Hur Chin, Nishioka Norman S, Gazelle G Scott
Gastrointestinal Unit and The Institute for Technology Assessment, Massachusetts General Hospital, Boston, USA.
J Natl Cancer Inst. 2004 Feb 18;96(4):316-25. doi: 10.1093/jnci/djh039.
Recent data suggest that nonsteroidal anti-inflammatory drugs, including aspirin, may prevent the progression of Barrett's esophagus to adenocarcinoma. However, use of aspirin is associated with numerous potential complications, including gastrointestinal bleeding and hemorrhagic strokes. We used a modeling approach to determine and compare the effectiveness and cost-effectiveness of aspirin with and without endoscopic surveillance to prevent esophageal adenocarcinoma.
A Markov Monte Carlo decision model was constructed to compare four strategies for management of Barrett's esophagus: aspirin therapy, endoscopic surveillance with biopsies, both, or neither. Patients who took a daily enteric-coated aspirin were modeled to have a 50% reduction in the incidence of esophageal adenocarcinoma but could have complications related to therapy, at which point the aspirin was discontinued. Potential cardiac benefits of aspirin and its role in the chemoprevention of other cancers were not included in the analysis. The analysis was from a societal perspective from age 55 years until death. Sensitivity analyses were performed to investigate the effects of changes in model parameters on estimated costs and effectiveness outcomes across a wide range of assumptions.
Aspirin therapy was more effective and less costly than no therapy, resulting in 0.19 more quality-adjusted life years (QALYs). The combination of aspirin and endoscopic surveillance produced 0.27 more QALYs than no therapy at a cost of 13,400 U.S. dollars more, for an associated incremental cost-effectiveness ratio of 49,600 U.S. dollars/QALY. Aspirin use in combination with endoscopic surveillance dominated endoscopic surveillance alone, resulting in 0.06 more QALYs and 11,400 U.S. dollars less cost. The model's results were sensitive to increasing age and to decreased benefit or delay in aspirin's chemopreventive efficacy.
Using published values of parameters, regardless of whether a patient undergoes endoscopic surveillance, aspirin use in the management of Barrett's esophagus appears to be a cost-effective strategy to prevent esophageal adenocarcinoma.
近期数据表明，包括阿司匹林在内的非甾体抗炎药可能会阻止巴雷特食管进展为腺癌。然而，使用阿司匹林会带来许多潜在并发症，包括胃肠道出血和出血性中风。我们采用建模方法来确定并比较使用和不使用内镜监测的阿司匹林预防食管腺癌的有效性和成本效益。
构建了一个马尔可夫蒙特卡洛决策模型，以比较巴雷特食管的四种管理策略：阿司匹林治疗、内镜活检监测、两者结合或两者都不采用。服用每日肠溶阿司匹林的患者被模拟为食管腺癌发病率降低50%，但可能出现与治疗相关的并发症，此时停用阿司匹林。分析未包括阿司匹林潜在的心脏益处及其在其他癌症化学预防中的作用。分析从社会角度出发，针对55岁直至死亡的人群。进行敏感性分析以研究模型参数变化对广泛假设下估计成本和有效性结果的影响。
阿司匹林治疗比不治疗更有效且成本更低，可增加0.19个质量调整生命年（QALY）。阿司匹林与内镜监测相结合比不治疗多产生0.27个QALY，但成本高出13400美元，相关增量成本效益比为49600美元/QALY。阿司匹林与内镜监测联合使用优于单独的内镜监测，可多产生0.06个QALY且成本降低11400美元。模型结果对年龄增长以及阿司匹林化学预防效果的益处降低或延迟敏感。
根据已发表的参数值，无论患者是否接受内镜监测，在巴雷特食管管理中使用阿司匹林似乎是预防食管腺癌的一种具有成本效益的策略。
