Background
Methods
Searches and study selection
No. | Search Term Category | Search Terms |
---|---|---|
1. | Disease | neoplas* OR |
cancer*OR | ||
carcin* OR | ||
tumo* OR | ||
adenocarcinoma* OR | ||
squamous cell carcinoma* OR | ||
malig* OR | ||
metasta* | ||
AND | ||
2. | Type of disease | gastro* OR |
oesophag* OR | ||
esophag* OR | ||
gastro-oesophag* OR | ||
gastro-esophag* OR | ||
gastroesophag* junction* OR | ||
gastro-esophag* junction* OR | ||
gastrooesophag* junction* OR | ||
gastro-oesophag* junction* OR | ||
esophagogastric junction* OR | ||
esophago-gastric junction* OR | ||
oesophagogastric junction* OR | ||
oesophago-gastric junction* OR | ||
oesophageal squamous cell carcinoma* OR | ||
esophageal squamous cell carcinoma* OR | ||
gut* OR | ||
gullet* OR | ||
food pipe OR | ||
stomach OR | ||
upper GI OR | ||
upper-GI OR | ||
upper gastrointestin* OR | ||
upper-gastrointestin* OR | ||
upper digestive tract* OR | ||
upper-digestive tract* OR | ||
intraepithelial OR | ||
intramucosal OR | ||
node* OR | ||
nodal | ||
AND | ||
3. | Intervention | endosono* OR |
EUS OR | ||
endoscopic ultraso* OR | ||
endoscopic-ultraso* OR | ||
EUS-FNA OR | ||
EUS-fine needle aspiration OR | ||
EUS fine-needle aspiration OR | ||
Endosonography-guided FNA OR | ||
Endoscopic ultrasound-fine needle aspiration OR | ||
Endoscopic ultrasound-guided fine needle aspiration OR | ||
Endoscopic ultrasound-guided fine-needle aspiration OR | ||
Endoscopic-ultrasound-guided fine-needle aspiration OR | ||
Endoscopic ultrasound guided fine needle aspiration OR | ||
Echoendoscop* OR | ||
Echo-endoscop*
| ||
AND | ||
Staging OR | ||
Preoperative staging OR | ||
Pre-operative staging | ||
AND | ||
4. | Outcome | econom* OR |
health economics OR | ||
economic evaluation OR | ||
cost-effective* OR | ||
cost effect* OR | ||
cost utility OR | ||
cost-utility OR | ||
cost-conseq* OR | ||
cost conseq* OR | ||
cost-benefit OR | ||
cost benefit OR | ||
cost-minimisation OR | ||
cost minimisation OR | ||
cost-minimization OR | ||
cost minimization OR | ||
cost* OR | ||
cost* analys* OR | ||
unit cost OR | ||
unit-cost OR | ||
unit-costs OR | ||
unit costs OR | ||
drug cost OR | ||
drug costs OR | ||
hospital costs OR | ||
health-care costs OR | ||
health care cost OR | ||
medical cost OR | ||
medical costs OR | ||
cost* efficacy* OR | ||
cost* analys* OR | ||
cost* allocation* OR | ||
cost* control* OR | ||
cost* illness* OR | ||
cost* affordable* OR | ||
cost* fee* OR | ||
cost* charge* | ||
economic model* OR | ||
markov* OR | ||
budget* OR | ||
healthcare economics OR | ||
health care economics OR | ||
cost analys* OR | ||
health-care cost* OR | ||
health care cost* OR | ||
hrqol OR | ||
Health related quality of life OR | ||
health-related quality of life OR | ||
quality-adjusted life year* OR | ||
quality adjusted life year* OR | ||
qaly OR | ||
Quality of life OR | ||
quality-of-life OR | ||
QoL |
Inclusion and exclusion criteria
Inclusion Criteria | Exclusion Criteria | |
---|---|---|
Population | All adults (aged 19 and above) who had cancer (i.e. localised tumour) of the oesophagus, stomach or gastro-oesophageal junction; free of metastatic disease. | Population aged below 19 years and had metastatic oesophageal, gastro-oesophageal or gastric cancer. |
Interventions | Use of endoscopic ultrasound (EUS) (also known as endosonography, echoendoscopy) staging in patient with oesophagus, gastro-oesophageal and gastric cancer. | Use of endoscopy only or ultrasound only, and use of EUS for non-cancer staging purposes e.g. treatment of cancer |
Comparators | Standard staging algorithm e.g. trans-abdominal ultrasound scan, computed tomography (CT) scan. Partial economic evaluations, when no formal comparator was used, were included. | |
Outcomes | All relevant full economic evaluation studies outcomes including (but not be restricted to) cost per QALY and cost per life-year gained; All other relevant economic outcomes including (but not be restricted to) resource use, direct and indirect costs, incremental benefits e.g. quality-adjusted survival or quality-adjusted life years (QALYs), health-related quality of life, cancer-specific quality of life and utility gained – this includes partial economic evaluation studies outcomes, which costs or consequences alone of a single intervention (e.g. EUS staging of GOC) were described, were included. | All outcomes unrelated to economic evidence of EUS staging of the oesophagus, gastro-oesophageal junction or gastric cancer. |
