Abstract
Abstract Barrett’s oesophagus is a precursor to oesophageal adenocarcinoma (OAC), which can be lethal if found at late stages. Stages of Barrett's oesophagus are generally divided into non-dysplasia or dysplasia. There is little doubt that patients with high-grade dysplasia require endoscopic intervention, usually with ablative techniques. Endoscopic treatment of low-grade dysplasia (LGD) has been more controversial, however. Our main aim was to improve cost-effectiveness of LGD ablation using length of Barrett's oesophagus to select high-risk individuals. A cost-utility analysis was undertaken using a Markov cohort model, which simulated progression and regression of non-dysplastic Barrett’s oesophagus (NDBE) to EAC (cycle length of 6 months, time horizon of 35 years). Health states included: NDBE, regression of metaplasia, low-grade dysplasia (LGD), high-grade dysplasia (HGD), EAC, and death. Cost pertaining to investigations and treatments were sourced from local health network. Quality-adjusted life-year (QALY) data were taken from literature values. Initial estimates of transition probabilities between health states were derived from literature and calibrated to lifetime risk of HGD and OAC using standardised methodology. One-way and probabilistic sensitivity analysis were conducted. Several strategies (39 total) were tested in this cost-utility analysis and were broadly divided into selective (length-based) or non-selective LGD ablation. In addition to LGD ablation, surveillance intervals for NDBE were altered to improve cost-effectiveness. In non-selective group of strategies, only 1 was found to be cost-effective, whereas 24 of 28 length-based LGD ablation strategies were found to be cost-effective (at a willingness to pay threshold of AU$50,000/QALY). Probabilistic analysis (1000 simulations) showed that exclusion of individuals with short segment Barrett's oesophagus (SSBE) from surveillance with ablation of LGD in long-segment Barrett's oesophagus (LSBE) was the most cost-effective strategy (AU$33,031/QALY). Patients with long-segment Barrett's oesophagus are at significantly higher risk of progression to adenocarcinoma. Results of this study indicate reducing endoscopic surveillance for SSBE with routine surveillance for LSBE with ablation of LGD when detected is cost-effective in 100% of the simulations. Several studies in recent years have shown similar results. Thus ablation of LGD in Barrett's oesophagus requires serious consideration, especially for high-risk individuals.
Published Version
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call