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Ann Thorac Surg 2002;74:1026-1032
© 2002 The Society of Thoracic Surgeons
a Digestive Diseases Center, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
b Center for Health Care Research and Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
c Dana-Farber Cancer Institute, Boston, Massachusetts, USA
d Department of Surgery, University of Maryland, Baltimore, Maryland, USA
e Department of Surgery, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
Accepted for publication June 7, 2002.
* Address reprint requests to Dr Wallace, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 210-CSB, PO Box 250327, Charleston, SC 29425 USA
e-mail: wallacem{at}musc.edu
Background. This study compares the health care costs and effectiveness of multiple staging options for patients with esophageal cancer. Techniques studied included computed tomographic (CT) scan, endoscopic ultrasound with fine-needle aspiration biopsy (EUS-FNA), positron emission tomography (PET), thoracoscopy/laparoscopy, and combinations of these.
Methods. A decision-analysis model was constructed to compare different staging strategies. Costs were derived from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases and from other Medicare reimbursement rates. Life expectancies were obtained from the 1973–1996 SEER database and adjusted for quality of life. Cost and effectiveness measures were discounted at 0% and 3% per year. Sensitivity and specificity measures were obtained from the published literature and a parallel prospective clinical trial, and all key variables were subjected to sensitivity analyses.
Results. Under baseline assumptions, CT + EUS-FNA was the most inexpensive strategy and offered more quality-adjusted life-years, on average, than all other strategies with the exception of PET + EUS-FNA. The latter was slightly more effective but also more expensive. The marginal cost-effectiveness ratio for PET + EUS-FNA was $60,544 per quality-adjusted life-year. These findings were robust and changed very little in all of the sensitivity analyses.
Conclusions. The combination of PET + EUS-FNA should be the recommended staging procedure for patients with esophageal cancer, unless resources are scarce or PET is unavailable. In these instances, CT + EUS-FNA can be considered the preferred strategy.
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