Cost-effectiveness of photodynamic therapy for high grade dysplasia in patients with Barrett's esophagus

Management of patients with Barrett's and high grade dysplasia (HGD) is controversial. Photodynamic therapy (PDT) has been proposed as an alternative to surgical resection for HGD in patients with Barrett's esophagus. AIM: To assess the cost-effectiveness of PDT for Barrett's esophagus with HGD compared with surgical resection. METHODS: Clinical data from published literature on the risks and survival following esophagectomy and PDT in patients with Barrett's esophagus with HGD was used in a Markov model that simulates lifetime events. Where data was unavailable, expert opinion was used and assessed with sensitivity analysis. We took the perspective of a payer and included direct costs for PDT and surgery. Our final outcome measure was cost per quality adjusted life year ($/QALY). RESULTS: By varying the efficacy of PDT, our model predicts that for PDT to be more effective than surgery, it needs to achieve an efficacy of ≥ 85%. With this level of efficacy, the $/QALY was $ 26,812 which compares favorably with other health care interventions. Sensitivity analysis confirmed the robustness of our results on efficacy of PDT. Average cost per patient in the surgical strategy was consistently lower Efficacy of PDT 50% 75% 85% 100% Marginal Effectiveness (yr.) -3.54 -0.85 0.67 3.7 Quality Adjusted Life Expectancy (yr.) 14.69 17.38 18.91 21.93 Marginal Costs $22,400 $19,600 $18,000 $14.800 Total Costs/ pt. $42,700 $40,000 $38.400 $35,000 Cost Per Quality Adjusted Life Year Surgery more effective Surgery more effective $26,800 $4,000 than the PDT strategy. CONCLUSION: Our model suggests that PDT can be a viable alternative to surgical resection, if it can achieve an 85% or greater reduction in cancer risk. Clinical trials of PDT for Barrett's esophagus should be designed to determine long term cancer risk reduction.