Endoscopic versus surgical therapy for early cancer in Barrett's esophagus: a decision analysis.
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.
Pohl
Heiko
H
Gastroenterology Section, VA Medical Center, White River Junction, 125 N. Main St., VT 05001, USA.
Sonnenberg
Amnon
A
Strobel
Sebastian
S
Eckardt
Alexander
A
Rösch
Thomas
T
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