Managing ulcerative colitis patients with endoscopically invisible low-grade dysplasia.
Parker B., Buchanan J., Wordsworth S., Keshav S., George B., East JE.
There is uncertainty regarding the optimal management of endoscopically invisible ("flat") low grade dysplasia in ulcerative colitis. Such a finding does not currently provide an automatic indication for colectomy; however, a recommendation of surveillance instead of surgery is controversial. The aim of this study was to determine the clinical and cost-effectiveness of colonoscopic surveillance versus colectomy for endoscopically invisible low-grade dysplasia of the colon in ulcerative colitis.A Markov model was used to evaluate the costs and health outcomes of surveillance and surgery over a 20-year timeframe. Outcomes evaluated were life years gained and quality-adjusted life years (QALYs). Cohorts of patients aged 25 to 75 were modelled including estimates from a validated surgical risk calculator and considering none, one or both of two key comorbidities: heart failure and obstructive airways disease.Surveillance is associated with more life years and QALYs compared with surgery from age 61 for those with no comorbidities, 51 for those with one comorbidity and age 25 for those with two comorbidities. At the current NICE threshold of $25,800 per QALY, ongoing surveillance was cost-effective at age 65 in those without comorbidities and at age 60 in those with either one or more comorbidities.Surveillance can be recommended from age 65 for those with no comorbidities; however in younger patients with typical postsurgical quality of life, colectomy may be more clinically and cost-effective. The results were sensitive to the colorectal cancer incidence rate in patients under surveillance and to quality of life after surgery.