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Cost-Effective Analysis of Gastric Cancer Screening in Japan
*S1600 The Role of Therapeutic Endoscopy for Postoperative Management of Obstructive Symptoms After Hand Assisted Roux-En-Y-Gastric Bypass Kristoffel R. Dumon, David Metz, Michael L. Kochman, Noel N. Williams BACKGROUND Stenosis of the gastrojejunal anastomosis is one of the major complications of Roux-en-Y gastric bypass (RYGB). The incidence of strictures after Hand Assisted Roux-en-Y Gastric Bypass (HALGB) as well as the functional result of their endoscopic management by balloon dilation has not been reported. METHODS We conducted a retrospective review of all patients undergoing HALGB in a single institution, single surgeon setting from June 2001 to June 2003. All patients with symptoms (nausea, emesis) potentially related to the gastroenteric anastomosis were studied with upper endoscopy. Patients with endoscopic evidence of strictures were treated by balloon dilation. All dilations were performed by a dedicated team of gastroenterologists. RESULTS 393 patients underwent HALGB during the study period. A total of 34 endoscopies were performed in 27 patients (23 female and 4 male). Strictures were identified in 13 patients (3.3%). 7 patients had an isolated stricture and 6 patients had the stricture in association with an anastomotic ulcer. Four patients had an anastomotic ulcer without evidence of stricture and 10 patients had a normal finding. The presenting symptoms did not differ between the different groups. A single endoscopic balloon dilation (10-18 mm through the scope CRE balloons) was successful in all patients with isolated strictures. A single dilation session was successful in only 2/6 patients with strictures complicated by ulcers. The remaining four patients required 2-3 dilation sessions each. The mean time after bypass for strictures to become symptomatic was 37 days post-operatively (range 29-57). Patients with isolated ulcers presented significantly later, a mean of 169 days after surgery (p<0.05). The mean time after surgery for a stricture complicated by an ulcer to present was 64 days. (p-value N.S. vs stricture) No complications occurred after endoscopic dilation CONCLUSIONS 1 The incidence of strictures after HALGB is comparable to other surgical approaches for RYGB. 2 Endoscopic dilation is a safe and effective approach. 3 Earlier presentation is associated with isolated stricture formation whereas later presentation is associated with anastomotic ulceration with or without a stricuture. 4 Symptom presentation cannot be used to identify the need for endoscopic intervention
*S1601 Do We Perform a Colonoscopy for Haemorrhoidal Bleeding ? Francois Agret, Stephane Nahon, Pierre Lahmek, Bruno Lesgourgues, Thierry Tuszynski, Nicolas Delas A colonoscopy is usually performed for haemorrhoidal bleeding, especially before a surgical procedure. The aim of this study was to assess the accuracy of this practice. Methods: Since 1989, clinical, biological, endoscopical and histological data from patients who underwent a colonoscopy were systematically recorded on a database. Patients with haemorrhoidal bleeding previously confirmed by a proctologic examination were included for study. Results: From 1989 to June 2003, 305 patients underwent a colonoscopy for haemorrhoidal bleeding. There were 111 women and 194 men, mean age was 50 + 13,4 years. Thirty-six (12%) had at least one or more digestive symptoms. Nineteen (6%) had a personal history of polyp and 1 (0,3%) of colorectal carcinoma; 19 (6%) had a familial history of colorectal carcinoma. The colonoscopy found: 1 adenomatous polyp > 10 mm in 4 cases (1,3%), a polyp <10 mm in 44 cases (14%) and no colorectal carcinoma. All patients with polyps >10 mm were older than 45 years and 2 had a familial history of colorectal carcinoma. Two polyps > 1 cm were localized in the right colon and two in the sigmoid. Conclusion: This study suggests that colonoscopy is not required for patients with haemorrhoidal bleeding, except for those having a risk factor for colorectal carcinoma such as age and familial history of colorectal carcinoma.
