High-resolution microendoscopy for esophageal cancer screening in China: A cost-effectiveness analysis

AIM:To study the cost-effectiveness of high-resolution microendoscopy(HRME)in an esophageal squamous cell carcinoma(ESCC)screening program in China.METHODS:A decision analytic Markov model of ESCC was developed.Separate model analyses were conducted for cohorts consisting of an averagerisk population or a high-risk population in China.Hypothetical 50-year-old individuals were followed until age 80 or death.We compared three different strategies for both cohorts:(1)no screening;(2)standard endoscopic screening with Lugol’s iodine staining;and(3)endoscopic screening with Lugol’s iodine staining and an HRME.Model parameters were estimated from the literature as well as from GLOBOCAN,the Cancer Incidence and Mortality Worldwide cancer database.Health states in the model included non-neoplasia,mild dysplasia,moderate dysplasia,high-grade dysplasia,intramucosal carcinoma,operable cancer,inoperable cancer,and death.Separate ESCC incidence transition rates were generated for the average-risk and high-risk populations.Costs in Chinese currency were converted to international dollars(I$)and were adjusted to 2012dollars using the Consumer Price Index.RESULTS:The main outcome measurements for this study were quality-adjusted life years(QALYs)and incremental cost-effectiveness ratio(ICER).For the average-risk population,the HRME screening strategy produced 0.043 more QALYs than the no screening strategy at an additional cost of I$646,resulting in an ICER of I$11808 per QALY gained.Standard endoscopic screening was weakly dominated.Among the high-risk population,when the HRME screening strategy was compared with the standard screening strategy,the ICER was I$8173 per QALY.For both the high-risk and average-risk screening populations,the HRME screening strategy appeared to be the most cost-effective strategy,producing ICERs below the willingness-topay threshold,I$23500 per QALY.One-way sensitivity analysis showed that,for the average-risk population,higher specificity of Lugol’s iodine(>40%)and lower specificity of HRME(<70%)could make Lugol’s iodine screening cost-effective.For the high-risk population,the results of the model were not substantially affected by varying the follow-up rate after Lugol’s iodine screening,Lugol’s iodine test characteristics(sensitivity and specificity),or HRME specificity.CONCLUSION:The incorporation of HRME into an ESCC screening program could be cost-effective in China.Larger studies of HRME performance are needed to confirm these findings.

Treatment of early stage(T1) esophageal adenocarcinoma:Personalizing the best therapy choice

Esophagectomy is considered the primary form of management for esophageal adenocarcinoma(EAC);however,the surgery is associated with high rates of morbidity and mortality.For patients with early-stage EAC,endoscopic resection(ER)presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks,but it is associated with higher rates of cancer recurrence following the procedure.For some patients,age and comorbidities may prevent them from having esophagectomy as a treatment option,while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences.Furthermore,while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life(QOL),so might the morbidity surrounding esophagectomy.In addition to considering health status,patient preferences,and impacts on QOL,physicians and patients must also consider what treatments would be both beneficial and available to the patient,considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER.Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data.We conclude with a request for more research of available options for early EAC patients,the conditions that determine when each option should be employed,and their effects not only on patient health but also QOL.

Evidence-based endoscopic management of Barrett’s esophagus

Barrett’s esophagus(BE)develops as a consequence of chronic esophageal acid exposure,and is the major risk factor for esophageal adenocarcinoma(EAC).The practices of endoscopic screening for—and surveillance of—BE,while widespread,have failed to reduce the incidence of EAC.The majority of EACs are diagnosed in patients without a known history of BE,and current diagnostic tools are lacking in their ability to stratify patients with BE into those at low risk and those at high risk for progression to malignancy.Nonetheless,advances in endoscopic imaging and mucosal therapeutics have provided unprecedented opportunities for intervention for BE,and have vastly altered the approach to management of BE-associated mucosal neoplasia.