterology 2022; 163:163-173. [PMID: 35364064 DOI: 10.1053/j.gastro.2022.03.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/23/2022] [Accepted: 03/22/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision. METHODS We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained. RESULTS Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm. CONCLUSIONS The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Epidemiology and Prevention Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Amir-Houshang Omidvari
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Brianna N Lauren
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - William D Hazelton
- Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francesca Lim
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chung Yin Kong
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Minyi Lee
- Gastrointestinal Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; The Graduate Program in Bioinformatics, Boston University, Boston, Massachusetts
| | - Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - John M Inadomi
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Georg Luebeck
- Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Lin YT, Liu TX, Chen J, Wang C, Chen Y. Cost-Effectiveness of Nivolumab Immunotherapy vs. Paclitaxel or Docetaxel Chemotherapy as Second-Line Therapy in Advanced Esophageal Squamous Cell Carcinoma in China. Front Public Health 2022; 10:923619. [PMID: 35844891 PMCID: PMC9277084 DOI: 10.3389/fpubh.2022.923619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/09/2022] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate and compare nivolumab's cost-effectiveness with chemotherapy in patients with advanced esophageal squamous cell carcinoma from the Chinese healthcare system perspective. To this end, the researchers utilized a partitioned survival model with three mutually exclusive health stages. The characteristics of the patients used as inclusion and exclusion criteria in this model were the same as those used for patients with advanced esophageal squamous cell carcinoma in the ATTRACTION-3 study. The ATTRACTION-3 trial, which took place between January 7, 2016 and November 12, 2018, also yielded important clinical data. Data on medical and economic preferences were collected from real-world clinical practices. Costs, quality-adjusted life years, and incremental cost-effectiveness ratio were calculated for the two therapy options. The model uncertainty was investigated using a deterministic and probabilistic sensitivity analysis. When compared to chemotherapy, nivolumab was linked with an increase of 0.28 quality-adjusted life years with an increased cost of US$ 36,956.81 per patient in the base case analysis of a hypothetical sample of 419 patients. The incremental cost-effectiveness ratio in the deterministic sensitivity analysis was US$ 132,029.46/quality-adjusted life year, with a 48.02% probability of being cost-effective at willingness-to-pay thresholds of US$ 132,029.22/quality-adjusted life year. The incremental cost-effectiveness ratio remained greater than US$ 80,000/quality-adjusted life year in the deterministic sensitivity analyses. To be more cost-effective and remain below the threshold of 37,653 US$/quality-adjusted life year, which the Chinese population can afford, nivolumab's price would have to be lowered sharply by 53.50%. Nivolumab is clinically beneficial but not cost-effective when compared to chemotherapy. A substantial reduction in nivolumab's drug acquisition cost would be necessary to make it cost-effective for immunotherapy.
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Affiliation(s)
- Ying-tao Lin
- Department of Drug Clinical Trial Administration Office, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Tian-xiu Liu
- Department of Thoracic Radiotherapy, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Jian Chen
- Department of Surgical Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Chang Wang
- Department of Medical Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Ying Chen
- Department of Drug Clinical Trial Administration Office, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
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Omidvari AH, Hazelton WD, Lauren BN, Naber SK, Lee M, Ali A, Seguin C, Kong CY, Richmond E, Rubenstein JH, Luebeck GE, Inadomi JM, Hur C, Lansdorp-Vogelaar I. The Optimal Age to Stop Endoscopic Surveillance of Patients With Barrett's Esophagus Based on Sex and Comorbidity: A Comparative Cost-Effectiveness Analysis. Gastroenterology 2021; 161:487-494.e4. [PMID: 33974935 PMCID: PMC8495224 DOI: 10.1053/j.gastro.2021.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 04/15/2021] [Accepted: 05/01/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Current guidelines recommend surveillance for patients with nondysplastic Barrett's esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity. METHODS We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental cost-effectiveness ratio of 1 more surveillance was just less than the willingness-to-pay threshold of $100,000/QALY. RESULTS The benefit of having 1 more surveillance endoscopy strongly depended on age, sex, and comorbidity. For men with NDBE and severe comorbidity, 1 additional surveillance at age 80 years provided 4 more QALYs per 1000 patients with BE at an additional cost of $1.2 million, whereas for women with severe comorbidity the benefit at that age was 7 QALYs at a cost of $1.3 million. For men with no, mild, moderate, and severe comorbidity, the optimal ages of last surveillance were 81, 80, 77, and 73 years, respectively. For women, these ages were younger: 75, 73, 73, and 69 years, respectively. CONCLUSIONS Our comparative modeling analysis illustrates the importance of considering comorbidity status and sex when deciding on the age to discontinue surveillance in patients with NDBE.
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Affiliation(s)
- Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - William D. Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Steffie K. Naber
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Minyi Lee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Claudia Seguin
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chun Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Joel H. Rubenstein
- Barrett’s Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Georg E. Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John M. Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chin Hur
- Department of Medicine, Columbia University, New York, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
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Sami SS, Moriarty JP, Rosedahl JK, Borah BJ, Katzka DA, Wang KK, Kisiel JB, Ragunath K, Rubenstein JH, Iyer PG. Comparative Cost Effectiveness of Reflux-Based and Reflux-Independent Strategies for Barrett's Esophagus Screening. Am J Gastroenterol 2021; 116:1620-1631. [PMID: 34131096 PMCID: PMC8315187 DOI: 10.14309/ajg.0000000000001336] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/12/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Minimally invasive tests for Barrett's esophagus (BE) detection have raised the prospect of broader nonreflux-based testing. Cost-effectiveness studies have largely studied men aged 50 years with chronic gastroesophageal reflux disease (GERD) symptoms. We evaluated the comparative cost effectiveness of BE screening tests in GERD-based and GERD-independent testing scenarios. METHODS Markov modeling was performed in 3 scenarios in 50 years old individuals: (i) White men with chronic GERD (GERD-based); (ii) GERD-independent (all races, men and women), BE prevalence 1.6%; and (iii) GERD-independent, BE prevalence 5%. The simulation compared multiple screening strategies with no screening: sedated endoscopy (sEGD), transnasal endoscopy, swallowable esophageal cell collection devices with biomarkers, and exhaled volatile organic compounds. A hypothetical cohort of 500,000 individuals followed for 40 years using a willingness to pay threshold of $100,000 per quality-adjusted life year (QALY) was simulated. Incremental cost-effectiveness ratios (ICERs) comparing each strategy with no screening and comparing screening strategies with each other were calculated. RESULTS In both GERD-independent scenarios, most non-sEGD BE screening tests were cost effective. Swallowable esophageal cell collection devices with biomarkers were cost effective (<$35,000/QALY) and were the optimal screening tests in all scenarios. Exhaled volatile organic compounds had the highest ICERs in all scenarios. ICERs were low (<$25,000/QALY) for all tests in the GERD-based scenario, and all non-sEGD tests dominated no screening. ICERs were sensitive to BE prevalence and test costs. DISCUSSION Minimally invasive nonendoscopic tests may make GERD-independent BE screening cost effective. Participation rates for these strategies need to be studied.
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Affiliation(s)
- Sarmed S. Sami
- Division of Surgery and Interventional Science, University College London, London, UK;
| | - James P. Moriarty
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jordan K. Rosedahl
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J. Borah
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David A. Katzka
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John B. Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Prasad G. Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Vissapragada R, Bulamu NB, Brumfitt C, Karnon J, Yazbeck R, Watson DI. Improving cost-effectiveness of endoscopic surveillance for Barrett's esophagus by reducing low-value care: a review of economic evaluations. Surg Endosc 2021; 35:5905-5917. [PMID: 34312726 DOI: 10.1007/s00464-021-08646-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ravi Vissapragada
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Department of Surgery, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia
| | - Norma B Bulamu
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia
| | - Christine Brumfitt
- Department of Surgery, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia
| | - Jonathan Karnon
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia
| | - Roger Yazbeck
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia.,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia
| | - David I Watson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia. .,Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, SA, 5042, Australia. .,Department of Surgery, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.
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9
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Marguet S, Adenis A, Delaine-Clisant S, Penel N, Bonastre J. Cost-Utility Analysis of Continuation Versus Discontinuation of First-Line Chemotherapy in Patients With Metastatic Squamous-Cell Esophageal Cancer: Economic Evaluation Alongside the E-DIS Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:676-682. [PMID: 33933236 DOI: 10.1016/j.jval.2020.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/21/2020] [Accepted: 11/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Continuous chemotherapy has been used to treat patients with metastatic esophageal squamous cell carcinoma (mESCC), despite weak evidence supporting a clinical benefit, associated side effects for the patients, and unjustified medical costs. In the French setting, we conducted a cost-utility analysis alongside the randomized E-DIS trial (NCT01248299), which compared first-line fluorouracil/platinum-based chemotherapy continuation (CT-CONT) to CT discontinuation (CT-DISC) in progressive-free patients after an initial 6-week treatment phase. METHODS A partitioned survival analysis was performed using patient-level data collected during the trial for survival outcomes, quality of life (EQ-5D-3L), and medical costs. The mean quality-adjusted life-years (QALYs) and medical costs were estimated over an 18-month period to assess the incremental net monetary benefit and incremental cost-effectiveness ratio. Uncertainty was handled using the nonparametric bootstrap and univariate analysis. Sixty-seven patients with mESCC were randomized and included in the cost-utility analysis. RESULTS On average, CT-CONT slightly decreased the number of QALYs (-0.038) and increased the cost per patient (+ €1177). At a willingness-to-pay threshold of €50 000/QALY, the incremental net monetary benefit was negative (-€3077 [95% confidence interval: -6564; 4359]), and the incremental cost-effectiveness ratio was -30 958€/QALY (CT-CONT dominated). The probability of the CT-CONT treatment option being cost-effective at a willingness-to-pay threshold of €50 000/QALY, compared to CT-DISC, was 29%. CONCLUSIONS CT-DISC may be considered as an alternative therapeutic option to CT-CONT in patients with mESCC who have stable disease after an initial chemotherapy treatment phase. A continuous chemotherapy could indeed reduce the number of QALYs because of the disutility associated with the continuous treatment.
