title: Endoscopic versus surgical therapy for early cancer in Barrett's esophagus: a decision analysis.
abstract: BACKGROUND
  Esophagectomy for early esophageal adenocarcinoma is associated with increased operative mortality and morbidity, but possibly a decreased recurrence rate compared with endoscopic therapy when using EMR and radiofrequency ablation.
  
  
  OBJECTIVE
  To compare the cost-effectiveness of esophagectomy and endoscopic therapy in the treatment of early esophageal adenocarcinoma.
  
  
  METHODS
  Decision analysis model.
  
  
  METHODS
  Incremental cost-effectiveness ratio.
  
  
  RESULTS
  During the 5-year study period, endoscopic therapy cost $17,000.00 and yielded 4.88 quality-adjusted life years, compared with $28,000.00 and 4.59, respectively, for esophagectomy. Varying the recurrence rates of cancer or Barrett's esophagus metaplasia after endoscopic therapy did not change the overall outcome. The sensitivity analysis demonstrated, however, that the outcome depended on the rate of lymph node involvement and operative mortality. Under the best of circumstances in favor of esophagectomy, such as 2% operative mortality, no reduced quality of life after esophagectomy, and a low 5-year survival rate after recurrence of endoscopic ablation, the risk of positive lymph nodes still needed to exceed 25% before esophagectomy became the preferred treatment option. This threshold is twice as high as the values reported for early submucosal cancer invasion.
  
  
  CONCLUSIONS
  Limited data are available about the long-term outcome of EMR and radiofrequency ablation.
  
  
  CONCLUSIONS
  Endoscopic therapy for early Barrett's esophagus adenocarcinoma is more effective and less expensive than esophagectomy. Even in early esophageal adenocarcinoma with submucosal invasion, endoscopic therapy is a cost-effective alternative to esophagectomy, especially in patients with a high operative risk.
authors.affiliation: Gastroenterology Section, VA Medical Center, White River Junction, 125 N. Main St., VT 05001, USA.
authors.forename: Heiko
authors.initials: H
authors.lastname: Pohl
authors.forename: Amnon
authors.initials: A
authors.lastname: Sonnenberg
authors.forename: Sebastian
authors.initials: S
authors.lastname: Strobel
authors.forename: Alexander
authors.initials: A
authors.lastname: Eckardt
authors.forename: Thomas
authors.initials: T
authors.lastname: Rösch
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D000368:Aged; D001471:Barrett Esophagus / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D017115:Catheter Ablation; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016629:Esophagectomy / Q000191:economics*; D004945:Esophagoscopy / Q000191:economics*; D006801:Humans; D008297:Male; D009092:Mucous Membrane / Q000601:surgery; D011788:Quality of Life; D016019:Survival Analysis