Ablative therapy cost-effective for many patients with Barrett's esophagus

NEW YORK (Reuters Health) - Ablative therapy is cost-effective for most patients with Barrett's esophagus, depending on the degree of dysplasia, according to a report in the June issue of Gastroenterology.

Standard management of Barrett's esophagus currently includes endoscopic surveillance with random biopsy of metaplastic tissue to detect cancer at a curable stage, the authors explain.

Dr. John M. Inadomi from San Francisco General Hospital, San Francisco, California, and colleagues used a decision analysis model, based on hypothetical patients with a mean age of 50, to determine whether endoscopic ablation of Barrett's esophagus is a cost-effective option to reduce mortality from esophageal adenocarcinoma.

For patients with high-grade dysplasia, radiofrequency ablation (RFA) or argon plasma coagulation (APC) proved significantly more cost-effective than surveillance alone, the authors report. In such patients, ablation "could increase life expectancy by 3 quality-adjusted years at an incremental cost of less than $6,000 compared with no intervention."

Surveillance or immediate esophagectomy would increase life expectancy compared to no surveillance, but they would do so at a cost higher than that of ablation.

The dominant strategy for patients with low-grade dysplasia appeared to be RFA, followed by surveillance limited to patients in whom metaplasia persists after ablation, the researchers note. Similarly, for patients with no dysplasia, the most cost-effective strategy would consist of endoscopic ablation, with surveillance limited to patients for whom ablation fails to eradicate metaplasia.

"If ablation permanently eradicates at least 28% of low-grade dysplasia or 40% of nondysplastic metaplasia, ablation would be preferred to surveillance," the authors report.

"Our data suggest that endoscopic ablation may be the preferred strategy for the management of Barrett's esophagus with high-grade dysplasia," the investigators conclude. "Ablation may also be preferred in subjects with low-grade dysplasia and nondyplastic diseases, but the cost effectiveness of this strategy is highly dependent on the long-term effectiveness of ablation therapy and whether surveillance endoscopy can be discontinued after a successful ablative procedure."

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