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Affiliation(s)
- Sophie Marguet
- Gustave Roussy, Université Paris-Saclay, Service de Biostatistique et d'Epidémiologie, Villejuif, France; Université Paris-Saclay, Paris-Sud University, Villejuif, France
| | - Antoine Adenis
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France
| | | | - Nicolas Penel
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France; Direction de la Recherche Clinique et de l'Innovation, Centre Oscar Lambret, Lille, France; Lille University Hospital, Lille, France
| | - Julia Bonastre
- Gustave Roussy, Université Paris-Saclay, Service de Biostatistique et d'Epidémiologie, Villejuif, France; Université Paris-Saclay, Paris-Sud University, Villejuif, France.
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Isseh M, Mueller L, Abunafeesa H, Imam Z, Shakaroun D, Abu Ghanimeh M, Isseh N, Miller J, Jafri SM, Lenhart A. An Urban Center Experience Exploring Barriers to Adherence to Endoscopic Surveillance for Non-Dysplastic Barrett's Esophagus. Cureus 2021; 13:e13030. [PMID: 33665052 PMCID: PMC7924167 DOI: 10.7759/cureus.13030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Data regarding barriers to Barrett’s esophagus (BE) surveillance is limited. Studying an urban center population, we aimed to characterize non-dysplastic BE surveillance rates and identify health, racial, and socioeconomic disparities affecting surveillance. Methods Patients with biopsy-confirmed BE were retrospectively identified between January 2002 and December 2012. Non-dysplastic BE patients were analyzed for adherence to established surveillance guidelines. Demographic, racial, comorbidities, and socioeconomic variables were extracted. Annual gross income (AGI) was utilized as a marker of socioeconomic status (SES). Univariate and multivariate analyses compared adherent vs. non-adherent patients to surveillance guidelines. Results A total of 217 patients with non-dysplastic BE were analyzed. The majority were male (67.3%) and Caucasian (75.6%), with only 47.5% adherent with the first surveillance endoscopy. Patients with a high average AGI were more likely to be adherent with the initial surveillance endoscopy than those with low AGI (p=0.032). Initial compliance with first surveillance was associated with better surveillance at regular intervals (p=0.001). No significant differences in age, primary language, insurance type, marital status, or Charlson Comorbidity Index (CCI) between adherent and non-adherent patients were found. Conclusions Although overall adherence to guidelines was suboptimal, this study identifies important socioeconomic disparities in the endoscopic surveillance for non-dysplastic BE. Identifying and understanding the barriers to care among these lower socioeconomic groups may ultimately lead to improved screening compliance and early BE detection.
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Affiliation(s)
- Mahmoud Isseh
- Internal Medicine, University of Michigan, Ann Arbor, USA
| | - Laurel Mueller
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | | | - Zaid Imam
- Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, USA
| | | | | | - Nazih Isseh
- Internal Medicine, The University of Tennessee Health Science Center, Memphis, USA
| | - Joseph Miller
- Emergency Medicine, Henry Ford Health System, Detroit, USA
| | | | - Adrienne Lenhart
- Gastroenterology, University of California Los Angeles, Los Angeles, USA
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11
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Omidvari AH, Roumans CA, Naber SK, Kroep S, Wijnhoven BP, van der Gaast A, de Jonge PJ, Spaander MC, Lansdorp-Vogelaar I. The Impact of the Policy-Practice Gap on Costs and Benefits of Barrett's Esophagus Management. Am J Gastroenterol 2020; 115:1026-1035. [PMID: 32618653 PMCID: PMC8563953 DOI: 10.14309/ajg.0000000000000578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Clinical guidelines recommend surveillance of patients with Barrett's esophagus (BE). However, the surveillance intervals in practice are shorter than policy recommendations. We aimed to determine how this policy-practice gap affects the costs and benefits of BE surveillance. METHODS We used the Netherlands as an exemplary Western country and simulated a cohort of 60-year-old patients with BE using the Microsimulation Screening Analysis model-esophageal adenocarcinoma (EAC) microsimulation model. We evaluated surveillance according to the Dutch guideline and more intensive surveillance of patients without dysplastic BE and low-grade dysplasia. For each strategy, we computed the quality-adjusted life years (QALYs) gained and costs compared with no surveillance. We also performed a budget impact analysis to estimate the increased costs of BE management in the Netherlands for 2017. RESULTS Compared with no surveillance, the Dutch guideline incurred an additional &OV0556;5.0 ($5.7) million per 1,000 patients with BE for surveillance and treatment, whereas 57 esophageal adenocarcinoma (EAC) cases (>T1a) were prevented. With intensive and very intensive surveillance strategies for both nondysplastic BE and low-grade dysplasia, the net costs increased by another &OV0556;2.5-5.6 ($2.8-6.5) million while preventing 10-19 more EAC cases and gaining 33-60 more QALYs. On a population level, this amounted to &OV0556;21-47 ($24-54) million (+32%-70%) higher healthcare costs in 2017. DISCUSSION The policy-practice gap in BE surveillance intervals results in 50%-114% higher net costs for BE management for only 10%-18% increase in QALYs gained, depending on actual intensity of surveillance. Incentives to eliminate this policy-practice gap should be developed to reduce the burden of BE management on patients and healthcare resources.
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Affiliation(s)
- Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Carlijn A.M. Roumans
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Steffie K. Naber
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sonja Kroep
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bas P.L. Wijnhoven
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ate van der Gaast
- Department of Oncology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter-Jan de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Manon C.W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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12
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Huang Z, Zhou B, Li Z, Liu C, Zheng C, Zeng R, Hong C, Xu L, Li E, Peng Y, Xu Y. Serum interleukin-8 as a potential diagnostic biomarker in esophageal squamous cell carcinoma. Cancer Biomark 2020; 29:139-149. [PMID: 32623391 DOI: 10.3233/cbm-201687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Esophageal squamous cell carcinoma (ESCC) has poor prognosis mainly due to the difficulty of making early diagnosis. Therefore, novel biomarkers are critically needed. OBJECTIVE We aimed to investigate the diagnostic value of serum interleukin-8 (IL-8) in ESCC. METHODS Data mining of TCGA was used to analyze expression level of IL-8 mRNA in esophageal carcinoma. Serum levels of IL-8 were measured in 103 ESCC patients and 86 normal controls by ELISA. Receiver operating characteristic (ROC) curve was used to evaluate its diagnostic accuracy. RESULTS IL-8 mRNA expression level and serum IL-8 concentration were both statistically higher in patients than normal controls (P< 0.001). ROC curve demonstrated that the optimum diagnostic cut-off for serum IL-8 was 80.082 pg/mL, providing an area under the curve (AUC) of 0.694 (95% CI: 0.620-0.768), with specificity of 86.0% and sensitivity of 42.7%. The AUC for early-stage ESCC was 0.618 (95% CI: 0.499-0.737), with sensitivity of 35.3% and specificity of 86.0%. Kaplan-Meier analysis and the log-rank test indicated that IL-8 may not be a prognostic predictor for ESCC. CONCLUSIONS Serum IL-8 was highly expressed in ESCC patients and may be a potential marker for early diagnosis of ESCC.
