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Ablation for Barrett's beats surveillance on cost: calculations favor radiofrequency ablation for high-grade dysplasia in Barrett's esophagus.


Radiofrequency ablation for high-grade dysplasia in the setting of Barrett's esophagus is more cost effective than endoscopic surveillance until progression to cancer, according to a report by Dr. Chin Hur and his colleagues.

Moreover, the use of radiofrequency ablation (RFA) for stable, confirmed low-grade dysplasia can also be cost effective, said the investigators.

Dr. Hur of Harvard Medical School and Massachusetts General Hospital, both in Boston, and his colleagues conducted several analyses comparing three treatment strategies for each of three disease states: Barrett's esophagus with high-grade dysplasia, Barrett's esophagus with low-grade dysplasia, and Barrett's esophagus with no dysplasia.

The treatment strategies consisted of surveillance followed by esophagectomy upon disease progression to cancer, RFA upon disease progression to a higher-grade dysplasia or cancer, or initial RFA before disease progression, the researchers said (Gastroenterology 2012 [doi:10.10530.gastro.2012.05.010]).

Cost calculations were based on Medicare reimbursement rates for 2011. The cost estimate for RFA, for example, was $6,400, and the cost of esophagectomy was $25,882. Based on these values, the authors then conducted a base-case analysis.

They found that in high-grade dysplasia, the strategy of initial RFA resulted in 0.704 more quality-adjusted life-years (QALYs) and cost $25,609 less than the strategy of surveillance without RFA followed by esophagectomy upon disease progression to cancer, assuming a 1% disease progression rate.

Similarly, in low-grade dysplasia, RFA upon disease progression to high-grade dysplasia also bested the strategy of surveillance until cancer and esophagectomy, resulting in 0.17 more QALYs and costing $7,446 less, assuming a 0.5% progression rate.

However, in low-grade dysplasia, when the investigators compared initial RFA versus surveillance until progression to high-grade dysplasia and then RFA, they found that the latter approach cost only $1,969 less than the former, and that the former was associated with a 0.108 gain in QALYs. That amounted to an incremental cost-effectiveness ratio of $18,231 per QALY--"below our willingness-to-pay threshold of $100,000/QALY, making it the most plausible strategy in terms of cost-effectiveness."

Finally, in scenarios involving Barrett's esophagus but no dysplasia, RFA upon progression of disease to high-grade dysplasia was still the most cost-effective strategy: It was associated with a savings of $7,709 as well as 0.194 additional QALYs, compared with esophagectomy upon disease progression to cancer, assuming a 0.33% progression rate.

The investigators noted that their model relies on a stringent definition of low-grade dysplasia that assumes "review and agreement between more than one expert pathologist" as well as a consistent level of dysplasia found on more than one endoscopy spaced at least 6 months apart.

In addition, the progression rates that were used in this analysis were based on the current literature, but were still estimates involving some uncertainty.

"We believe that a multicenter, randomized, controlled trial for initial RF ablation versus surveillance in patients with BE without dysplasia is needed to confirm our model results and to inform clinical decision making," the researchers added.

Long-term follow-up data from such a study could "provide much needed data regarding cancer progression and the need for surveillance, which significantly impacts the cost-effectiveness and patients' preferences for RFA," Dr. Hur and his colleagues concluded.


Major Finding: In Barrett's esophagus, radiofrequency ablation of high-grade dysplasia resulted in 0.704 more quality-adjusted life-years and cost $25,609 less than surveillance of high-grade dysplasia with esophagectomy upon progression to cancer, assuming a 1% disease progression rate.

Data Source: The findings were from a decision analytic Markov model comparing the cost-effectiveness of radiofrequency ablation in Barrett's esophagus with high-grade dysplasia, low-grade dysplasia, or no dysplasia.

Disclosures: The authors stated that they had no relevant disclosures. The study was supported by grants from the National Institutes of Health.
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Author:Napoli, Denise
Publication:Internal Medicine News
Date:Sep 1, 2012
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