An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy.
BACKGROUND
This study compares the health care costs and effectiveness of multiple staging options for patients with esophageal cancer. Techniques studied included computed tomographic (CT) scan, endoscopic ultrasound with fine-needle aspiration biopsy (EUS-FNA), positron emission tomography (PET), thoracoscopy/laparoscopy, and combinations of these.


METHODS
A decision-analysis model was constructed to compare different staging strategies. Costs were derived from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases and from other Medicare reimbursement rates. Life expectancies were obtained from the 1973-1996 SEER database and adjusted for quality of life. Cost and effectiveness measures were discounted at 0% and 3% per year. Sensitivity and specificity measures were obtained from the published literature and a parallel prospective clinical trial, and all key variables were subjected to sensitivity analyses.


RESULTS
Under baseline assumptions, CT + EUS-FNA was the most inexpensive strategy and offered more quality-adjusted life-years, on average, than all other strategies with the exception of PET + EUS-FNA. The latter was slightly more effective but also more expensive. The marginal cost-effectiveness ratio for PET + EUS-FNA was $60,544 per quality-adjusted life-year. These findings were robust and changed very little in all of the sensitivity analyses.


CONCLUSIONS
The combination of PET + EUS-FNA should be the recommended staging procedure for patients with esophageal cancer, unless resources are scarce or PET is unavailable. In these instances, CT + EUS-FNA can be considered the preferred strategy.
Wallace
Michael B
MB
Digestive Diseases Center, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston 29425, USA. wallacem@musc.edu
Nietert
Paul J
PJ
Earle
Craig
C
Krasna
Mark J
MJ
Hawes
Robert H
RH
Hoffman
Brenda J
BJ
Reed
Carolyn E
CE
D001707:Biopsy, Needle; D002986:Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D019160:Endosonography; D004938:Esophageal Neoplasms / Q000175:diagnosis*; D006801:Humans; D010535:Laparoscopy; D009367:Neoplasm Staging / Q000191:economics / Q000379:methods*; D012680:Sensitivity and Specificity; D013906:Thoracoscopy; D014055:Tomography, Emission-Computed; D014057:Tomography, X-Ray Computed