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Affiliation(s)
- Zeting Huang
- Shantou University Medical College, Shantou, Guangdong, China
- Shantou University Medical College, Shantou, Guangdong, China
| | - Bin Zhou
- Shantou University Medical College, Shantou, Guangdong, China
- Shantou University Medical College, Shantou, Guangdong, China
| | - Zheng Li
- Shantou University Medical College, Shantou, Guangdong, China
- Shantou University Medical College, Shantou, Guangdong, China
| | - Cantong Liu
- Department of Clinical Laboratory Medicine, The Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Precision Medicine Research Centre, Shantou University Medical College, Shantou, Guangdong, China
| | - Chunwen Zheng
- Shantou University Medical College, Shantou, Guangdong, China
| | - Ruijie Zeng
- Shantou University Medical College, Shantou, Guangdong, China
| | - Chaoqun Hong
- Department of Oncological Laboratory Research, The Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Liyan Xu
- Institute of Oncologic Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Enmin Li
- Department of Biochemistry and Molecular Biology, Shantou University Medical College, Shantou, Guangdong, China
| | - Yuhui Peng
- Department of Clinical Laboratory Medicine, The Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Precision Medicine Research Centre, Shantou University Medical College, Shantou, Guangdong, China
| | - Yiwei Xu
- Department of Clinical Laboratory Medicine, The Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Precision Medicine Research Centre, Shantou University Medical College, Shantou, Guangdong, China
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13
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Alnasser S, Agnihotram R, Martel M, Mayrand S, Franco E, Ferri L. Predictors of dysplastic and neoplastic progression of Barrett’s esophagus. Can J Surg 2019; 62:93-99. [PMID: 30907564 DOI: 10.1503/cjs.008716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background It is unknown why some cases of Barrett’s esophagus progress to invasive malignant disease rapidly while others do so more slowly or not at all. The aim of this study was to identify demographic and endoscopic factors that predict dysplastic and neoplastic progression in patients with Barrett’s esophagus. Methods Patients with Barrett’s esophagus who were assessed in 2000–2010 were assessed for inclusion in this retrospective study. Demographic and endoscopic variables were collected from an endoscopy database and the medical chart. Dysplastic and neoplastic progression was examined by time-to-event analysis. We used Cox proportional hazard regression modelling and generalized estimating equation methods to identify variables that were most predictive of neoplastic progression. Results A total of 518 patients had Barrett’s esophagus confirmed by endoscopy and pathology and at least 2 surveillance visits. Longer Barrett’s esophagus segment (≥ 3 cm) (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1–1.3) and increased age (≥ 60 yr) (OR 3.5, 95% CI 1.7–7.4) were independent predictors of progression from nondysplasia to dysplastic or neoplastic grades. Presence of mucosal irregularities (OR 8.6, 95% CI 2.4–30.4) and increased age (OR 5.1, 95% CI 1.6–16.6) were independent predictors of progression from nondysplasia to high-grade dysplasia or adenocarcinoma. Conclusion Increased age, longer Barrett’s segment and presence of mucosal irregularities were associated with increased risk of dysplastic and neoplastic progression. In addition to dysplasia, these factors may help stratify patients according to risk of neoplastic progression and be used to individualize surveillance. More prospective studies with larger samples are required to validate these results.
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Affiliation(s)
- Saleh Alnasser
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Raman Agnihotram
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Myriam Martel
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Serge Mayrand
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Eduardo Franco
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
| | - Lorenzo Ferri
- From the Department of General Surgery, McGill University Health Centre, Montreal, Que. (Alnasser); the Department of Epidemiology and Biostatistics – Cancer Epidemiology, McGill University, Montreal, Que. (Agnihotram, Franco); and the Ringgold Standard Institution – Gastroenterology, McGill University Health Centre, Montréal, Que. (Martel, Mayrand, Ferri)
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14
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Li S, Chung DC, Mullen JT. Screening high-risk populations for esophageal and gastric cancer. J Surg Oncol 2019; 120:831-846. [PMID: 31373005 DOI: 10.1002/jso.25656] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/17/2019] [Indexed: 12/17/2022]
Abstract
Cancers of the esophagus and stomach remain important causes of mortality worldwide, in large part because they are most often diagnosed at advanced stages. Thus, it is imperative that we identify and treat these cancers in earlier stages. Due to significant heterogeneity in incidence and risk factors for these cancers, it has been challenging to develop standardized screening recommendations. This review summarizes the current recommendations for screening populations at high risk of developing esophagogastric cancers.
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Affiliation(s)
- Selena Li
- Departments of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel C Chung
- Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John T Mullen
- Departments of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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15
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Pollit V, Graham D, Leonard C, Filby A, McMaster J, Mealing SJ, Lovat LB, Haidry RJ. A cost-effectiveness analysis of endoscopic eradication therapy for management of dysplasia arising in patients with Barrett's oesophagus in the United Kingdom. Curr Med Res Opin 2019; 35:805-815. [PMID: 30479169 DOI: 10.1080/03007995.2018.1552407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Vicki Pollit
- a York Health Economics Consortium , York , United Kingdom
| | - David Graham
- b Department of Gastroenterology , University College London Hospital , United Kingdom
- c Division of Surgery and Science , University College London Hospital , United Kingdom
| | | | | | | | | | - Laurence B Lovat
- b Department of Gastroenterology , University College London Hospital , United Kingdom
- c Division of Surgery and Science , University College London Hospital , United Kingdom
| | - Rehan J Haidry
- b Department of Gastroenterology , University College London Hospital , United Kingdom
- c Division of Surgery and Science , University College London Hospital , United Kingdom
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16
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Honing J, Kievit W, Bookelaar J, Peters Y, Iyer PG, Siersema PD. Endosheath ultrathin transnasal endoscopy is a cost-effective method for screening for Barrett's esophagus in patients with GERD symptoms. Gastrointest Endosc 2019; 89:712-722.e3. [PMID: 30385112 DOI: 10.1016/j.gie.2018.10.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 10/06/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Judith Honing
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Jan Bookelaar
- Department for Health Evidence, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
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Definition of Barrett Esophagus in the United States: Support for Retention of a Requirement for Goblet Cells. Am J Surg Pathol 2019; 42:264-268. [PMID: 29016405 DOI: 10.1097/pas.0000000000000971] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett esophagus (BE) predisposes patients to the development of esophageal adenocarcinoma (EAC). However, the global definition of BE is controversial. Pathologists in Europe and the United States require intestinal metaplasia (IM) within columnar-lined mucosa (CLM) in the tubular esophagus to diagnose BE, whereas in the UK and Japan only the presence of CLM is required. To aid in establishing an appropriate definition for BE, we evaluated whether IM accompanies EAC in a US patient cohort. We examined a series of 139 consecutive patients who underwent endoscopic mucosal resections or esophagectomies for EAC performed at a US tertiary care center. The resection specimens were evaluated for the presence (IM+) or absence (IM-) of IM within CLM. Ninety-seven (70%) patients were IM+. Tumors found in IM- patients tended to be advanced at the time of resection (57% pT3 or greater, IM-; 31% pT3 or greater, IM+; P=0.02) such that the tumor may have "overgrown" zones of IM. We hypothesized that changes as a result of neoadjuvant chemotherapy or radiation might mask preexisting IM. When evaluating this hypothesis, we found that 34 of 39 of treatment-naive patients were IM+. Two of the 5 IM- patients had prior IM+ biopsies resulting in 92% of treatment-naive patients who were IM+. In our US hospital population, CLM with IM in the tubular esophagus is found in association with EAC in 70% to 92% of patients. We believe that based on these data the United States definition of BE should continue to require the presence of IM.
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18
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Guan CT, Song GH, Li BY, Gong YW, Hao CQ, Xue LY, Chen WQ, Wei WQ. Endoscopy screening effect on stage distributions of esophageal cancer: A cluster randomized cohort study in China. Cancer Sci 2018; 109:1995-2002. [PMID: 29635717 PMCID: PMC5989864 DOI: 10.1111/cas.13606] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/02/2018] [Indexed: 12/29/2022] Open
Abstract
Efficacy of endoscopic screening for esophageal cancer is not sufficiently definitive and lacks randomized controlled trial evidence. The present study proved short‐term screening efficacy through describing and comparing disease stage distributions of intervention and control populations. Villages from Linzhou and Cixian were cluster randomly allocated to the intervention or to the control group and the target population of 52 729 and 43 068 individuals was 40‐69 years old, respectively, and the actual enrolled numbers were 18 316 and 21 178, respectively. TNM stage information and study‐defined stage information of esophageal cases from 2012 to 2016 were collected. Stage distributions were compared between the intervention and control groups in the total target population, as well as in the subgroup populations in terms of enrolment and before or after intervention. There were a total of 199 and 141 esophageal cancer cases in the intervention and control groups, respectively. For the target population, distributions of TNM stage were borderline significant between the two groups after intervention (P = .093). However, subgroup analysis of the enrolled population during the after‐intervention period had statistical significance for both TNM and study‐defined stage. Natural TNM stage distributions were approximately 32%, 41%, 24% and 3% for stages I to IV vs 71%, 19%, 7% and 3% in the intervention population. The natural study‐defined stage distributions from early, middle to advanced stages were approximately 18%, 49% and 33% vs 59%, 33% and 8%. Early‐stage esophageal cancer cases accounted for a higher proportion after endoscopy screening, and the efficacy in the target population depends on the intervention compliance.