not clear whether gastric cancer screening is cost-effective, and if so, which strategy is the most cost effective. Aim: The aim of this study is to evaluate whether gastric cancer screening is cost-effective in Japan, and which strategy is the most costeffective. Methods: We conducted cost-effective analysis of the following six strategies using Markov model when 50-year-old asymptomatic Japanese men receive gastric cancer screening for 10 years: 1) no screening, 2) annual Indirect Xray (gastrography taken on predetermined 8 positions in mobile vans; the original method of mass screening in Japan), 3) annual UGI series, 4) annual pepsinogen measurement, 5) annual EGD (EGD q1y), 6) EGD every 3 years (EGD q3y). We assumed that in strategies #2 to #4, 100% of people with any abnormal finding suggesting gastric cancer proceed with EGD for further evaluation. The most assumptions were based on published literature. When data were not available from literature, we seek expert opinion. Only direct costs were considered. DATA 4.0 (TreeAge software Inc.) was used for analysis. Results: In a base- case analysis, compliance was assumed to be 50%. The most effective strategy for Japanese men was EGD q3y. When compared with no screening, this strategy resulted in 401 years of life gained per 10,000 persons, and the incremental cost-effective (CE) ratio was approximately $61,000 per year of life gained. The effectiveness of EGD q1y was comparable to that of EGD q3y. However, the cost was prohibitoly high. In this model, incremental CE ratio of annual indirect X-ray was approximately $133,000 per year of life gained when compared with no screening. Conclusions: Although annual indirect X-ray has been used for gastric cancer screening in Japan for more than 40 years, this strategy may not be cost-effective for 50-year-old asymptomatic Japanese men. Screening with EGD every 3 years may be more costeffective strategy and it should be compared with other screening strategies in prospective fashion.
*S1603 Photodynamic Therapy (PDT) for Barrett's Esophagus with HighGrade Dysplasia (BE + HGD): Cost-Effectiveness Model with Probabilistic Sensitivity Analysis Dan Comay, Gord Blackhouse, Ron Goeree, David Armstrong, John K. Marshall BACKGROUND: PDT is an emerging therapy for BE+HGD. We assessed the cost-effectiveness of PDT vs. immediate esophagectomy (ESO) and intensive endoscopic surveillance (SURV). METHODS: A Markov decision tree was constructed to estimate costs and outcomes of PDT, ESO and SURV in a hypothetical cohort of males aged 50 yrs with BE+HGD. Outcomes included unadjusted life years (LY) and quality adjusted life years (QALY). Direct medical costs (2003 Can$) were measured from the perspective of a provincial Ministry of Health. The model time horizon was 5 yrs (cycle length 3 mos) with subsequent survival estimated from Canadian life tables. Costs and outcomes were discounted at 3%. Transition probabilities and utilities were estimated from literature review and subjected to deterministic and probabilistic sensitivity analyses. RESULTS: Base-case results and incremental cost effectiveness ratios (ICER) are summarized in Table. For LY, PDT dominated ESO if perioperative mortality >10%. For QALY, PDT dominated ESO in the base-case. QALY for ESO exceeded PDT if health utility post esophagectomy >0.92 (base-case 0.80) or progression to cancer post-PDT >3.8% per cycle (base case 1.7%). Results were robust to variation in initial success of PDT ablation. A scatterplot depicting the distribution of incremental costs and QALY for PDT and ESO relative to SURV from 1000 Monte Carlo simulations is shown in Figure. CONCLUSIONS: In patients with BE+HGD, PDT and ESO are cost-effective alternatives to SURV. PDT dominates ESO for QALY in the base-case. Funding from Axcan Pharma
*S1602 Cost-Effective Analysis of Gastric Cancer Screening in Japan Kenji Kobayashi, Tetsuya Mine Background: Mass screening of gastric cancer in Japan has been implemented nationwide since 1960. Although gastric cancer screening in Japan has been thought to be effective, no randomized control study has been conducted to demonstrate the efficacy of gastric cancer screening in Japan. Furthermore, it is
VOLUME 59, NO. 5, 2004
GASTROINTESTINAL ENDOSCOPY
P137
*S1601 Do We Perform a Colonoscopy for Haemorrhoidal Bleeding ? Francois Agret, Stephane Nahon, Pierre Lahmek, Bruno Lesgourgues, Thierry Tuszynski, Nicolas Delas A colonoscopy is usually performed for haemorrhoidal bleeding, especially before a surgical procedure. The aim of this study was to assess the accuracy of this practice. Methods: Since 1989, clinical, biological, endoscopical and histological data from patients who underwent a colonoscopy were systematically recorded on a database. Patients with haemorrhoidal bleeding previously confirmed by a proctologic examination were included for study. Results: From 1989 to June 2003, 305 patients underwent a colonoscopy for haemorrhoidal bleeding. There were 111 women and 194 men, mean age was 50 + 13,4 years. Thirty-six (12%) had at least one or more digestive symptoms. Nineteen (6%) had a personal history of polyp and 1 (0,3%) of colorectal carcinoma; 19 (6%) had a familial history of colorectal carcinoma. The colonoscopy found: 1 adenomatous polyp > 10 mm in 4 cases (1,3%), a polyp <10 mm in 44 cases (14%) and no colorectal carcinoma. All patients with polyps >10 mm were older than 45 years and 2 had a familial history of colorectal carcinoma. Two polyps > 1 cm were localized in the right colon and two in the sigmoid. Conclusion: This study suggests that colonoscopy is not required for patients with haemorrhoidal bleeding, except for those having a risk factor for colorectal carcinoma such as age and familial history of colorectal carcinoma.