Type of Evidence | Full economic evaluation evidence (i.e. cost-effectiveness, cost-utility and cost-benefit analyses) related to EUS staging of oesophageal, gastro-oesophageal junction and gastric cancer were considered. Other economic studies that contain partial economic evaluation or no evaluation context (e.g. cost analyses, cost-description studies, cost-outcome descriptions, budgetary studies, outcome-description studies in terms of utility gained, health-related quality of life and cancer-specific quality of life measures such as QALYs and FACT-G score) were also considered. Economic evaluation studies conducted alongside RCTs, non-RCTs, quasi-experimental trials, epidemiological research, cohort studies, and modelling studies were considered. | Non-research studies such as editorials, case reports or other descriptive studies. |
General | Language – English. Years – 1996-2016 and 2016–2018 | Language – Not written or translated into English. Years – Before 1996. |
Data extraction
Quality assessment
Data synthesis
Results
Literature search: identification of studies
Study descriptions
Authors, year, country | Aims of the study | Type of participants (n) | Type of study, methodology | Study perspective | Price year, currency (unit) | Type of intervention / staging technique | Method of delivery | Length of follow-up | Cost of intervention / staging technique | Type of economic analysis conducted | Outcomes / results / conclusionsa |
---|---|---|---|---|---|---|---|---|---|---|---|
Shumaker et al. (2002) [26], USA. | To determine (1) the relative proportions of each oesophageal cancer stage in a group of patients referred for preoperative staging with EUS, (2) the proportion of patients with EUS stage 1 and 4 tumours that would not be treated with combined modality therapy, and (3) to estimate the potential cost savings of performing preoperative EUS in oesophageal cancer patients. | Patients with oesophageal cancer receiving preoperative staging with EUS (n = 180, 82% men and mean age 66.5 years). | Cost analysis using a retrospective review of a large multicentre national computerised endoscopic database. Data between February 1998 and October 2000 were extracted, reviewed and analysed. | Not stated specifically, the authors described US Medicare data | Price year: 2000 Currency: US dollars (USD$) | NA: retrospective review of a large national endoscopic database. | NA | NA | The cost of EUS for preoperative staging of oesophageal cancer was estimated at $634 per patient (£697 per patient, 2017 price year) | Cost analysis study: the potential cost savings of performing preoperative EUS in oesophageal cancer patients. | Preoperative staging of oesophageal cancer with EUS can facilitate cost savings by reducing the need for additional treatments in stage 1 and 4 oesophageal cancer (a significant proportion of patients – 26% in this series). |
Chang et al. (2003) [27], USA | To determine the impact of EUS combined with FNA on patients’ choice of therapy and on the cost of care. | Patients diagnosed with oesophageal cancer (squamous-cell or adenocarcinoma) who were referred to the University of California’s Irvine Medical Center for preoperative EUS staging between August 1993 and August 1997 (n = 60, 39 men, 21 women and mean age 68 ± 10 years). These patients were all being considered for surgical resection and had undergone standard evaluation including CT which showed no evidence of distant metastases. | Cost analysis alongside prospective case series. | Not stated specifically, the study was undertaken in California, USA. | Not stated specifically, the authors described their cost analyses were based on the published direct costs of endosonography-guided aspiration biopsy and thoracotomy published in 1997 (Gress et al., 1997). Currency: US dollars (USD$) | NA: cost analysis study alongside prospective case series. | NA | Based on the data used in the cost analyses, the length of follow-up was, on average, 17 months (range 1–51 months). | The cost of EUS-FNA biopsy based on the published direct costs of endosonography-guided aspiration biopsy (Gress et al., 1997) was estimated at $1975 per patient (outpatient) (£3528 per patient, 2017 price year). | Cost analysis study: the cost of care for these patients was calculated to explore whether or not the use of EUS decreases the cost of managing patients with oesophageal cancer. | Patients’ decisions on whether to undergo medical or surgical treatment correlated significantly with their overall tumour staging, suggesting that the information provided by EUS played a significant role in patients’ decision-making. EUS-guided therapy potentially reduces the cost of managing patients with oesophageal cancer by USD$12,340 per patient (£10,510 per patient, 2017 price year) due to reduced number of thoracotomies undertaken (patient choice). |