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Affiliation(s)
- Chen-Tao Guan
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Guo-Hui Song
- Department of Epidemiology, Cancer Institute/Hospital of Cixian, Cixian, China
| | - Bian-Yun Li
- Department of Epidemiology, Cancer Institute/Hospital of Linzhou, Linzhou, China
| | - Yan-Wei Gong
- Department of Epidemiology, Cancer Institute/Hospital of Cixian, Cixian, China
| | - Chang-Qing Hao
- Department of Endoscopy, Cancer Institute/Hospital of Linzhou, Linzhou, China
| | - Li-Yan Xue
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wan-Qing Chen
- National Office for Cancer Prevention and Control, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wen-Qiang Wei
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Chedgy F, Fogg C, Kandiah K, Barr H, Higgins B, McCord M, Dewey A, De Caestecker J, Gadeke L, Stokes C, Poller D, Longcroft-Wheaton G, Bhandari P. Acetic acid-guided biopsies in Barrett's surveillance for neoplasia detection versus non-targeted biopsies (Seattle protocol): A feasibility study for a randomized tandem endoscopy trial. The ABBA study. Endosc Int Open 2018; 6:E43-E50. [PMID: 29340297 PMCID: PMC5766339 DOI: 10.1055/s-0043-120829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Barrett's esophagus is a potentially pre-cancerous condition, affecting 375,000 people in the UK. Patients receive a 2-yearly endoscopy to detect cancerous changes, as early detection and treatment results in better outcomes. Current treatment requires random mapping biopsies along the length of Barrett's, in addition to biopsy of visible abnormalities. As only 13 % of pre-cancerous changes appear as visible nodules or abnormalities, areas of dysplasia are often missed. Acetic acid chromoendoscopy (AAC) has been shown to improve detection of pre-cancerous and cancerous tissue in observational studies, but no randomized controlled trials (RCTs) have been performed to date. PATIENTS AND METHODS A "tandem" endoscopy cross-over design. Participants will be randomized to endoscopy using mapping biopsies or AAC, in which dilute acetic acid is sprayed onto the surface of the esophagus, highlighting tissue through an whitening reaction and enhancing visibility of areas with cellular changes for biopsy. After 4 to 10 weeks, participants will undergo a repeat endoscopy, using the second method. Rates of recruitment and retention will be assessed, in addition to the estimated dysplasia detection rate, effectiveness of the endoscopist training program, and rates of adverse events (AEs). Qualitative interviews will explore participant and endoscopist acceptability of study design and delivery, and the acceptability of switching endoscopic techniques for Barrett's surveillance. RESULTS Endoscopists' ability to diagnose dysplasia in Barrett's esophagus can be improved. AAC may offer a simple, universally applicable, easily-acquired technique to improve detection, affording patients earlier diagnosis and treatment, reducing endoscopy time and pathology costs. The ABBA study will determine whether a crossover "tandem" endoscopy design is feasible and acceptable to patients and clinicians and gather outcome data to power a definitive trial.
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Affiliation(s)
| | | | | | - Hugh Barr
- Royal Gloucestershire Hospital, Gloucester, Gloucestershire, UK
| | | | - Mimi McCord
- Heartburn Cancer UK, Basingstoke, Hampshire, UK
| | - Ann Dewey
- University of Portsmouth, Portsmouth
| | | | - Lisa Gadeke
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Clive Stokes
- Royal Gloucestershire Hospital, Gloucester, Gloucestershire, UK
| | | | | | - Pradeep Bhandari
- Portsmouth Hospitals NHS Trust, Portsmouth, UK,Corresponding author Pradeep Bhandari Portsmouth Hospitals NHS TrustSouthwick Hill RoadCosham, UK, PO6 3LY+4402392286822
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20
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Moriarty JP, Shah ND, Rubenstein JH, Blevins CH, Johnson M, Katzka DA, Wang KK, Wongkeesong LM, Ahlquist DA, Iyer PG. 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. Gastrointest Endosc 2018; 87:88-94.e2. [PMID: 28455158 PMCID: PMC5656556 DOI: 10.1016/j.gie.2017.04.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 04/13/2017] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- James P. Moriarty
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Joel H. Rubenstein
- Veteran’s Affairs Center for Clinical Management Research, Ann Arbor, MI and Barrett’s Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | | | - Michele Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - David A. Ahlquist
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Bojke L, Manca A, Asaria M, Mahon R, Ren S, Palmer S. How to Appropriately Extrapolate Costs and Utilities in Cost-Effectiveness Analysis. PHARMACOECONOMICS 2017; 35:767-776. [PMID: 28470594 DOI: 10.1007/s40273-017-0512-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Costs and utilities are key inputs into any cost-effectiveness analysis. Their estimates are typically derived from individual patient-level data collected as part of clinical studies the follow-up duration of which is often too short to allow a robust quantification of the likely costs and benefits a technology will yield over the patient's entire lifetime. In the absence of long-term data, some form of temporal extrapolation-to project short-term evidence over a longer time horizon-is required. Temporal extrapolation inevitably involves assumptions regarding the behaviour of the quantities of interest beyond the time horizon supported by the clinical evidence. Unfortunately, the implications for decisions made on the basis of evidence derived following this practice and the degree of uncertainty surrounding the validity of any assumptions made are often not fully appreciated. The issue is compounded by the absence of methodological guidance concerning the extrapolation of non-time-to-event outcomes such as costs and utilities. This paper considers current approaches to predict long-term costs and utilities, highlights some of the challenges with the existing methods, and provides recommendations for future applications. It finds that, typically, economic evaluation models employ a simplistic approach to temporal extrapolation of costs and utilities. For instance, their parameters (e.g. mean) are typically assumed to be homogeneous with respect to both time and patients' characteristics. Furthermore, costs and utilities have often been modelled to follow the dynamics of the associated time-to-event outcomes. However, cost and utility estimates may be more nuanced, and it is important to ensure extrapolation is carried out appropriately for these parameters.
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Affiliation(s)
- Laura Bojke
- Centre for Health Economics, University of York, Heslington, York, yo10 5dd, UK.
| | - Andrea Manca
- Centre for Health Economics, University of York, Heslington, York, yo10 5dd, UK
| | - Miqdad Asaria
- Centre for Health Economics, University of York, Heslington, York, yo10 5dd, UK
| | - Ronan Mahon
- Centre for Health Economics, University of York, Heslington, York, yo10 5dd, UK
| | | | - Stephen Palmer
- Centre for Health Economics, University of York, Heslington, York, yo10 5dd, UK
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22
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Saxena N, Inadomi JM. Effectiveness and Cost-Effectiveness of Endoscopic Screening and Surveillance. Gastrointest Endosc Clin N Am 2017; 27:397-421. [PMID: 28577764 DOI: 10.1016/j.giec.2017.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Nina Saxena
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA
| | - John M Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA.
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23
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Krishnamoorthi R, Borah B, Heien H, Das A, Chak A, Iyer PG. Rates and predictors of progression to esophageal carcinoma in a large population-based Barrett's esophagus cohort. Gastrointest Endosc 2016; 84:40-46.e7. [PMID: 26772891 PMCID: PMC4912845 DOI: 10.1016/j.gie.2015.12.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/30/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Rates of progression to esophageal adenocarcinoma in subjects with Barrett's esophagus (BE) are lower than previously estimated. Identification of predictors of progression will enable risk stratification of BE subjects, potentially making current surveillance programs more efficient. We aimed to assess the potential of demographic and lifestyle factors, obesity, and medications in predicting progression in BE. METHODS BE subjects were identified from the General Practice Research Database using validated diagnostic codes. BE subjects developing esophageal cancer (EC) 12 months after their index BE diagnosis were defined as progressors. Time-to-event analysis was used to assess the overall risk of progression to EC. Cox proportional hazards models and time-varying marginal structural models were used to assess predictors of progression. RESULTS Included in the analysis were 9660 BE patients. The mean age (SD) of the study subjects was 63 (13.5) years; 62.6% were men. One hundred three subjects (1.1%) progressed to EC. The mean (SD) follow-up since initial diagnosis was 4.8 (3.3) years. The incidence of EC was 2.23 per 1000 person-years of follow-up. Increasing age, male gender, and being overweight (body mass index, 25-29.9) were found to be independent predictors of progression. When time-varying models were used, proton pump inhibitor (PPI) and statin use were protective against progression. CONCLUSIONS In this large population-based cohort of patients with BE, increasing age, male gender, and being overweight predicted progression to EC, whereas PPI and statin use were protective against EC development. These factors may aid in developing a risk score to predict the risk of progression and chemopreventive strategies in patients with BE.
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Affiliation(s)
| | - Bijan Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN 55905
| | - Herbert Heien
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN 55905
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, AZ
| | - Amitabh Chak
- Division of Gastroenterology & Hepatology, Case Western Reserve University, Cleveland, OH
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
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Cost-Effectiveness of Cetuximab for Advanced Esophageal Squamous Cell Carcinoma. PLoS One 2016; 11:e0153943. [PMID: 27100871 PMCID: PMC4839693 DOI: 10.1371/journal.pone.0153943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 04/06/2016] [Indexed: 01/09/2023] Open
Abstract
Background Costly biologicals in palliative oncology are emerging at a rapid pace. For example, in patients with advanced esophageal squamous cell carcinoma addition of cetuximab to a palliative chemotherapy regimen appears to improve survival. However, it simultaneously results in higher costs. We aimed to determine the incremental cost-effectiveness ratio of adding cetuximab to first-line chemotherapeutic treatment of patients with advanced esophageal squamous cell carcinoma, based on data from a randomized controlled phase II trial. Methods A cost effectiveness analysis model was applied based on individual patient data. It included only direct medical costs from the health-care perspective. Quality-adjusted life-years and incremental cost-effectiveness ratios were calculated. Sensitivity analysis was performed by a Monte Carlo analysis. Results Adding cetuximab to a cisplatin-5-fluorouracil first-line regimen for advanced esophageal squamous cell carcinoma resulted in an the incremental cost-effectiveness ratio of €252,203 per quality-adjusted life-year. Sensitivity analysis shows that there is a chance of less than 0.001 that the incremental cost-effectiveness ratio will be less than a maximum willingness to pay threshold of €40,000 per quality-adjusted life-year, which is representative for the threshold used in The Netherlands and other developed countries. Conclusions Addition of cetuximab to a cisplatin-5-fluorouracil first-line regimen for advanced esophageal squamous cell carcinoma is not cost-effective when appraised according to currently accepted criteria. Cost-effectiveness analyses using outcome data from early clinical trials (i.c. a phase II trial) enable pharmaceutical companies and policy makers to gain early insight into whether a new drug meets the current eligibility standards for reimbursement and thereby potential admittance for use in regular clinical practice.