not clear whether gastric cancer screening is cost-effective, and if so, which strategy is the most cost effective. Aim: The aim of this study is to evaluate whether gastric cancer screening is cost-effective in Japan, and which strategy is the most costeffective. Methods: We conducted cost-effective analysis of the following six strategies using Markov model when 50-year-old asymptomatic Japanese men receive gastric cancer screening for 10 years: 1) no screening, 2) annual Indirect Xray (gastrography taken on predetermined 8 positions in mobile vans; the original method of mass screening in Japan), 3) annual UGI series, 4) annual pepsinogen measurement, 5) annual EGD (EGD q1y), 6) EGD every 3 years (EGD q3y). We assumed that in strategies #2 to #4, 100% of people with any abnormal finding suggesting gastric cancer proceed with EGD for further evaluation. The most assumptions were based on published literature. When data were not available from literature, we seek expert opinion. Only direct costs were considered. DATA 4.0 (TreeAge software Inc.) was used for analysis. Results: In a base- case analysis, compliance was assumed to be 50%. The most effective strategy for Japanese men was EGD q3y. When compared with no screening, this strategy resulted in 401 years of life gained per 10,000 persons, and the incremental cost-effective (CE) ratio was approximately $61,000 per year of life gained. The effectiveness of EGD q1y was comparable to that of EGD q3y. However, the cost was prohibitoly high. In this model, incremental CE ratio of annual indirect X-ray was approximately $133,000 per year of life gained when compared with no screening. Conclusions: Although annual indirect X-ray has been used for gastric cancer screening in Japan for more than 40 years, this strategy may not be cost-effective for 50-year-old asymptomatic Japanese men. Screening with EGD every 3 years may be more costeffective strategy and it should be compared with other screening strategies in prospective fashion.
*S1603 Photodynamic Therapy (PDT) for Barrett's Esophagus with HighGrade Dysplasia (BE + HGD): Cost-Effectiveness Model with Probabilistic Sensitivity Analysis Dan Comay, Gord Blackhouse, Ron Goeree, David Armstrong, John K. Marshall BACKGROUND: PDT is an emerging therapy for BE+HGD. We assessed the cost-effectiveness of PDT vs. immediate esophagectomy (ESO) and intensive endoscopic surveillance (SURV). METHODS: A Markov decision tree was constructed to estimate costs and outcomes of PDT, ESO and SURV in a hypothetical cohort of males aged 50 yrs with BE+HGD. Outcomes included unadjusted life years (LY) and quality adjusted life years (QALY). Direct medical costs (2003 Can$) were measured from the perspective of a provincial Ministry of Health. The model time horizon was 5 yrs (cycle length 3 mos) with subsequent survival estimated from Canadian life tables. Costs and outcomes were discounted at 3%. Transition probabilities and utilities were estimated from literature review and subjected to deterministic and probabilistic sensitivity analyses. RESULTS: Base-case results and incremental cost effectiveness ratios (ICER) are summarized in Table. For LY, PDT dominated ESO if perioperative mortality >10%. For QALY, PDT dominated ESO in the base-case. QALY for ESO exceeded PDT if health utility post esophagectomy >0.92 (base-case 0.80) or progression to cancer post-PDT >3.8% per cycle (base case 1.7%). Results were robust to variation in initial success of PDT ablation. A scatterplot depicting the distribution of incremental costs and QALY for PDT and ESO relative to SURV from 1000 Monte Carlo simulations is shown in Figure. CONCLUSIONS: In patients with BE+HGD, PDT and ESO are cost-effective alternatives to SURV. PDT dominates ESO for QALY in the base-case. Funding from Axcan Pharma
*S1602 Cost-Effective Analysis of Gastric Cancer Screening in Japan Kenji Kobayashi, Tetsuya Mine Background: Mass screening of gastric cancer in Japan has been implemented nationwide since 1960. Although gastric cancer screening in Japan has been thought to be effective, no randomized control study has been conducted to demonstrate the efficacy of gastric cancer screening in Japan. Furthermore, it is
VOLUME 59, NO. 5, 2004
GASTROINTESTINAL ENDOSCOPY
P137