Medical decision analysis of chemoprevention against esophageal adenocarcinoma

Background & Aims: Chemoprevention of esophageal adenocarcinoma using nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the risk of cancer in patients with Barrett's esophagus. The aim of the study was to assess the cost-effectiveness of this strategy. Methods: The incremental cost-effectiveness ratio (ICER) of chemoprevention (compared with endoscopic surveillance or with no surveillance) was analyzed with a computer model of a Markov process. Results: Under baseline conditions for all patients with Barrett's esophagus (neoplastic and nonneoplastic), the ICER of chemoprevention ranges between $12,700 and $18,500 per life-year saved. However, these cost values are sensitive to variations in the costs of chemoprevention, incidence of cancer in patients with Barrett's esophagus, and efficacy of NSAIDs in reducing the incidence of cancer, which can shift the ICER into a cost range that is prohibitively expensive. Conversely, in those patients with Barrett's esophagus and high-grade dysplasia, the ICER ranges between $3900 and $5000. Chemoprevention remains a cost-effective option even under rather unfavorable conditions, such as higher cost and lower efficacy of chemoprevention and lower incidence of cancer. Conclusions: This model suggests that a high incidence of esophageal adenocarcinoma in high-grade dysplasia renders chemoprevention cost-effective even in the presence of less-favorable conditions. However, chemoprevention may not be a cost-effective measure in the general population of all patients with Barrett's esophagus, depending on unknown factors such as cost and efficacy of chemoprevention as well as true incidence of cancer.