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25
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Theron BT, Padmanabhan H, Aladin H, Smith P, Campbell E, Nightingale P, Cooper BT, Trudgill NJ. The risk of oesophageal adenocarcinoma in a prospectively recruited Barrett's oesophagus cohort. United European Gastroenterol J 2016; 4:754-761. [PMID: 28408992 DOI: 10.1177/2050640616632419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 01/19/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Varying rates of oesophageal adenocarcinoma (OAC) complicating Barrett's oesophagus (BO) have been reported. Recent studies and meta-analyses suggest a lower incidence, questioning the value of endoscopic surveillance. AIM We aimed to retrospectively examine the rate of OAC, risk factors and causes of death in a prospectively recruited BO cohort. METHODS Data from patients with BO from a cohort from 1982-2007 were studied. Patients were subdivided into surveyed, failed to attend surveillance and unfit for surveillance. Standardised mortality ratios (SMR) were calculated for common causes of death. Cox proportional hazards models were used to determine which factors were associated with progression to OAC. RESULTS In total, 671 BO patients (61% male) were studied; 37 (76% male) were diagnosed with OAC. OAC incidence was 0.47% per annum and stable across three decades (1982-1991 0.56%, 1992-2001 0.46%, 2002-2012 0.41% (p = 0.8)). All-cause mortality was increased for the whole cohort (SMR 163(95% CI 145-183)). Mortality from OAC appeared higher in patients who failed to attend surveillance (SMR 3216(95% CI 1543-5916)) compared with surveyed (SMR 1753(95% CI 933-2998)) and those unfit for surveillance due to co-morbidity (SMR 440(95% CI 143-1025)). Multivariable analysis identified low-grade dysplasia (HR 4.4(95% CI 1.56-12.43), p = 0.005) and length of BO (HR 1.2(95% (1.1-1.3)), p < 0.001)) as associated with OAC. CONCLUSIONS Progression to OAC appeared stable over three decades at 0.47% per annum. Patients with BO had a modest increase in all-cause mortality and a large increase in OAC mortality, particularly if fit for surveillance. Low-grade dysplasia and the length of the BO segment were associated with developing OAC.
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Affiliation(s)
- B T Theron
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - H Padmanabhan
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - H Aladin
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - P Smith
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - E Campbell
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
| | - P Nightingale
- Welcome Trust Clinical Research Facility, University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | - B T Cooper
- Gastroenterology Unit, City Hospital, Birmingham, UK
| | - N J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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26
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Yu M, O'Leary RM, Kaz AM, Morris SM, Carter KT, Chak A, Chandar A, Willis JE, Moinova HR, Markowitz SD, Brenner DE, Anandabapasathy S, Westerhoff M, Wong CJ, Shaheen NJ, Chen Y, Barnholtz-Sloan JS, Grady WM. Methylated B3GAT2 and ZNF793 Are Potential Detection Biomarkers for Barrett's Esophagus. Cancer Epidemiol Biomarkers Prev 2015; 24:1890-7. [PMID: 26545406 DOI: 10.1158/1055-9965.epi-15-0370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Barrett's esophagus (BE) is a preneoplastic condition in which normal esophageal squamous epithelium (SQ) is replaced by specialized intestinal metaplasia. It is the presumed precursor for esophageal adenocarcinoma (EAC) as well as the strongest risk factor for this cancer. Unfortunately, many patients with BE go undiagnosed under the current BE screening guidelines. The development of noninvasive and accurate BE detection assays could potentially identify many of these undiagnosed BE patients. METHODS DNA methylation is a common epigenetic alteration in BE. Therefore, we conducted a genome-wide methylation screen to identify potential BE biomarkers. Samples from SQ (N = 12), stomach (N = 28), and BE (N = 29) were analyzed and methylation levels at over 485,000 CpG sites were compared. Pyrosequencing assays were used to validate the results and MethyLight assays were developed to detect the methylated alleles in endoscopic brushings. RESULTS We discovered two genes, B3GAT2 and ZNF793, that are aberrantly methylated in BE. Clinical validation studies confirmed B3GAT2 and ZNF793 methylation levels were significantly higher in BE samples (median = 32.5% and 33.1%, respectively) than in control tissues (median = 2.29% and 2.52%, respectively; P < 0.0001 for both genes). Furthermore, gene-specific MethyLight assays could accurately detect BE (P < 0.0001 for both) in endoscopic brushing samples. CONCLUSION B3GAT2 and ZNF793 are hypermethylated in BE, and the methylation status of these genes can be used to detect BE in tissue samples. IMPACT These findings support the development of methylated B3GAT2 and ZNF793 as biomarkers for noninvasive assays for the detection of BE.
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Affiliation(s)
- Ming Yu
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rachele M O'Leary
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Andrew M Kaz
- Research and Development Service, VA Puget Sound Health Care System, Seattle, Washington. Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Shelli M Morris
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kelly T Carter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio. Division of Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Apoorva Chandar
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio. Division of Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Joseph E Willis
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Helen R Moinova
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Sanford D Markowitz
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio. Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Dean E Brenner
- University of Michigan Medical Center, Ann Arbor, Michigan
| | | | - Maria Westerhoff
- Department of Anatomic Pathology, University of Washington School of Medicine, Seattle, Washington
| | - Chao-Jen Wong
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nicholas J Shaheen
- Division of Gastroenterology & Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Yanwen Chen
- Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Jill S Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - William M Grady
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington. Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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27
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Old O, Moayyedi P, Love S, Roberts C, Hapeshi J, Foy C, Stokes C, Briggs A, Jankowski J, Barr H. Barrett's Oesophagus Surveillance versus endoscopy at need Study (BOSS): protocol and analysis plan for a multicentre randomized controlled trial. J Med Screen 2015; 22:158-64. [PMID: 25767103 DOI: 10.1177/0969141315575052] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/06/2015] [Indexed: 08/30/2023]
Abstract
OBJECTIVES The absolute annual risk of patients with Barrett's oesophagus (BO) developing oesophageal adenocarcinoma (OAC) is ≤ 0.5%. Screening BO patients for malignant progression using endoscopic surveillance is widely practised. To assess the efficacy and cost-effectiveness of this, we developed a protocol for a randomized controlled trial of surveillance versus 'at need' endoscopy. METHODS In a multicentre trial, 3400 BO patients randomized to either 2-yearly endoscopic surveillance or 'at need' endoscopy will be followed up for 10 years. Urgent endoscopy will be offered to all patients who develop symptoms of dysphagia, unexplained weight loss > 7lb (3.2 kg), iron deficiency anaemia, recurrent vomiting, or worsening upper gastrointestinal symptoms. Participants must have endoscopically and histologically confirmed BO, with circumferential BO ≥ 1 cm or maximal tongue/island length ≥ 2 cm. Candidates with existing oesophageal high-grade dysplasia or cancer, or previous upper gastrointestinal cancer will be excluded. Primary outcome will be overall survival. Secondary outcomes will be cost effectiveness (cost per life year saved and quality adjusted life years); cancer-specific survival; time to OAC diagnosis and stage at diagnosis; morbidity and mortality related to any interventions; and frequency of endoscopy. CONCLUSIONS This randomized trial will provide data to evaluate the efficacy and cost-effectiveness of screening BO patients for OAC.
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Affiliation(s)
- Oliver Old
- Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN
| | - Paul Moayyedi
- Division of Gastroenterology, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5
| | - Sharon Love
- Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD
| | - Corran Roberts
- Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD
| | - Julie Hapeshi
- Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN
| | - Chris Foy
- Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN
| | - Clive Stokes
- Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN
| | - Andrew Briggs
- University of Glasgow, Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, 1 Lilybank Gardens, Glasgow G12 8RZ
| | - Janusz Jankowski
- University Hospitals Coventry and Warwickshire, University of Warwick, Warwickshire, CV2 2DX
| | - Hugh Barr
- Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN
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Abstract
Although there are many unanswered questions with Barrett esophagus, we can safely say that the incidence is increasing, chemoprevention strategies for the prevention of Barrett metaplasia and its progression to adenocarcinoma may be in the offing, surveillance should be considered for all patients who are discovered to have Barrett esophagus, RFA is the treatment of choice for those with HGD and strongly considered in those with LGD, EMR should be the treatment of choice for patients with nodular high-grade Barrett esophagus, and, finally, vagal-sparing esophagectomy reserved for patients with persistent HGD or a strong suspicion of carcinoma, with consideration of a concomitant fundoplication.
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Affiliation(s)
- Mark Splittgerber
- Division of General Surgery, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, FL, USA.