Russell et al. (2013) [11], UK | To examine whether the addition of EUS to usual staging uses resources cost-effectively. | Patients with proven cancer of the oesophagus, stomach or gastro-oesophageal junction; medically fit for both surgery (even if not planned) and chemotherapy, free of metastatic disease and had not started treatment. Both their ASA (America Society of Anesthesiologists) grading and their WHO performance status had to be 1 or 2 (n = 213, 165 male; mean age 64.4 years; EUS group (n = 107); No EUS group (n = 106)). | Cost-effectiveness analysis alongside a multi-centre randomised controlled trial (RCT) namely ‘COGNATE trial’. The study explored whether giving EUS scan in addition to standard staging algorithms would be more cost-effective compared to standard staging algorithms. | NHS perspective, focusing on health-care resources used by participants including investigation, treatment and palliation, and other elements of secondary and pharmaceutical care. | Price year 2008 Currency: Pounds Sterling (£) | Cancer staging with EUS vs. without EUS | Patients randomised to intervention group received EUS scan in addition to standard staging algorithms. Patients randomised to control group received standard staging algorithms. | Study follow-up period was 54 months or until death, whichever came first. Main analyses of the study (including health economic analysis) used 48 months. | The cost of EUS scan was £551 (day case) (£648, 2017 price year), £1477 (outpatient) (£1737, 2017 price year) and £3781 (inpatient) (£4447, 2017 price year). | Cost-effectiveness analysis using QALY as a measure of effect – The difference in cost and QALY between intervention and control groups was calculated; the probabilities of the EUS intervention being cost-effective at different willingness-to-pay thresholds were estimated. | EUS reduced net use of health-care resources by £2860 (£3364, 2017 price year) and had an increase of 0.1969 in estimated mean QALYs. Combining these estimated benefits and savings yields probability of 96.6% that EUS is cost-effective in the sense of achieving the NICE criterion of costing less than £20,000 to gain a QALY [28]. |
Authors, year, country | Aims of the study | Type of participants | Type of study, methodology | Perspective of the model | Price year, currency (unit) | Type of intervention / staging technique | Analysis | Time horizon | Outcome measure(s) | Outcomes / results / conclusionsa |
---|---|---|---|---|---|---|---|---|---|---|
Hadzijahic et al. (2000) [29], USA | To determine whether it is less costly to request CT or EUS first to identify advanced oesophageal cancer; to determine which variables most affect the overall cost of identifying advanced disease. | Oesophageal cancer patients who underwent both CT and EUS between July 1995 and April 1999 (n = 124, mean age = 62.7 years, 98 (79%) men, and 72 (58%) white). | Cost-minimisation study using decision tree model to compare which of the two initial staging strategies (EUS first or CT first strategy) would cost less to detect advanced disease in patients diagnosed endoscopically with oesophageal cancer. | Not stated specifically, the study took local referral centre perspective. | Price year: 1999 Currency: US dollars (USD$). | CT first strategy vs. EUS first strategy. | Decision analysis using decision tree model. | Not stated specifically. | Overall cost of identifying advanced disease of the two strategies: EUS first and CT first strategies. | Initial CT is the least costly strategy if the probability of finding advanced disease by initial CT is greater than 20%, if the probability of finding advanced disease by initial EUS is less than 30%, or if the cost of EUS is greater than 3.5 times the cost of CT. EUS found advanced disease more frequently than CT (44% vs. 13%; p < 0.0001) and initial EUS was the least costly strategy (Initial EUS strategy expected cost was US$804 (£824, 2017 price year) vs. initial CT strategy expected cost $844 (£867, 2017 price year)). |
Harewood et al. (2002) [30], USA | To examine which staging/management technique was the least costly: EUS FNA, CT-guided FNA or surgical management of oesophageal tumours. | Patients with apparently “resectable” oesophageal cancer on CT (i.e. patients with non-metastatic oesophageal cancer). | Cost-minimisation study using decision tree model to determine which strategy is least costly among the different alternatives: CT-FNA, EUS-FNA and ‘proceed straight to surgery’ options. | Third party payer perspective. | Price year: 2001 Currency: US dollars (USD$). | CT-FNA vs. EUS-FNA vs. ‘proceed directly to surgery’. | Decision analysis using decision tree model. | Not stated specifically. | Least costly staging strategy among the three strategies (CT-FNA vs. EUS-FNA vs Surgery) | EUS FNA was the least costly strategy at $13,811 (£14,578, 2017 price year), followed by surgery at $13,992 (£14,768, 2017 price year) and CT-FNA at $14,350 (£15,147, 2017 price year). EUS FNA remained the least costly option, provided that the prevalence of celiac lymph node (CLN) involvement was greater than 16%. Below this value, surgery became the least costly strategy. The final outcome of the model was also sensitive to variation in the sensitivity of EUS FNA. Provided that the sensitivity of EUS-FNA was greater than 66%, EUS-FNA remained the least costly staging option in the management of oesophageal tumours. Despite changing the values of two or three variables simultaneously in the two- and three-way sensitivity analyses, the result still showed that EUS FNA remained the least costly strategy. |
