Dawn Provenzale

Barrett's esophagus : A new look at surveillance based on emerging estimates of cancer risk

OBJECTIVE:Surveillance of Barretts patients is recommended, to detect dysplasia and early cancer. The reported risk for developing cancer varies substantially, however. Our previous analysis used an average cancer incidence of 1/75 patient-years (PY). Recent reports suggest that the risk may range from 1/251 to 1/208 PY in combined series of patients with long segment Barretts esophagus (LSBE, >3 cm), and short segment Barretts esophagus (SSBE), and up to 1% annually in patients with SSBE. Our goal was to consider these new estimates of cancer risk in a cost-utility analysis of surveillance of patients with Barretts esophagus.METHODS:Using our previously published model, we incorporated an average of the recent estimates of cancer risk (0.4% annually, 1/227 PY), and our primary data on quality of life after esophagectomy. We included actual variable (direct) costs and used a discount rate of 5%. From the perspective of an HMO, the model evaluates surveillance every 1–5 yr and no surveillance, with esophagectomy performed if high grade dysplasia is diagnosed, and calculates the incremental cost-utility ratios for each strategy.RESULTS:The results suggest that, at our baseline, annual cancer risk surveillance every 5 yr is the only viable strategy. More frequent surveillance costs more and yields a lower life expectancy. The incremental cost-utility ratio for surveillance every 5 yr is

Race, treatment, and survival among colorectal carcinoma patients in an equal‐access medical system

98,000/quality-adjusted life year (QALY) gained, comparable to the incremental cost-effectiveness ratios of accepted practices (heart transplantation and screening for tuberculosis in selected populations,

Clinical and demographic predictors of Barrett's esophagus among patients with gastroesophageal reflux disease: a multivariable analysis in veterans.

160,000/LY gained and

Colorectal Cancer: National and International Perspective on the Burden of Disease and Public Health Impact

216,000/LY gained, respectively).CONCLUSIONS:Surveillance of Barretts patients should extend life, with incremental cost-utility ratios that compare favorably with some accepted medical practices. Policy makers can compare the cost of surveillance to that of other accepted practices to determine their willingness to fund surveillance.

Quality of life measurement in gastroenterology: what is available?

The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma.

A descriptive evaluation of eligibility for therapy among veterans with chronic hepatitis C virus infection

Background The subgroup of patients with gastroesophageal reflux disease (GERD) that should undergo endoscopy to rule out Barretts esophagus (BE) has not been well defined. Goals To examine demographic and clinical variables predictive of BE before endoscopy. Study A validated GERD questionnaire was administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE shown by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once or more each week. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe). Univariate analysis and multivariable logistic regression were performed to determine whether demographic characteristics and the duration, severity, and frequency of GERD symptoms were associated with the identification of BE. Results Eighty-five percent of the GERD patients and 82% of the BE patients completed the questionnaire. There was no difference between the groups in terms of race, gender, or proton pump inhibitor use. The BE patients were older (median age, 64 vs. 57 years, p = 0.04). In multivariable logistic regression, an age of more than 40 years (p = 0.008), the presence of heartburn or acid regurgitation (p = 0.03), and heartburn more than once a week (p = 0.007) were all independent predictors of the presence of BE. Interestingly, patients with BE were less likely to report severe GERD symptoms (p = 0.0008) and nocturnal symptoms (p = 0.03). Duration of symptoms, race, alcohol, and smoking history were not associated with BE. Conclusions Upper endoscopy should be performed in GERD patients more than 40 years of age who report heartburn once or more per week. The severity of symptoms and the presence of nocturnal symptoms are not reliable indicators of the presence of BE.

A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis.

Colorectal cancer is a significant cause of morbidity and mortality in the United States and throughout the world. The importance of this disease to gastroenterologists cannot be understated, given that screening and surveillance colonoscopy are dominant segments of clinical practice. The United States is the only country in the world where incidence and mortality rates from colorectal cancer are reported to be decreasing significantly, but health disparities in cancer screening, treatment, and survival persist. Health disparities are also evident worldwide, where the impact of this disease is staggering. In fact, rates of cancer are increasing in many parts of the world. Eliminating barriers to cancer screening and treatment could lead to substantial gains in quality and quantity of life and decrease the burden of colorectal cancer on public health. Programmatic and opportunistic screening programs have already had a measurable impact on disease burden, although the optimal screening strategy remains a matter of debate. Screening programs vary throughout the world, and further refinement will require a tailored approach because of differences in politics and fiscal reality among individual countries. Despite the strong impact of colorectal cancer on public health, there is cause for optimism and room for hope.

Prophylactic colectomy or surveillance for chronic ulcerative colitis ? A decision analysis

Monitoring and enhancement of a patients health-related quality of life (HRQL) is an important element of research and medical care. In a previous article, we provided an overview of HRQL measurement. Now we will review the structure and properties of the most commonly used generic and digestive disease-specific HRQL instruments and illustrates their use in the gastroenterology and hepatology literature. Generic measures have been used to study specific diseases as well as to compare HRQL in GI and nongastrointestinal disease. Disease specific instruments have been developed for inflammatory bowel disease, irritable bowel syndrome, dyspepsia, gastroesophageal reflux disease, liver disease, and GI malignancy. Further work is needed to compare disease-specific instruments and to define the most appropriate uses of HRQL measurement in clinical trial and community practice settings.

Risk for colon adenomas in patients with rectosigmoid hyperplastic polyps.

Goal To assess the number of chronic hepatitis C patients eligible for therapy. Background Recent studies have shown improved response rates to treatment of chronic hepatitis C infection. However, treatment with interferon alfa has major side effects, and many patients may not be eligible for therapy. Study One hundred consecutive patients with positive hepatitis C serologies at the Durham Veterans Affairs Medical Center were evaluated. Medical records were reviewed, and the patients were interviewed. Patients were considered ineligible for therapy if they had severe mental illness, hazardous alcohol consumption, current drug abuse, decompensated cirrhosis, dementia, terminal illness, diabetic ketoacidosis, and severe cardiac or pulmonary disease or if they were homeless. Results Of the 100 patients, 92% were male and 51% were African American. The mean age was 47.3 ± 5.6 years. Only 32 of the 100 patients were eligible for therapy. Hazardous alcohol consumption was present in 44%. Major depressive symptoms were present in 12%. Conclusions The minority of chronic hepatitis C patients were eligible for therapy. Significant rates of hazardous alcohol consumption and psychiatric disorders were present. For these patients to complete or become eligible for therapy, a multidisciplinary approach with psychiatric and substance abuse treatment will be necessary.

The Cost Effectiveness of Radiofrequency Ablation for Barrett's Esophagus

A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis