© 2004 by Oxford University Press
© 2004 Oxford University Press
CORRESPONDENCE |
RESPONSE: Re: Cost-Effectiveness of Aspirin Chemoprevention for Barrett's Esophagus
Affiliations of authors: Gastrointestinal Unit (CH, NN) and Institute for Technology Assessment (CH, GSG), Massachusetts General Hospital, Boston
Correspondence to: Chin Hur, MD, Massachusetts General Hospital, Gastrointestinal Unit & Institute for Technology Assessment, 101 Merrimac St., 10th floor, Boston, MA 02114 (e-mail: chur{at}partners.org)
We thank Drs. Jankowski and Moayyedi for their comments and agree that chemoprevention for Barrett's esophagus is an extremely timely issue. Our disease model of Barrett's esophagus found that aspirin chemoprevention could be a cost-effective management tool for a patient with Barrett's esophagus. However, as we acknowledged in our discussion, the principal limitation of the model's findings involved the uncertainty that surrounds many of the parameter estimates used to depict the natural history of Barrett's esophagus. Because the progression of Barrett's esophagus to esophageal adenocarcinoma occurs in a small percentage of patients and over a long period, the logistical barriers to performing a rigorous clinical trial that is sufficiently large and with adequate follow-up have prevented such a study until now. This lack of randomized controlled trial data has created a vacuum in our understanding of the natural history of Barrett's esophagus.
We applaud Drs. Jankowski and Moayyedi for their ambitious randomized controlled trial that has already started enrolling patients. Their trial appears to be a prodigious undertaking but should provide much-needed information on the natural history of Barrett's esophagus and chemoprevention that has largely been extrapolated from retrospective or small, observational type studies.
The results of our cost-effectiveness analysis found that the use of aspirin was likely to be cost-saving (both more effective and less costly) when compared with management without aspirin. Sensitivity analyses found these results to be robust in that model assumptions, such as the assumed progression rate to cancer, had to be much lower than modeled in the base case for the results to change. However, for the results of our analysis to be valid, the results of the proposed randomized controlled trial are needed to confirm the parameter estimates used to model the natural history of Barrett's esophagus and the effect of aspirin.
We look forward to a natural link between the proposed trial and our model. As the short-term and long-term results of the trial become available, they will provide the basis for improved parameter estimates to incorporate into our model for updated analyses. In this way, our model and its predictions will constantly be improving and, at any point in time, will be able to provide management recommendations derived from the most current data available.
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J Natl Cancer Inst 2004 96: 885-887.
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