CA -- eLetters for Lazcano-Ponce et al., 51 (6) 349-364

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Eduardo C. Lazcano-Ponce, J. F. Miquel, Nubia Muñoz, Rolando Herrero, Catterina Ferrecio, Ignacio I. Wistuba, Patricia Alonso de Ruiz, Gerardo Aristi Urista, and Flavio Nervi
Epidemiology and Molecular Pathology of Gallbladder Cancer
CA Cancer J Clin 2001; 51: 349-364 [Abstract] [Full text] [PDF]

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Cost Analysis of Secondary Prevention of Gallbladder Cancer: Andrea Cariati (7 June 2005)

Cost Analysis of Secondary Prevention of Gallbladder Cancer 7 June 2005

Andrea Cariati,
Medical Director, General Surgery
Villa Scassi Hospital
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Re: Cost Analysis of Secondary Prevention of Gallbladder Cancer

andrea.cariati{at}libero.it Andrea Cariati

Gallbladder cancer is usually a fatal complication of cholelithiasis. It is the most common malignant lesion of the biliary tract (1). In the different countries it has large variations of incidence. It has an annual incidence of 0.4 (men)-1 (women)/100,000 in USA and of 3.8-10.3 /100,000 among American Indians of New Mexico (1). The highest incidences (up to 7.5 per 100,000 for men and 15 per 100,000 for women) are seen in Bolivians (1). The incidence rises with age with a peak among females over the age of 65 (1). Surgical treatment in advanced cases is ineffective. The prognosis is poor: only 0-10% five-year survival rate for all stages (2, 3). The etiology of this tumour is multifactorial. In fact, gallbladder carcinomas can be divided in: a) carcinoma related to gallstones (squamous cell carcinoma, adeno-squamous cell carcinoma, the majority of adenocarcinomas); b) carcinoma non associated at all with gallstones but with other factors or conditions as pancreato-biliary reflux, pancreaticobiliary maljunction and gallbladder adenoma (gallbladder polyps of 1 cm. or more) (4).
However the 80% of gallbladder cancer is associated with large cholesterol or combination gallstones (1, 5) and in particular with long- standing gallstones (4). The progression from epithelium dysplasia to invasive carcinoma of the gallbladder is nearly 15 years. Several studies have shown that the overall incidence of carcinoma of the gallbladder in patients with cholelithiasis is 0.1-1 % (8, 9).
The prevalence of gallstones in the adult general population range from 10 % (men) to 20 % (women) in Europe and it increase with age (10). It means that among adult population the prevalence of gallstones is 10000(men)-20000(women) / 100000.
It is possible to estimate that in low incidence areas for gallbladder cancer as USA and Italy (0.5-1 / 100000) (1) a group of 20000 woman with gallstones will develop a gallbladder carcinoma during a 20- year period in 20 cases. The prevalence of gallstones in Chile is nearly 20% in men and 40% in women (11). The annual incidence of gallbladder carcinoma in these populations is 5-15/100,000. It means that, in these areas, in a group of 40000 women with gallstones, 300 will develop a gallbladder carcinoma over a 20-year period.
In theory, the prophylactic cholecystectomy among people with asymptomatic gallstones could prevent almost the 80% of all gallbladder cancer. The main limit of this procedure is the excessive cost. In fact, actually elective laparoscopic cholecystectomy has a cost of nearly 2000,00 euro (12, 13). It means that in high risk areas the secondary prevention of 300 gallbladder cancers would cost 80.000.000,00 euro (40000 x 2000,00 euro).
Actually nearly the 20% of the women with gallstones underwent operation for symptomatic disease (14). It means that in a group of 40,000 women with gallstones 8,000 would be operated at the time of diagnosis for biliary diseases and among the other 32,000 patients another 20% (6,400) would be operated during the successive 20 years (total 14.400). Three hundreds women would be cured or operated for gallbladder cancer (each DRG for biliary or pancreatic malignant diseases in Italy is 10.000,00 euro) with a cost of 300.000,00 euro. The comprehensive costs are of 28.800.000,00 euro (14.400 x 2000,00 euro) for cholelithiasis and 300.000,00 euro for gallbladder cancer (total: 29.100.000,00 euro) with a spare of nearly 50.000.000,00 euro.
In conclusion, the secondary prevention of gallbladder cancer among people with asymptomatic gallstones would triplicate the costs of public health for the treatment of benignant and malignant biliary tract diseases.
At the moment the secondary prevention of gallbladder cancer in low- and high-risk countries can be achieved by prophylactic cholecystectomy in selected high risk groups as: patients with porcelain gallbladder (15), patients with cholesterol or combination stones larger than 3 cm. (5), patients with gallbladder polyps larger than 1 cm. (16).
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