Re: Cost-effectiveness of aspirin chemoprevention for Barrett's esophagus.

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.