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29
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Domper Arnal MJ, Ferrández Arenas &A, Lanas Arbeloa &A. Esophageal cancer: Risk factors, screening and endoscopic treatment in Western and Eastern countries. World J Gastroenterol 2015; 21:7933-7943. [PMID: 26185366 PMCID: PMC4499337 DOI: 10.3748/wjg.v21.i26.7933] [Citation(s) in RCA: 659] [Impact Index Per Article: 73.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 03/11/2015] [Accepted: 04/17/2015] [Indexed: 02/07/2023] Open
Abstract
Esophageal cancer is one of the most unknown and deadliest cancers worldwide, mainly because of its extremely aggressive nature and poor survival rate. Esophageal cancer is the 6th leading cause of death from cancer and the 8th most common cancer in the world. The 5-year survival is around 15%-25%. There are clear differences between the risk factors of both histological types that affect their incidence and distribution worldwide. There are areas of high incidence of squamous cell carcinoma (some areas in China) that meet the requirements for cost-effectiveness of endoscopy for early diagnosis in the general population of those areas. In Europe and United States the predominant histologic subtype is adenocarcinoma. The role of early diagnosis of adenocarcinoma in Barrett’s esophagus remains controversial. The differences in the therapeutic management of early esophageal carcinoma (high-grade dysplasia, T1a, T1b, N0) between different parts of the world may be explained by the number of cancers diagnosed at an early stage. In areas where the incidence is high (China and Japan among others) early diagnoses is more frequent and has led to the development of endoscopic techniques for definitive treatment that achieve very effective results with a minimum number of complications and preserving the functionality of the esophagus.
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30
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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.
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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
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Whiteman DC, Appleyard M, Bahin FF, Bobryshev YV, Bourke MJ, Brown I, Chung A, Clouston A, Dickins E, Emery J, Eslick GD, Gordon LG, Grimpen F, Hebbard G, Holliday L, Hourigan LF, Kendall BJ, Lee EY, Levert-Mignon A, Lord RV, Lord SJ, Maule D, Moss A, Norton I, Olver I, Pavey D, Raftopoulos S, Rajendra S, Schoeman M, Singh R, Sitas F, Smithers BM, Taylor AC, Thomas ML, Thomson I, To H, von Dincklage J, Vuletich C, Watson DI, Yusoff IF. Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol 2015; 30:804-20. [PMID: 25612140 DOI: 10.1111/jgh.12913] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.
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Affiliation(s)
- David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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Bennett C, Moayyedi P, Corley DA, DeCaestecker J, Falck-Ytter Y, Falk G, Vakil N, Sanders S, Vieth M, Inadomi J, Aldulaimi D, Ho KY, Odze R, Meltzer SJ, Quigley E, Gittens S, Watson P, Zaninotto G, Iyer PG, Alexandre L, Ang Y, Callaghan J, Harrison R, Singh R, Bhandari P, Bisschops R, Geramizadeh B, Kaye P, Krishnadath S, Fennerty MB, Manner H, Nason KS, Pech O, Konda V, Ragunath K, Rahman I, Romero Y, Sampliner R, Siersema PD, Tack J, Tham TCK, Trudgill N, Weinberg DS, Wang J, Wang K, Wong JYY, Attwood S, Malfertheiner P, MacDonald D, Barr H, Ferguson MK, Jankowski J. BOB CAT: A Large-Scale Review and Delphi Consensus for Management of Barrett's Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia. Am J Gastroenterol 2015; 110:662-82; quiz 683. [PMID: 25869390 PMCID: PMC4436697 DOI: 10.1038/ajg.2015.55] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/03/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Barrett's esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD). METHODS We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations. RESULTS In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients. CONCLUSIONS In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.
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Affiliation(s)
- Cathy Bennett
- Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| | | | | | | | - Yngve Falck-Ytter
- Case Western Reserve University School of Medicine, Case and VA Medical Center Cleveland, Cleveland, Ohio, USA
| | - Gary Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | - John Inadomi
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Khek-Yu Ho
- National University Health System, Singapore, Singapore
| | - Robert Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eamonn Quigley
- Weill Cornell Medical College and Houston Methodist Hospital, Houston, Texas, USA
| | | | | | | | | | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Yeng Ang
- University of Manchester, Manchester, UK
| | - James Callaghan
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | | | - Rajvinder Singh
- Lyell McEwin Hospital/University of Adelaide, Adelaide, South Australia, Australia
| | | | | | - Bita Geramizadeh
- Department of Pathology, Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Philip Kaye
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sheila Krishnadath
- Gastrointestinal Oncology Research Group, AMC, Amsterdam, The Netherlands
| | | | - Hendrik Manner
- Department of Gastroenterology HSK Wiesbaden, Wiesbaden, Germany
| | - Katie S Nason
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Oliver Pech
- Krankenhaus Barmherzige Brueder, Regensburg, Germany
| | - Vani Konda
- University of Chicago, Chicago, Illinois, USA
| | - Krish Ragunath
- Queens Medical Centre, University of Nottingham, Nottingham, UK
| | | | | | | | | | - Jan Tack
- University of Leuven, Leuven, Belgium
| | | | - Nigel Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | | | - Jean Wang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Jennie Y Y Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - David MacDonald
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Hugh Barr
- Gloucestershire Royal Hospital, Gloucester, UK
| | | | - Janusz Jankowski
- University Hospitals Coventry and Warwickshire and University of Warwick, Coventry, UK
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Abstract
Objectives: The aim of this study was to identify and critically appraise the use of Value of Information (VOI) analyses undertaken as part of health technology assessment (HTA) reports in England and Wales.Methods: A systematic review of National Institute for Health Research (NIHR) funded HTA reports published between 2004 and 2013 identified the use of VOI methods and key analytical details in terms of: (i) types of VOI methodology used; (ii) parameters and key assumptions; and (iii) conclusions drawn in terms of the need for further research.Results: A total of 512 HTA reports were published during the relevant timeframe. Of these, 203 reported systematic review and economic modeling studies and 25 of these had used VOI method(s). Over half of the twenty-five studies (n = 13) conducted both EVPI (Expected Value of Perfect Information) and EVPPI (Expected Value of Partial Perfect Information) analyses. Eight studies conducted EVPI analysis, three studies conducted EVPI, EVPPI, and EVSI (Expected Value of Sampling Information) analyses and one study conducted EVSI analysis only. The level of detail reporting the methods used to conduct the VOI analyses varied.Conclusions: This review has shown that the frequency of the use of VOI methods is increasing at a slower pace compared with the published volume of HTA reports. This review also suggests that analysts reporting VOI method(s) in HTA reports should aim to describe the method(s) in sufficient detail to enable and encourage decision-makers guiding research prioritization decisions to use the potentially valuable outputs from quantitative VOI analyses.
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Abstract
Value of information analysis is a quantitative method to estimate the return on investment in proposed research projects. It can be used in a number of ways. Funders of research may find it useful to rank projects in terms of the expected return on investment from a variety of competing projects. Alternatively, trialists can use the principles to identify the efficient sample size of a proposed study as an alternative to traditional power calculations, and finally, a value of information analysis can be conducted alongside an economic evaluation as a quantitative adjunct to the 'future research' or 'next steps' section of a study write up. The purpose of this paper is to present a brief introduction to the methods, a step-by-step guide to calculation and a discussion of issues that arise in their application to healthcare decision making. Worked examples are provided in the accompanying online appendices as Microsoft Excel spreadsheets.
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Abdalla M, Dhanekula R, Greenspan M, Mobarhan S, Patil A, Jakate S, Giusto D, Silva R, Li H, Melson J. Dysplasia detection rate of confirmatory EGD in nondysplastic Barrett's esophagus. Dis Esophagus 2014; 27:505-10. [PMID: 23020509 DOI: 10.1111/j.1442-2050.2012.01431.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Current guidelines for endoscopic surveillance of Barrett's esophagus (BE) recommend that patients with newly diagnosed BE undergo confirmatory esophagogastroduodenoscopy (EGD) to exclude the presence of dysplasia. The extent to which confirmatory endoscopy alters management and detects missed dysplasia in newly diagnosed BE has not been reported. The frequency with which confirmatory endoscopy changed surveillance management in patients with newly diagnosed BE was assessed. A two center cohort analysis was conducted on patients newly diagnosed with BE. The rate of dysplasia on confirmatory endoscopy for patients who had nondysplastic BE was obtained. Demographic and endoscopic variables were assessed for association with dysplasia detection using Firth logistic regression model. Out of the 146 patients newly diagnosed with BE and initially determined to be without dysplasia, 12 had dysplasia on the confirmatory second EGD (8.2%). Eleven of 12 cases with dysplasia on confirmatory endoscopy had long-segment BE (LSBE). Among all the LSBE cases in our cohort, 11 had newly diagnosed dysplasia on confirmatory EGD, 29.7% (11/37). The average number of biopsies obtained from the 11 LSBE cases with dysplasia was comparable with the rest of the LSBE cases without dysplasia (6.73 and 5.42, respectively, P-value 0.205). The rate of dysplasia detection in short-segment BE (SSBE) was much lower, 0.95% (1 out of 105). There were no cases of high-grade dysplasia (HGD) or cancer detected in any SSBE case. HGD was detected on confirmatory EGD in two cases, both were LSBE. Segment length was the only statistically significant factor to predict the presence of dysplasia on confirmatory endoscopy (odds ratio 9.158, P. 0.008). Confirmatory EGD in newly diagnosed LSBE had significant rate of dysplasia detection (29.7%) in this cohort. Among patients with SSBE, there was a low rate of dysplasia detection with confirmatory EGD, less than 1% of cases. No additional cases of HGD or esophageal carcinoma in SSBE cases were detected. This suggests that the yield of confirmatory EGD is greater in patients with LSBE.