Wallace et al. (2002) [31], USA | To compare the health care costs and effectiveness of multiple staging options for patients with oesophageal cancer. | All Medicare-eligible patients whose invasive oesophageal cancer was diagnosed between January 1991 and December 1996. Data were obtained retrospectively from the SEER–Medicare databases. | Cost-effectiveness study using decision tree model to compare the costs and effectiveness of six strategies (CT alone vs. CT + EUS vs. CT + TL vs. CT + EUS + TL vs CT + PET+EUS vs. PET+EUS). | Third-party payer perspective | Price year: 2000 Currency: US dollars (USD$). | The costs and effectiveness of the six strategies were compared – CT alone vs. CT + EUS vs. CT + TL vs. CT + EUS + TL vs CT + PET+EUS vs. PET+EUS. | Decision analysis using decision tree model. | Not stated specifically | Cost, QALYs and cost per QALY of the six strategies | Under baseline assumptions, CT + EUS-FNA was the least costly strategy and offered more QALYs, on average, than all other strategies with the exception of PET+EUS-FNA. The latter was slightly more effective but also more costly. The marginal cost-effectiveness ratio comparing PET+EUS-FNA with CT + EUS-FNA was $60,544 per QALY (£66,588 per QALY, 2017 price year). These findings were robust and changed very little in all of the sensitivity analyses. |
Quality assessment
Question no. | CASP economic evaluation checklist questionsab | Response (√, x, NC or NA) | ||
---|---|---|---|---|
Studies (author and year) | ||||
Shumaker et al. (2002) [26] | Chang et al. (2003) [27] | Russell et al. (2013) [11] | ||
1 | Was a well-defined question posed? | √ | √ | √ |
2 | Was a comprehensive description of the competing alternatives given? | NA | NA | √ |
3 | Does the paper provide evidence that the programme would be effective (i.e. would the programme do more good than harm)? | √ | √ | √ |
4 | Were the effects of the intervention identified, measured and valued appropriately? | NA | NA | √ |
5a | Were all important and relevant resources required and health outcome costs for each alternative identified? | NC | NC | √ |
5b | Were all important and relevant resources required and health outcome costs for each alternative measured in appropriate units? | √ | √ | √ |
5c | Were all important and relevant resources required and health outcome costs for each alternative valued credibly? | √ | NC | √ |
6 | Were costs and consequences adjusted for different times at which they occurred (discounting)? | x | x | √ |
7 | What were the results of the evaluation? | √ | √ | √ |
8 | Was an incremental analysis of the consequences and cost of alternatives performed? | NA | NA | √ |
9 | Was an adequate sensitivity analysis performed? | √ | x | √ |
10 | Is the programme likely to be equally effective in your context or setting? | √ | √ | √ |
11 | Are the costs translatable to your setting? | x | x | √ |
12 | Is it worth doing in your setting? | √ | √ | √ |
Score, ratio™ (%) | 8/11 (73%) | 6/11 (55%) | 14/14 (100%) |
Quality Criterion | Philips et al’ economic modelling checklist questionsa | Response (√, x, NC or NA) | ||
---|---|---|---|---|
Studies (author and year) | ||||
Hadzijahic et al. (2000) [29] | Harewood et al. (2002) [30] | Wallace et al. (2002) [31] | ||
S1 | Is there a clear statement of the decision problem? | √ | √ | √ |
Is the objective of the evaluation and model specified and consistent with the stated decision problem? | √ | √ | √ | |
Is the primary decision-maker specified? | NC | √ | √ | |
S2 | Is the perspective of the model stated clearly? | x | √ | √ |
Are the model inputs consistent with the stated perspective? | NC | √ | √ | |
Has the scope of the model been stated and justified? | √ | √ | √ | |
Are the outcomes of the model consistent with the perspective, scope and overall objective of the model? | √ | √ | √ | |
S3 | Is the structure of the model consistent with a coherent theory of the health condition under evaluation? | √ | √ | √ |
Are the sources of data used to develop the structure of the model specified? | √ | √ | √ | |
Are the causal relationships described by the model structure justified appropriately? | NA | NA | NA | |
S4 | Are the structural assumptions transparent and justified? | √ | √ | √ |
Are the structural assumptions reasonable given the overall objective, perspective and scope of the model? | √ | √ | √ | |
