Cost-effectiveness of palliation of unresectable esophageal cancer.
BACKGROUND
Different modalities of palliation for obstructive symptoms in patients with unresectable esophageal cancer (EC) exist. However, these therapeutic alternatives have significant differences in costs and effectiveness.


METHODS
A Markov model was designed to compare the cost-effectiveness (CE) of self-expandable stent (SES), brachytherapy and laser in the palliation of unresectable EC. Patients were assigned to one of the strategies, and the improvement in swallowing function was compared given the treatment efficacy, probability of survival, and risks of complications associated to each strategy. Probabilities and parameters for distribution were based on a 9-month time frame.


RESULTS
Under the base-case scenario, laser has the lowest CE ratio, followed by brachytherapy at an incremental cost-effectiveness ratio (ICER) of $4,400.00, and SES is a dominated strategy. In the probabilistic analysis, laser is the strategy with the highest probability of cost-effectiveness for willingness to pay (WTP) values lower than $3,201 and brachytherapy for all WTP yielding a positive net health benefit (NHB) (threshold $4,440). The highest probability of cost-effectiveness for brachytherapy is 96%, and consequently, selection of suboptimal strategies can lead to opportunity losses for the US health system, ranging from US$ 4.32 to US$ 38.09 million dollars over the next 5-20 years.


CONCLUSIONS
Conditional to the WTP and current US Medicare costs, palliation of unresectable esophageal cancers with brachytherapy provides the largest amount of NHB and is the strategy with the highest probability of CE. However, some level of uncertainly remains, and wrong decisions will be made until further knowledge is acquired.
da Silveira
Eduardo B
EB
Division of Gastroenterology, Portland VA Medical Center, Oregon Health and Science University, 3710 SW US Veterans Hospital Road, P3GI, Portland, OR, 97239, USA. eduardo.dasilveira@va.gov
Artifon
Everson L
EL
D001918:Brachytherapy / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003680:Deglutition Disorders / Q000191:economics / Q000209:etiology / Q000628:therapy; D004938:Esophageal Neoplasms / Q000150:complications / Q000191:economics* / Q000628:therapy*; D006801:Humans; D053685:Laser Therapy / Q000191:economics; D015233:Models, Statistical; D010166:Palliative Care / Q000191:economics* / Q000379:methods; D015607:Stents / Q000191:economics; D014481:United States