消融治疗Barrett食管高级别发育异常具有成本效益

哈佛大学和麻省总医院的Chin Hur博士在9月刊《胃肠病学》杂志上撰文指出，采用射频消融(RFA)治疗Barrett食管患者的高级别发育异常，比内镜监测至进展为癌症再手术切除的做法更具成本效益。而且，采用RFA治疗稳定型、经确诊的低级别发育异常，也具有成本效益。(Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.05.010])。

Hur博士及其同事开展了多项分析，对3种疾病状态下3种治疗策略分别进行了比较。3种疾病状态是：Barrett食管伴高级别发育异常，Barrett食管伴低级别发育异常，以及Barrett食管不伴发育异常。3种治疗策略是：监测发现疾病进展为癌症时实施食管切除术；监测发现疾病进展为更高级别发育异常或癌症时实施RFA治疗；初始即采取RFA治疗。

成本计算的依据是Medicare提供的2011年医疗报销率。例如，估算得出的RFA成本为6,400美元，食管切除术成本为25,882美元。

研究者发现，对于高级别发育异常，假设疾病进展率为1%，则与监测发现进展为癌症时行食管切除术的策略相比，初始即采取RFA治疗的策略可增加0.704质量校正生命年(QALY)，并减少25,609美元的成本。

与之相似，对于低级别发育异常，监测发现进展为高级别发育异常时实施RFA，可比监测发现进展为癌症时行食管切除术增加0.17 QALY和节省7,446美元。不过，与初始即采取RFA治疗相比，监测发现进展为高级别发育异常时实施RFA仅能节省1,969美元，且QALY反而减少0.108。

这相当于每增加1个QALY需要花费18,231美元，大大低于研究者认为合理的成本效益比例阈值——100,000美元/ QALY，从而使这一策略最具成本效益。

对于Barrett食管不伴发育异常的患者，监测发现进展为高级别发育异常时实施RFA的策略仍然最具成本效益：假定疾病进展率为0.33%，与监测发现进展为癌症时行食管切除术相比，可节省7,709美元并增加0.194 QALY。

研究者声称在这项研究中无相关利益冲突。这项研究获得了国立卫生研究院的资金支持。

爱思唯尔版权所有  未经授权请勿转载

By: DENISE NAPOLI, Internal Medicine News Digital Network

Radiofrequency ablation for high-grade dysplasia in the setting of Barrett’s esophagus is more cost effective than endoscopic surveillance until progression to cancer, reported Dr. Chin Hur and his colleagues in the September issue of Gastroenterology.

Moreover, the use of radiofrequency ablation (RFA) for stable, confirmed low-grade dysplasia can also be cost effective, said the investigators.

Dr. Hur of Harvard University and Massachusetts General Hospital, both in Boston, and his colleagues conducted several analyses comparing three treatment strategies for each of three disease states: Barrett’s esophagus with high-grade dysplasia, Barrett’s esophagus with low-grade dysplasia, and Barrett’s esophagus with no dysplasia.

The treatment strategies consisted of surveillance followed by esophagectomy upon disease progression to cancer, RFA upon disease progression to a higher-grade dysplasia or cancer, or initial RFA before disease progression (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.05.010]).

Cost calculations were based on Medicare reimbursement rates for 2011. The cost estimate for RFA, for example, was $6,400, and the cost of esophagectomy was $25,882. Based on these values, the authors then conducted a base-case analysis.

They found that in high-grade dysplasia, the strategy of initial RFA resulted in 0.704 more quality-adjusted life-years (QALYs) and cost $25,609 less than the strategy of surveillance without RFA followed by esophagectomy upon disease progression to cancer, assuming a 1% disease progression rate.

Similarly, in low-grade dysplasia, RFA upon disease progression to high-grade dysplasia also bested the strategy of surveillance until cancer and esophagectomy, resulting in 0.17 more QALYs and costing $7,446 less, assuming a 0.5% progression rate.

However, in low-grade dysplasia, when comparing initial RFA versus surveillance until progression to high-grade dysplasia and then RFA, the authors found that the latter approach cost only $1,969 less than the former, and that the former was associated with a 0.108 gain in QALYs.

That amounted to an incremental cost-effectiveness ratio of $18,231 per QALY – "below our willingness-to-pay threshold of $100,000/QALY, making it the most plausible strategy in terms of cost-effectiveness."

Finally, in scenarios involving Barrett’s esophagus but no dysplasia, RFA upon progression of disease to high-grade dysplasia was still the most cost-effective strategy: It was associated with a savings of $7,709 as well as 0.194 additional QALYs, compared with esophagectomy upon disease progression to cancer, assuming a 0.33% progression rate.

The authors noted that their model relies on a stringent definition of low-grade dysplasia that assumes "review and agreement between more than one expert pathologist" as well as a consistent level of dysplasia found on more than one endoscopy spaced at least 6 months apart. In addition, the progression rates used in this analysis were based on the current literature, but were still estimates involving some uncertainty.

"We believe that a multicenter, randomized, controlled trial for initial RF ablation versus surveillance in patients with BE without dysplasia is needed to confirm our model results and to inform clinical decision making," they added.

Long-term follow-up data from such a study could "provide much needed data regarding cancer progression and the need for surveillance, which significantly impacts the cost-effectiveness and patients’ preferences for RFA."

The authors stated that they had no disclosures relevant to this study. The study was supported by grants from the National Institutes of Health.