Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus.
BACKGROUND
Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities.


METHODS
By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer.


RESULTS
Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%.


CONCLUSIONS
Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.
Vij
Rohini
R
Division of Gastroenterology and Hepatology, Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, California, USA.
Triadafilopoulos
George
G
Owens
Douglas K
DK
Kunz
Pamela
P
Sanders
Gillian D
GD
D000230:Adenocarcinoma / Q000175:diagnosis; D001471:Barrett Esophagus / Q000188:drug therapy* / Q000191:economics / Q000601:surgery; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D018450:Disease Progression; D004938:Esophageal Neoplasms / Q000175:diagnosis; D016629:Esophagectomy / Q000191:economics; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D010778:Photochemotherapy / Q000191:economics*; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome