Abstract
BackgroundThe management of Barrett's esophagus (BE), particularly high grade dysplasia (HGD), is an area of much debate and controversy. Surgical esophagectomy, intensive endoscopic surveillance and mucosal ablative techniques, especially photodynamic therapy (PDT), have been proposed as possible management strategies. The purpose of this study was to determine the health related quality of life associated with Barrett's esophagus and many of the pivotal health states associated with Barrett's HGD management.Methods20 patients with Barrett's esophagus were enrolled in a pilot survey study at a large urban hospital. The utility of Barrett's esophagus without dysplasia (current health state) as well as various health states associated with HGD management (hypothetical states as the subject did not have HGD) were measured using a validated health utility instrument (Paper Standard Gamble). These specific health states were chosen for the study because they are considered pivotal in Barrett's HGD decision making. Information regarding Barrett's HGD was presented to the subject in a standardized format that was designed to be easily comprehendible.ResultsThe average utility scores (0–1 with 0 = death and 1 = perfect health) for the various Barrett's esophagus associated states were: BE without dysplasia-0.95; Post-esophagectomy for HGD with dysphagia-0.92; Post-PDT for HGD with recurrence uncertainty-0.93; Post-PDT for HGD with recurrence uncertainty and dysphagia-0.91; Intensive endoscopic surveillance for HGD-0.90.ConclusionWe present the scores for utilities associated with Barrett's esophagus as well as various states associated with the management of HGD. The results of our study may be useful in advising patients and providers regarding expected outcomes of the various HGD management strategies as well as providing utility scores for future cost-effectiveness analyses.
Highlights
The management of Barrett's esophagus (BE), high grade dysplasia (HGD), is an area of much debate and controversy
Clinical and demographic features The mean age of the subjects in the study was 64.6 years and 55% (11/20) were male. 20% of the subjects had undergone a Nissen fundoplication surgery, 15% had a history of dysphagia and 10% had a history of Barrett's
We present estimates of utilities for Barrett's esophagus as well as various health states associated with Barrett's HGD management and therapy using the Paper Standard Gamble instrument
Summary
The management of Barrett's esophagus (BE), high grade dysplasia (HGD), is an area of much debate and controversy. Barrett's esophagus (BE) is a result of chronic reflux disease and is a risk factor for esophageal adenocarcinoma [1] following a proposed dysplasia-carcinoma sequence: intestinal metaplasia (BE); to low grade dysplasia (LGD); to high grade dysplasia (HGD); to adenocarcinoma. Publications have reported a wide range 27–73% [410] of missed and concomitant cancers when patients with HGD detected by endoscopic biopsy undergo surgical resection. The largest published study to date of more than 1000 patients with over a 7 year period of follow-up found that the 'missed' esophageal cancer rate in HGD was lower than previous reports [13], further arguing that the risks of surgery may outweigh the potential benefits and that endoscopic surveillance may be a reasonable strategy
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