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Affiliation(s)
- M Abdalla
- Advocate Christ Medical Center, Oak Lawn, USA
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Zaninotto G, Bennett C. Surveillance for low-grade dysplastic Barrett's oesophagus: one size fits all? World J Surg 2014; 39:578-85. [PMID: 24919861 DOI: 10.1007/s00268-014-2661-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This paper reviews the role of low-grade dysplasia (LGD) as a marker of progression in Barrett's oesophagus (BO). Albeit with its limits due to the difficulty of its diagnosis and the low agreement among pathologists, LGD remains the most relevant single prognostic factor of progression, and, when the diagnosis is confirmed by two or three pathologists, the chances of progression to high-grade dysplasia or invasive adenocarcinoma are as high as 40%. On the other hand, BO patients who remain dysplasia free at several follow-up examinations seem to have a very low likelihood of progression. The diagnosis of LGD should be confirmed by two pathologists, and surveillance programs should be tailored depending on the presence or persistent absence of LGD. Ablative therapy should be also considered for cases where LGD persists in a series of follow-ups.
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Affiliation(s)
- Giovanni Zaninotto
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK,
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Gordon LG, Mayne GC, Hirst NG, Bright T, Whiteman DC, Watson DI. Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus. Gastrointest Endosc 2014; 79:242-56.e6. [PMID: 24079411 DOI: 10.1016/j.gie.2013.07.046] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/29/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic surveillance for non-dysplastic Barrett's esophagus (BE) is contentious and its cost effectiveness unclear. OBJECTIVE To perform an economic analysis of endoscopic surveillance strategies. DESIGN Cost-utility analysis by using a simulation Markov model to synthesize evidence from large epidemiologic studies and clinical data for surveillance, based on international guidelines, applied in a coordinator-managed surveillance program. SETTING Tertiary care hospital, South Australia. PATIENTS A total of 2040 patient-years of follow-up. INTERVENTION (1) No surveillance, (2) 2-yearly endoscopic surveillance of patients with non-dysplastic BE and 6-monthly surveillance of patients with low-grade dysplasia, (3) a hypothetical strategy of biomarker-modified surveillance. MAIN OUTCOME MEASUREMENTS U.S. cost per quality-adjusted life year (QALY) ratios. RESULTS Compared with no surveillance, surveillance produced an estimated incremental cost per QALY ratio of $60,858. This was reduced to $38,307 when surveillance practice was modified by a hypothetical biomarker-based strategy. Sensitivity analyses indicated that the likelihood that surveillance alone was cost-effective compared with no surveillance was 16.0% and 60.6% if a hypothetical biomarker-based strategy was added to surveillance, at an acceptability threshold of $100,000 per QALY gained. LIMITATIONS Treatment options for BE that overlap those for symptomatic GERD were omitted. CONCLUSION By using best available estimates of the malignant potential of BE, endoscopic surveillance of patients with non-dysplastic BE is unlikely to be cost-effective for the majority of patients and depends heavily on progression rates between dysplasia grades. However, strategies that modify surveillance according to cancer risk might be cost-effective, provided that high-risk individuals can be identified and prioritized for surveillance.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland, Australia; QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - George C Mayne
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicholas G Hirst
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland, Australia
| | - Timothy Bright
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - David C Whiteman
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | | | - David I Watson
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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de Jonge PJF, van Blankenstein M, Grady WM, Kuipers EJ. Barrett's oesophagus: epidemiology, cancer risk and implications for management. Gut 2014; 63:191-202. [PMID: 24092861 PMCID: PMC6597262 DOI: 10.1136/gutjnl-2013-305490] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although endoscopic surveillance of patients with Barrett's oesophagus has been widely implemented, its effectiveness is debateable. The recently reported low annual oesophageal adenocarcinoma risk in population studies, the failure to identify most Barrett's patients at risk of disease progression, the poor adherence to surveillance and biopsy protocols, and the significant risk of misclassification of dysplasia all tend to undermine the effectiveness of current management, in particular, endoscopic surveillance programmes, to prevent or improve the outcomes of patients with oesophageal adenocarcinoma. The ongoing increase in incidence of Barrett's oesophagus and consequent growth of the surveillance population, together with the associated discomfort and costs of endoscopic surveillance, demand improved techniques for accurately determining individual risk of oesophageal adenocarcinoma. More accurate techniques are needed to run efficient surveillance programmes in the coming decades. In this review, we will discuss the current knowledge on the epidemiology of Barrett's oesophagus, and the challenging epidemiological dilemmas that need to be addressed when assessing the current screening and surveillance strategies.
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Affiliation(s)
- Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, , Rotterdam, The Netherlands
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Watari J, Oshima T, Fukui H, Tomita T, Miwa H. Carcinogenesis of Barrett's esophagus: a review of the clinical literature. Clin J Gastroenterol 2013; 6:399-414. [PMID: 26182128 DOI: 10.1007/s12328-013-0412-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 07/25/2013] [Indexed: 11/25/2022]
Abstract
Barrett's esophagus (BE) is a premalignant condition of esophageal adenocarcinoma (EAC). Although the incidence of BE has risen rapidly in the West, it is rare in Asia despite a recent increase in the prevalence of gastroesophageal reflux disease. Controversies over the definition of BE are presented because most cases show short-segment BE, especially ultra-short BE, in Asia. Here we review possible risk factors for the development of EAC, particularly possible roles of ethnicity, specialized intestinal metaplasia (SIM), BE length, and environmental factors, such as Helicobacter pylori infection and obesity. Additionally, we summarize recent studies on the effect of chemoprevention including proton pump inhibitors, nonsteroidal anti-inflammatory drugs or aspirin in order to reduce the risk of neoplastic progression in BE patients. Although substantial knowledge of risk factors of dysplasia/EAC in BE is shown, the risk for neoplastic development may be influenced by geographic variation, study population, the presence or absence of SIM or dysplasia at baseline, and the small number of BE patients investigated. Recently, the efficiency of surveillance for BE patients has been discussed from the standpoint of cost-effectiveness. It may be too difficult to draw conclusions because no randomized clinical trials of BE surveillance have been performed.
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Affiliation(s)
- Jiro Watari
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Tadayuki Oshima
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hirokazu Fukui
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Toshihiko Tomita
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hiroto Miwa
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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Gordon LG, Mayne GC. Cost-effectiveness of Barrett's oesophagus screening and surveillance. Best Pract Res Clin Gastroenterol 2013; 27:893-903. [PMID: 24182609 DOI: 10.1016/j.bpg.2013.08.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/19/2013] [Accepted: 08/26/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic screening and surveillance of patients with Barrett's oesophagus to detect oesophageal cancer at earlier stages is contentious. As a consequence, their cost-effectiveness is also debatable. Current health economic evidence shows mixed results for demonstrating their value, mainly due to varied assumptions around progression rates to cancer, quality of life and treatment pathways. No randomized controlled trial exists to definitively support the efficacy of surveillance programs and one is unlikely to be undertaken. Contemporary treatment, cost and epidemiological data to contribute to cost-effectiveness analyses are needed. Risk assessment to stratify patients at low- or high-risk of developing cancer should improve cost-effectiveness outcomes as higher gains will be seen for those at higher risk, and medical resource use will be avoided in those at lower risk. Rapidly changing technologies for imaging, biomarker testing and less-invasive endoscopic treatments also promise to lower health system costs and avoid adverse events in patients.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland 4131, Australia.
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Corley DA, Mehtani K, Quesenberry C, Zhao W, De Boer J, Weiss NS. Impact of endoscopic surveillance on mortality from Barrett's esophagus-associated esophageal adenocarcinomas. Gastroenterology 2013; 145:312-9.e1. [PMID: 23673354 PMCID: PMC3767470 DOI: 10.1053/j.gastro.2013.05.004] [Citation(s) in RCA: 186] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/11/2013] [Accepted: 05/06/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS Although patients with Barrett's esophagus commonly undergo endoscopic surveillance, its effectiveness in reducing mortality from esophageal/gastroesophageal junction adenocarcinomas has not been evaluated rigorously. METHODS We performed a case-control study in a community-based setting. Among 8272 members with Barrett's esophagus, we identified 351 esophageal adenocarcinoma: 70 in persons who had a prior diagnosis of Barrett's esophagus (who were eligible for surveillance); 51 of these patients died, 38 as a result of the cancers (cases). Surveillance histories were contrasted with a sample of 101 living persons with Barrett's esophagus (controls), matched for age, sex, and duration of follow-up evaluation. RESULTS Surveillance within 3 years was not associated with a decreased risk of death from esophageal adenocarcinoma (adjusted odds ratio, 0.99; 95% confidence interval, 0.36-2.75). Fatal cases were nearly as likely to have received surveillance (55.3%) as were controls (60.4%). A Barrett's esophagus length longer than 3 cm and prior dysplasia each were associated with subsequent mortality, but adjustment for these did not change the main findings. Although all patients should be included in evaluations of effectiveness, excluding deaths related to cancer treatment and patients who failed to complete treatment, changed the magnitude, but not the significance, of the association (odds ratio, 0.46; 95% confidence interval, 0.13-1.64). CONCLUSIONS Endoscopic surveillance of patients with Barrett's esophagus was not associated with a substantially decreased risk of death from esophageal adenocarcinoma. The results do not exclude a small to moderate benefit. However, if such a benefit exists, our findings indicate that it is substantially smaller than currently estimated. The effectiveness of surveillance was influenced partially by the acceptability of existing treatments and the occurrence of treatment-associated mortality.
