Screening of Barrett: Is it cost-effective ? Is there a high-risk ......T Ponchon Ed. Herriot...
Transcript of Screening of Barrett: Is it cost-effective ? Is there a high-risk ......T Ponchon Ed. Herriot...
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Screening of Barrett:
Is it cost-effective ?
Is there a high-risk population ?
T Ponchon
Ed. Herriot Hospital
Lyon, France
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Barrett’s esophagus (BE) is an acquired condition in
which the normal squamous epithelium of the
esophagus is replaced by a metaplasic columnar
lining.
Double definition:
- endoscopic: “there is a glandular mucosa at
the lower part of the esophagus”
- histologic: “this glandular mucosa is a
specialized intestinal metaplasia”
This change is strongly related to chronic
gastroesophageal reflux (GERD).
10-15% of GERD patients have Barrett’s esophagus
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GERD
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
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GERD Screening ?
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
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GERD Screening ?
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
2 PARTS
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GERD Screening ?
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
2 PARTS
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GERD Screening ?
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
2 PARTS
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GERD Screening ?
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
CostEffectiveusingendoscopy
Kastelein FGut 2015
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GERD Screening ?
Barrett’s esophagus
Low Grade Dysplasia
High grade dysplasia
Invasive carcinoma
Costeffectiveness???
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Screening of Barrett’s esophagus
is a highly debated topic………
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Screening of Barrett’s esophagus
PROS
Some interesting prerequisites…..
CONS
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Screening of Barrett’s esophagus
PROS
Some interesting prerequisites…..
CONS
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Pros……
1- RISING INCIDENCE OF
ESOPHAGEAL
ADENOCARCINOMA
Last 3 decades in western
countries
Germany: incidence X 7
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Pros…..
2- POOR PROGNOSIS of
ESOPHAGEAL CARCINOMA
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Pros……..
2- POOR PROGNOSIS of
ESOPHAGEAL CARCINOMA
5 year survival: 15-50%
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Pros……..
3- A WELL ESTABLISHED
PREMALIGNANT CONDITION
The Barrett’s esophagus
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High grade
Dysplasia ?
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Non
dysplastic
Barrett
NBI
+ Acetic acid
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NBI 180
Moins de risque de « rater » des
anomalies macroscopiques
NBI
+ Acetic acid
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High grade dysplasia
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Pros……
4- EARLY DETECTION
of BARRETT’S ESOPHAGUS
May lead to better survival and
may save lifes
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4,978 SEER-Medicare patients identified with esophageal adenocarcinomaOnly 577 (12%) had preexisting BE
BE patients had overall lower stage (28.5% stage I vs. 12.8% stage IV) than those without preexisting BE (16.4% stage I vs. 30.6% stage IV).
Overall survival was better among patients in the BE group (hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.50-0.61)
After adjusting for lead-time bias, the HRs attenuated to null
Tramontano AC, Am J Gastroenterol 2017
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Pros……
5- EARLY ENDOSCOPIC
TREATMENT OF HIGH GRADE
DYSPLASIA
on BARRETT’S ESOPHAGUS
leads to better survival and saves
lifes
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Screening of Barrett’s esophagus
PROS
Some interesting prerequisites…..
CONS
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CONS……..
To promote screening of a disease,
some factors are also mandatory:
1- a well defined population to screen
2- a low cost of the screening method
3- a high acceptance rate of the
screening method
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CONS……..
1- The risk is not so high
2- a well defined population to screen ?
3- a low cost of the screening method ?
4- a high acceptance rate of the
screening method ?
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CONS……..
1- The risk is not so high
2- a well defined population to screen ?
3- a low cost of the screening method ?
4- a high acceptance rate of the
screening method ?
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1- Recent data indicate that the incidence of cancer in
Barrett’s esophagus is lower than in the first cohort studies:
1 per 400 pts per year
2- Subjects with Barrett’s esophagus have the same age-
adjusted life expectancy than the general population and no
decrease in mortality has been demonstrated in patients
who are undergoing surveillance
3- In cohort study, the evolution of patients with Barrett’s
esophagus mainly depends on other diseases
Cons….
Risk of Barrett not so high….
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nbr mean FU (y) FU (pt-y) nbr car 1 case
per….pt-y
Mc Donald BMJ 2000 143 4.4 5
Bani-Hani EJGH 2000 357 3.5 1249 12 104
69 (male)
537 (fem)
Weston AJG 99 108 3.5 361 5 72
O Connor AJG 99 136 4.2 570 2 285
Streitz AJG 98 149 3.8 510 7 73
Katz AJG 98 102 563 3
Rana Dis Eso 2000 44 418 2 209
Van der Burgh Gut 97 155 9.3 1440 8 180
Ferraris EJGH 97 187 3 562 3 187
Drewitz AJG 99 170 4.8 834 4 208
Nilsson SCJ 2000 199 797 5 159
Screening: the risk of cancer ?
