December 17, 2019

Optimizing Barrett's management

Optimizing Barrett's management

Investigators in the CISNET Esophagus consortium employed comparative modeling to develop recommendations on clinical management (surveillance frequency and endoscopic eradication therapy) of persons with low grade or non-dysplastic Barrett's esophagus.

Clin Gastroenterol Hepatol.2019 Dec 6

Optimizing Management of Patients With Barrett's Esophagus and Low-grade or No Dysplasia Based On Comparative Modeling


Amir-Houshang Omidvari, Ayman Ali, William D Hazelton, Sonja Kroep, Minyi Lee, Steffie K Naber, Brianna N Lauren, Sassan Ostvar, Ellen Richmond, Chun Yin Kong , Joel H Rubenstein, Iris Lansdorp-Vogelaar, Georg Luebeck, Chin Hur, John Inadomi

PMID: 31816445 DOI: 10.1016/j.cgh.2019.11.058 

Abstract

Background & aims: Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients.

Methods: We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness to pay threshold of $100,000 per quality-adjusted life year (QALY).

Results: In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23%-75% of cases of esophageal adenocarcinoma , but increased costs to $6.2-$17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY).

Conclusions: Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women.