Potential impact of preoperative EUS on esophageal cancer management and cost

Background: The purpose of this study was to determine the relative proportions of esophageal cancer stages in a group of patients referred for preoperative EUS, to determine the proportions of EUS stage 1 and 4 tumors that would not be treated with combined modality therapy, and to estimate the impact of the EUS diagnosis of these stages on costs. Methods: A large national endoscopic database was reviewed retrospectively to identify cases of esophageal cancer in which there was a referral for preoperative staging with EUS. Data were analyzed as to demographics, histology and tumor stage by EUS according to the American Joint Commission for Cancer tumor node metastasis classification system for esophageal cancer. Cost estimates were based on Medicare reimbursement rates and published figures. Results: Of 188 EUS procedures done for preoperative staging of esophageal cancer (82% men, mean age 66.5 years), the histopathologic types of cancer were: adenocarcinoma, 107; squamous cell carcinoma, 39; and unknown histology, 42. Numbers and proportions of patients by American Joint Commission for Cancer group stage based on 162 procedures for which complete staging information was available are as follows: Stage I, 23 patients (14%); Stage II, 51 (31%); Stage III, 69 (43%); and Stage IV, 19 (12%). Therefore, for every 100 patients staged before surgery with EUS (cost $63,420), 14 patients with Stage I disease would be spared neoadjuvant chemoradiotherapy (saving $122,192) and 12 patients with Stage IV cancer would be spared surgery (saving $285,600) for an average cost savings of $3443 per patient. Conclusion: Preoperative staging of esophageal cancer with EUS identifies a significant proportion of patients (26% in this series) with stage I and IV tumors who may be spared combined modality therapy with an associated potential for cost savings.