S5 | Is there a clear definition of the options under evaluation? | √ | √ | √ |
Have all feasible and practical options been evaluated? | √ | √ | √ | |
Is there justification for the exclusion of feasible options? | NA | NA | NA | |
S6 | Is the chosen model type appropriate given the decision problem and specified causal relationships within the model? | √ | √ | √ |
S7 | Is the time horizon of the model sufficient to reflect all important differences between options? | x | x | X |
Are the time horizon of the model, the duration of treatment and the duration of treatment effect described and justified? | x | x | X | |
S8 | Do the disease states (state transition model) or the pathways (decision tree model) reflect the underlying biological process of the disease in question and the impact of interventions? | √ | √ | √ |
S9 | Is the cycle length defined and justified in terms of the natural history of disease? | NA | NA | NA |
D1 | Are the data identification methods transparent and appropriate given the objectives of the model? | √ | NC | √ |
Where choices have been made between data sources, are these justified appropriately? | NA | √ | √ | |
Has particular attention been paid to identifying data for the important parameters in the model? | √ | √ | X | |
Has the quality of the data been assessed appropriately? | x | x | x | |
Where expert opinion has been used, are the methods described and justified? | NA | NA | x | |
D2 | Is the data modelling methodology based on justifiable statistical and epidemiological techniques? | √ | NC | √ |
D2a | Is the choice of baseline data described and justified? | √ | √ | √ |
Are transition probabilities calculated appropriately? | NA | NA | NA | |
Has a half-cycle correction been applied to both cost and outcome? | NA | NA | NA | |
If not, has this omission been justified? | NA | NA | NA | |
D2b | If relative treatment effects have been derived from trial data, have they been synthesised using appropriate techniques? | NA | NA | NA |
Have the methods and assumptions used to extrapolate short-term results to final outcomes been documented and justified? | NA | NA | NA | |
Have alternative assumptions been explored through sensitivity analysis? | √ | √ | √ | |
Have assumptions regarding the continuing effect of treatment once treatment is complete been documented and justified? | NA | NA | NA | |
Have alternative assumptions regarding the continuing effect of treatment been explored through sensitivity analysis? | NA | NA | NA | |
D2c | Are the costs incorporated into the model justified? | √ | √ | √ |
Has the source for all costs been described? | √ | √ | √ | |
Have discount rates been described and justified given the target decision-maker? | NC | NA | √ | |
D2d | Are the utilities incorporated into the model appropriate? | NA | NA | √ |
Is the source for the utility weights referenced? | NA | NA | X | |
Are the methods of derivation for the utility weights justified? | NA | NA | X | |
D3 | Have all data incorporated into the model been described and referenced in sufficient detail? | NC | √ | √ |
Has the use of mutually inconsistent data been justified (i.e. are assumptions and choices appropriate)? | NC | NC | √ | |
Is the process of data incorporation transparent? | √ | x | X | |
If data have been incorporated as distributions, has the choice of distribution for each parameter been described and justified? | NA | NA | NA | |
If data have been incorporated as distributions, is it clear that second order uncertainty is reflected? | NA | NA | NA | |
D4 | Have the four principal types of uncertainty been addressed? |
x
| x | X |
If not, has the omission of particular forms of uncertainty been justified? |
x
| x | X | |
D4a | Have methodological uncertainties been addressed by running alternative versions of the model with different methodological assumptions? |
x
| x | X |
D4b | Is there evidence that structural uncertainties have been addressed via sensitivity analysis? |
x
| x | X |
D4c | Has heterogeneity been dealt with by running the model separately for different subgroups? | x | x | x |
D4d | Are the methods of assessment of parameter uncertainty appropriate? | √ | √ | √ |
If data are incorporated as point estimates, are the ranges used for sensitivity analysis stated clearly and justified? | NC | √ | √ | |
C1 | Is there evidence that the mathematical logic of the model has been tested thoroughly before use? | x | x | x |
C2 | Are any counterintuitive results from the model explained and justified? | NA | NA | NA |
If the model has been calibrated against independent data, have any differences been explained and justified? | NA | NA | NA | |
Have the results of the model been compared with those of previous models and any differences in results explained? | x | x | x | |
Score, ratio™ (%) | 21/38 (55%) | 24/38 (63%) | 28/43 (65%) |