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Affiliation(s)
- Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California,Kaiser Permanente, San Francisco Medical Center, Seattle, Washington
| | - Kunal Mehtani
- Kaiser Permanente, San Francisco Medical Center, Seattle, Washington
| | - Charles Quesenberry
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Wei Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jolanda De Boer
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington
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Abstract
Oesophageal adenocarcinoma will soon cease to be a rare form of cancer for people born after 1940. In many Western countries, its incidence has increased more rapidly than other digestive cancers. Incidence started increasing in the Seventies in England and USA, 15 years later in Western Europe and Australia. The cumulative risk between the ages of 15 and 74 is particularly striking in the UK, with a tenfold increase in men and fivefold increase in women in little more than a single generation. Prognosis is poor with a 5-year relative survival rate of less than 10%. The main known risk factors are gastro-oesophageal reflux, obesity (predominantly mediated by intra-abdominal adipose tissues) and smoking. Barrett's oesophagus is a precancerous lesion, however, the risk of degeneration has been overestimated. In population-based studies the annual risk of adenocarcinoma varied between 0.12% and 0.14% and its incidence between 1.2 and 1.4 per 1000 person-years. Only 5% of subjects with Barrett's oesophagus die of oesophageal adenocarcinoma. On the basis of recent epidemiological data, new surveillance strategies should be developed. The purpose of this review is to focus on the epidemiology and risk factors of oesophageal adenocarcinoma.
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43
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Estores D, Velanovich V. Barrett esophagus: epidemiology, pathogenesis, diagnosis, and management. Curr Probl Surg 2013; 50:192-226. [PMID: 23601575 DOI: 10.1067/j.cpsurg.2013.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Benaglia T, Sharples LD, Fitzgerald RC, Lyratzopoulos G. Health benefits and cost effectiveness of endoscopic and nonendoscopic cytosponge screening for Barrett's esophagus. Gastroenterology 2013; 144:62-73.e6. [PMID: 23041329 DOI: 10.1053/j.gastro.2012.09.060] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 09/21/2012] [Accepted: 09/24/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS We developed a model to compare the health benefits and cost effectiveness of screening for Barrett's esophagus by either Cytosponge™ or by conventional endoscopy vs no screening, and to estimate their abilities to reduce mortality from esophageal adenocarcinoma. METHODS We used microsimulation modeling of a hypothetical cohort of 50-year-old men in the United Kingdom with histories of gastroesophageal reflux disease symptoms, assuming the prevalence of Barrett's esophagus to be 8%. Participants were invited to undergo screening by endoscopy or Cytosponge (invitation acceptance rates of 23% and 45%, respectively), and outcomes were compared with those from men who underwent no screening. We estimated the number of incident esophageal adenocarcinoma cases prevented and the incremental cost-effectiveness ratio of quality-adjusted life years (QALYs) of the different strategies. Patients found to have high-grade dysplasia or intramucosal cancer received endotherapy. Model inputs included data on disease progression, test accuracy, post-treatment status, and surveillance protocols. Costs and benefits were discounted at 3.5% per year. Supplementary and sensitivity analyses comprised esophagectomy management of high-grade dysplasia or intramucosal cancer, screening by ultrathin nasal endoscopy, and different assumptions of uptake of screening invitations for either strategy. RESULTS We estimated that compared with no screening, Cytosponge screening followed by treatment of patients with dysplasia or intramucosal cancer costs an additional $240 (95% credible interval, $196-$320) per screening participant and results in a mean gain of 0.015 (95% credible interval, -0.001 to 0.029) QALYs and an incremental cost-effectiveness ratio of $15.7 thousand (K) per QALY. The respective values for endoscopy were $299 ($261-$367), 0.013 (0.003-0.023) QALYs, and $22.2K. Screening by the Cytosponge followed by treatment of patients with dysplasia or intramucosal cancer would reduce the number of cases of incident symptomatic esophageal adenocarcinoma by 19%, compared with 17% for screening by endoscopy, although this greater benefit for Cytosponge depends on more patients accepting screening by Cytosponge compared with screening by endoscopy. CONCLUSIONS In a microsimulation model, screening 50-year-old men with symptoms of gastroesophageal reflux disease by Cytosponge is cost effective and would reduce mortality from esophageal adenocarcinoma compared with no screening.
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Affiliation(s)
- Tatiana Benaglia
- Medical Research Council, Biostatistics Unit, Cambridge, United Kingdom
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Steuten L, van de Wetering G, Groothuis-Oudshoorn K, Retèl V. A systematic and critical review of the evolving methods and applications of value of information in academia and practice. PHARMACOECONOMICS 2013; 31:25-48. [PMID: 23329591 DOI: 10.1007/s40273-012-0008-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
OBJECTIVE This article provides a systematic and critical review of the evolving methods and applications of value of information (VOI) in academia and practice and discusses where future research needs to be directed. METHODS Published VOI studies were identified by conducting a computerized search on Scopus and ISI Web of Science from 1980 until December 2011 using pre-specified search terms. Only full-text papers that outlined and discussed VOI methods for medical decision making, and studies that applied VOI and explicitly discussed the results with a view to informing healthcare decision makers, were included. The included papers were divided into methodological and applied papers, based on the aim of the study. RESULTS A total of 118 papers were included of which 50 % (n = 59) are methodological. A rapidly accumulating literature base on VOI from 1999 onwards for methodological papers and from 2005 onwards for applied papers is observed. Expected value of sample information (EVSI) is the preferred method of VOI to inform decision making regarding specific future studies, but real-life applications of EVSI remain scarce. Methodological challenges to VOI are numerous and include the high computational demands, dealing with non-linear models and interdependency between parameters, estimations of effective time horizons and patient populations, and structural uncertainties. CONCLUSION VOI analysis receives increasing attention in both the methodological and the applied literature bases, but challenges to applying VOI in real-life decision making remain. For many technical and methodological challenges to VOI analytic solutions have been proposed in the literature, including leaner methods for VOI. Further research should also focus on the needs of decision makers regarding VOI.
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Affiliation(s)
- Lotte Steuten
- Department of Health Technology and Services Research, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands.
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Abstract
Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.
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Affiliation(s)
- Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Watson DI. Oesophageal adenocarcinoma: the men's health problem you do not want to have! ANZ J Surg 2012; 82:571-2. [DOI: 10.1111/j.1445-2197.2012.06186.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- David I. Watson
- Flinders University Department of Surgery; Flinders Medical Centre; Bedford Park; South Australia; Australia
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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.
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Affiliation(s)
- George C Mayne
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.
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Gordon LG, Hirst NG, Mayne GC, Watson DI, Bright T, Cai W, Barbour AP, Smithers BM, Whiteman DC, Eckermann S. Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia. J Gastrointest Surg 2012; 16:1451-61. [PMID: 22644445 DOI: 10.1007/s11605-012-1911-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/07/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios. METHODS A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken. RESULTS Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368). CONCLUSION These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia.
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Kariyawasam VC, Bourke MJ, Hourigan LF, Lim G, Moss A, Williams SJ, Fanning SB, Chung AM, Byth K. Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett's esophagus. Gastrointest Endosc 2012; 75:938-44. [PMID: 22381529 DOI: 10.1016/j.gie.2011.12.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Whether early Barrett's neoplasia has a predilection for particular spatial locations in shorter segment disease is currently unknown. Anatomic factors may play a role in lesion location because of differing levels of mucosal acid exposure. OBJECTIVE To identify high-risk lesion locations, which has important implications for surveillance strategies. DESIGN We interrogated a prospectively maintained database of patients who underwent endoscopic resection (ER) for Barrett's neoplasia at 2 Australian tertiary centers. Lesions targeted for ER were characterized and their location in the distal esophagus was noted as on a clock face. A Z test of proportions was used to test for deviation from uniformity in the distribution of lesions. SETTING Two Australian tertiary centers. PATIENTS Patients who underwent ER for Barrett's neoplasia. MAIN OUTCOME MEASUREMENTS Lesion location in the distal oesophagus, resected specimen histology. RESULTS A total of 146 consecutive patients had ER for biopsy-proven high-grade dysplasia or esophageal adenocarcinoma. A total of 75 patients had Barrett's segment length of 5 cm or less and a visible lesion. Five patients had 2 visible lesions giving a total of 80 lesions. ER of 66 lesions (82.5%) led to the identification of advanced pathology: 37 high-grade dysplasia (46%), 24 mucosal adenocarcinoma (30%), 5 submucosal adenocarcinoma (6%). Of a total of 80 lesions, 43 (53.8%) (95% CI, 42.9%-64.7%) were centered within the 2- to 5-o'clock arc, comprising 25% of the circumference. This area also accounted for 36 (54.5%) of the 66 lesions with advanced histology (95% CI, 42.5%-66.5%). All confidence intervals lie wholly above the 25% expected in a uniform circular distribution (P < .05). LIMITATIONS Observational study in a tertiary center. CONCLUSIONS In Barrett's maximal segments of 5 cm or less, the 2- to 5-o'clock arc, accounts for approximately 50% of macroscopically visible lesions and associated early neoplasia. This finding has important implications for surveillance strategies.
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Affiliation(s)
- Viraj C Kariyawasam
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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