1 per 200 pts per year
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More recently……
Risk = 1 per 400 pts or less: 1 per 600
pts
0.27%: Wani SB, Gastroenterology 2010;138:475c.
0.22%: Bhat J Nat Cancer Inst 2011; 103: 1047-1059
0.3%: Desai TK Gut 2012; 61: 970-976
0.14%: Holmberg D Eur J Cancer 2017; 75; 41-46
Risk level stays the same after 5 years of F-UN’Guyen T Am J Gastroenterol 2017
The risk of cancer ?
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CONS……..
1- The risk is not so high
2- a well defined population to screen ?
3- a low cost of the screening method ?
4- a high acceptance rate of the
screening method ?
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1- Recent data also indicate that the prevalence of
Barrett’s esophagus is higher than suggested by
previous data:
10-25% in pts referred for screening colonoscopy
2- 40% of patients with esophageal carcinoma do not
experience GERD and would not be detected
through screening programs
This means: even if there is a high-risk group
(white>50y with long history of heatburn), the
population to screen is very large
Screening: a population to screen ?
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CONS……..
1- The risk is not so high
2- a well defined population to screen ?
3- a low cost of the screening method ?
4- a high acceptance rate of the
screening method ?
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Is screening Barrett’s esophagus cost-effective
using endoscopy ?
AGA Chicago workshop Sharma GE 2004
Endoscopic screening of Barrett’s esophagus is not cost-
effective in general population
In a group at risk ?Endoscopic screening of Barrett’s esophagus is not cost-effective
in white adults age > 50y with > 5-10 years of heartburn
because a large majority of cases will be missed
With a different method ? (less expensive)
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Cost-effectiveness analysis
$95,559 per quality-adjusted life year QALY saved.
The prevalence rates of esophageal adenocarcinoma, would have to increase by 654% to generate an incremental cost-effectiveness ratio (ICER) of less than $50,000 per QALY.
So cost still too high Gupta N GIE 2011
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Alternative teststo improvethe tolerance and acceptance to reduce cost
1- nasogastroscope2- esophageal capsule3- cytosponge
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Alternative teststo improvethe tolerance and acceptanceto reduce cost
1- nasogastroscope2- esophageal capsule3- cytosponge
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Nasogastroscope
Video 5 mmone plan bending
Single-use sheathVision sciences65 cmoperating channeldiameter: 5.1mm
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Number of pts refusing another procedure in the same conditions:
Oral gastroscopy: 25.2%
Nasogastroscopy: 10.3%
p<0.001
SFED study, 500 pts, 10 centers,
randomized study oral standard
vs naso
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All studies demonstrate that:
1) nasal approach (except 2 studies)
2) reduction in endoscope diameter
improve patient tolerance to gastroscopy
Dean R Gastrointest Endosc1996; Gorelick AB J Clin Gastroenterol 2001;
Sorbi D Gastroenterology 1999; Campo R, Endosc 1998; Yagi J Endoscopy
2005; Dumortier J Gastrointest Endosc 2003; Preiss C Endoscopy 2003;
Murata A J Hepatol Gastroenterol 2007; Zaman A Gastrointest Endosc 1999;
Birkner B Endoscopy 2003; Thota PN Endoscopy 2005; Garcia RT
Gastroenterology 2003; Watanabe H Dig Dis Sci 2009; Trevisani L World J
Gastroenterology 2007; Stroppa I Dig Liv Dis 2008; Mulcahy HE Endosc
2011; Kadayiifci A J Gastrointest Liver Dis 2014.
Without negative effect on the quality of biopsies
(1335 pts)Walter T J Clin Gastroenterol 2010
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Alternative teststo improvethe tolerance and acceptance to reduce cost
1- nasogastroscope2- esophageal capsule3- cytosponge
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Esophageal capsule
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Could videocapsule be helpful for the detection of Barrett’s esophagus ?
First problem: no biopsies
Second problem: Sensitivity = 77%Bhardwaj A, Am J Gastroenterol 09
Metanalysis, 9 studies, 618 pts
Better application: dg and f-u of eso varices
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Alternative teststo improvethe tolerance and acceptanceto reduce cost
1- nasogastroscope2- esophageal capsule3- cytosponge
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Cytosponge
Best 1 study501 participantsSensitivity 73%, specificity 94% if BE > 1cm
Best 2 study1110 participantsSensitivity 87%, specificity 92% if BE > 3cm
SR Kadri BMJ 2010; Ross-Iness CS PLoS Med 2015
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CONCLUSION
Incidence of esophageal car isrisingBut screening for BE is stillnot cost-effective
We need a better test